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The Intersection of Attitudes and Organizational Factors by Provider Type in Dissemination and Implementation of an Evidence-Based Practice for Child Anxiety: A Mixed Methods Approach _ Rinad Beidas 4_30_13

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Transcript of "The Intersection of Attitudes and Organizational Factors by Provider Type in Dissemination and Implementation of an Evidence-Based Practice for Child Anxiety: A Mixed Methods Approach _ Rinad Beidas 4_30_13"

  1. 1. Non-Doctoral;Positive Attitudes• Confidence inimplementing CBT• Lack of space andresources to implementas intended• FundingNon-Doctoral;Positive Attitudes• Confidence inimplementing CBT• Lack of space andresources to implementas intended• FundingBackground• Ecological approaches to dissemination and implementation (DI) recommendconsideration of the relationship between individual- and organizational-level (IOL)factors associated with DI of evidence-based practices in mental health (EBPs;Damschroder et al., 2009).• Two potentially important individual-level therapist variables are therapist degree status(i.e., doctoral versus non-doctoral) and attitudes (Aarons, 2006). Research illustratesthat educational background may be related to therapist attitudes towards EBPs(Aarons, 2004). Limited research has examined the relationship between educationalbackground and therapist perception of organizational environment. Previous workindicates doctoral therapists may endorse differences in perceptions of organizationalenvironment including adequacy of resources and motivation for change compared tonon-doctoral counterparts (Downey et al., 2012)• Further research is needed to examine the relationship between degree status, attitudestowards EBPs, and perception of organizational factors. This is especially salient giventhat previous work has focused on attitudes of those with doctoral degrees even thoughmost community mental health clinic (CMHC) therapists do not have doctoral degrees• Calls for a mixed-methods approach in implementation science cite the need for a morenuanced understanding of implementation issues faced in the community (Palinkas etal., 2011)• The current study uses a mixed-methods design to examine the intersection ofquantitative data (i.e., attitudes as measured by the Evidence-Based Attitudes Scale;Aarons, 2004) with qualitative themes around implementation barriers andorganizational factors emergent from semi-structured interviews conducted withtherapists who participated in training for an EBP of the treatment of child anxiety,cognitive-behavioral therapy (CBT; Beidas et al,. 2012).Methods  Stratified ThemesDoctoral; Positive: “As a psychologist…”; “My current practice…”; “I implemented theprogram…but within my system”Doctoral; Less Positive: “I have been able to apply the concepts from training, even if I don’thave enough time in the work setting to actually do full kind of Coping Cat treatment”.Non-Doctoral; Positive: “…(adequate training gave) me the confidence and the tools tobe able to identify who CBT would work for and then the tools to be able to actuallyimplement it with someone”.Non-Doctoral; Less Positive: “In…our structure we generally see people when they’re here (inthe medical setting) and so they often aren’t willing to commit to come in regularly outside ofthat (medical treatment)”.Universal Themes• Managerial support (including supervision, openness, educated management, materials, andpassive assent to therapist practice) as a facilitator of implementation• Setting (e.g., school or medical) as a facilitator of or barrier to implementationDiscussion• The present study provides information on barriers and organizational factors in therapists;stratified by doctoral status and attitude level. Doctoral-level therapists with positive attitudeswere more likely to report autonomy and ownership whereas doctoral-level therapists with lesspositive attitudes reported required usage of CBT and lack of time for therapy as intended.Striking divergence existed between doctoral level therapists with differing attitudes. Non-doctoral therapists reported funding and lack of space and resources as a barrier; non-doctoraltherapists with positive attitudes reported more confidence in their use of CBT.• Given that the overwhelming majority of providers in the community are non-doctoral level,these findings suggest the reality of CMHCs from the perspective of front-line providers.CMHCs tend to have high rates of turnover which may be due to lower organizational climateand culture (Glisson and James, 2002). One possible explanation for the differences we foundbetween doctoral and non-doctoral providers is their level of autonomy. Interventions thatincrease autonomy for non-doctoral providers may increase satisfaction towards theirorganization and attitudes towards EBPs which may result in increased provision of EBPs.• Limitations include: therapists volunteered for initial training study, the self-report of attitudes,barriers, and organizational-level factors, the inclusion of graduate students in doctoral status,and potentially a third variable of setting as a determinant of organizational-level factors andattitudes.• Future directions include exploration of other qualitative themes (e.g., adaptation of EBPs) andstratifying by other quantitative measures (e.g., the Organizational Readiness for Change) aswell as stratifying by professional type (e.g., psychologist, psychiatrist, social worker, nurse).MeasuresDegree status was operationalized as doctoral (i.e., participants with a completed doctoral degreesuch as PhD, PsyD, EdD, MD, or DO and graduate students enrolled in doctoralprograms at baseline) or non-doctoral (i.e., participants not having completed a doctoraldegree such as MA, MS, MFT, RN, BA)Evidence-Based Practice Attitude Scale (EBPAS; Aarons 2005) measured individual-level therapistvariables (i.e., appeal, requirements, openness and divergence). The total score was used tostratify our qualitative data.• Appeal refers to the extent to which a therapist will adopt a new practice if it is intuitivelyappealing• Requirements refer to the extent to which a therapist will adopt a new practice if requiredby the organization or legally mandated• Openness is the extent to which a therapist is generally receptive to using newinterventions• Divergence is the extent to which a therapist perceives research-based treatments as notuseful clinicallySemi-structured interviews (Stirman et al., 2012) were used to generate qualitative themes.Questions were open-ended and follow-up probes were included to tailor the interview tothe participants’ responses and to elicit information about participant experiences andperceptions implementing CBT. Example questions directly dealing with the intersectionof implementation barriers and organizational factors were:• How are specific elements of CBT working in your practice (i.e., exposures)?• What types of policies, procedures, or characteristics of your agency make it either easier or more difficultto use CBT?• Is there anything management could or should to support the use of CBT? How do they show support?• What do you feel you would need to keep using CBT or what would you need to change for you to useit more?Procedures• Therapists in the Philadelphia metropolitan area volunteered to receive training in CBT forchild anxiety. Attitudes and demographics were measured prior to training (see Beidas etal., 2012)• Semi-structured interviews (approximately 45-60 minutes) and the EBPAS were conducted2-years later with a sample of therapists who participated in the training studyResultsAnalysis• Interviews were digitally recorded, transcribed, and coded with a comprehensive schemedeveloped for the study through a consensus line-by-line reading of 8 transcripts. Separatecodes were established for implementation barriers and organizational factors (Beidas et al2013)• Interviews segments coded for organizational factors and/or barriers were stratified byprovider type and high/low EBPAS total score (Mean = 3.04 ; Median = 3.00) using QSRNVIVO 10 software• We conducted data analysis by extracting universal themes reported by all participants andthen themes stratified by attitude and doctoral statusThe intersection of attitudes and organizational factors by provider type in dissemination and implementation of an evidence-based practice for child anxiety: A mixed methods approachMargaret Mary Downey, BA1; Mark Gallagher, BA1; Jessica Watkins1; Prianna Pathak1; Julie Edmunds, MA2; Phillip Kendall, PhD2; and Rinad Beidas, PhD11University of Pennsylvania Perelman School of Medicine, Center for Mental Health Policy and Services Research2 Temple University, Department of Psychology Funding for this research project was supported by the following grants from the National Institutes ofFunding for this research project was supported by the following grants from the National Institutes ofMental Health: Beidas (F31 MH083333; K23 MH099179); Kendall (F31 MH083333; U01Mental Health: Beidas (F31 MH083333; K23 MH099179); Kendall (F31 MH083333; U01MH063747). Invaluable training and consultation provided by Shimrit Kedden of the University ofMH063747). Invaluable training and consultation provided by Shimrit Kedden of the University ofPennsylvania Mixed Methods Research Lab.Pennsylvania Mixed Methods Research Lab.Doctoral;Positive Attitudes•Autonomy• Ownership overpositionDoctoral;Positive Attitudes•Autonomy• Ownership overpositionDoctoral; LessPositive Attitudes•Required use of CBT•Lack of time fortherapy as intendedDoctoral; LessPositive Attitudes•Required use of CBT•Lack of time fortherapy as intendedNon-Doctoral; LessPositive Attitudes• Lack of regular accessto clients• Lack of space andresources to implementas intended• FundingNon-Doctoral; LessPositive Attitudes• Lack of regular accessto clients• Lack of space andresources to implementas intended• FundingParticipantsN = 5092.0% FemaleAges: 23 - 75 (M = 35.09, SD = 10.85)Race/Ethnicity:Caucasian 74.0 %African-American 8.0%Asian 8.0 %Other 4.0 %Clinical Experience:0 to 372 months (M = 69.59, SD = 86.85)Degree Status:Non-Doctoral = 28; Doctoral = 22Education:64.0 % had a master’s degree18.0 % enrolled in a graduate program6.0 % had a doctorate in philosophy4.0 % had a medical degree4.0 % had a doctorate in psychology4.0 % had a doctorate in education

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