Week 4 journal start assignmentgroupthinkdefine groupthink.

Week 4 - Journal
Start Assignment
Groupthink
Define groupthink. Describe how groupthink can get in the way
of problem solving in groups. How can groupthink be avoided?
Describe an experience that you might have had with
groupthink, and describe the associated challenges you have
faced solving problems in a group. How did the situation get
resolved?
Your reflective journal entry should contain 450-750 words.
Week 4 - Assignment
Annotated Bibliography and Final Paper Topic Choice
My topic: Benefits and qualities of groups in human services
This final paper preparation assignment will require the
following:
· State your topic choice for the Final Paper and explain why
you chose it. (1 paragraph)
· Provide a brief summary of what you plan to research about
your topic. For example, in-depth paper might require regarding
the pros and cons of INFJ MBTI personality type in groups
compared to ISTJ personality types in groups, while an in-
breadth topic might examine 16 MBTI personality types
interacting in groups. (1 paragraph)
· Explain what you hope to learn through the experience. (1
paragraph)
· Compile an annotated bibliography, which will consist of no
fewer than eight scholarly resources that are less than 6 years
old, with the exception that you may include no more than two
older articles that are widely recognized as seminal or classic
works. Click here to view a list of topics and topic
categoriesDownload Click here to view a list of topics and topic

categories, one of which may provide a useful starting point for
your Final Paper topic selection.
Review the following guidelines regarding how to create an
annotated bibliography in APA style, 6th edition:
References
Moya, E. M., Chávez-Baray, S. M., Martínez, O., & Aguirre-
Polanco, A. (2016). Exploring Intimate Partner Violence and
Sexual Health Needs in the Southwestern United States:
Perspectives from Health and Human Services Workers. Health
& Social Work, 41(1), e29–e37. https://doi-org.proxy-
library.ashford.edu/10.1093/hsw/hlv080
Watts, L., Schoder, M., & Hodgson, D. (2018). The Experiences
of Human Service Managers in Contexts of Change and
Uncertainty. Australian Social Work, 71(3), 306–318.
https://doi-org.proxy-
library.ashford.edu/10.1080/0312407X.2018.1448093
Bowman, L. G., Hardesty, S. L., Sigurdsson, S. O., McIvor, M.,
Orchowitz, P. M., Wagner, L. L., & Hagopian, L. P. (2019).
Utilizing group-based contingencies to increase hand washing in
a large human service setting. Behavior Analysis in
Practice, 12(3), 600–611. https://doi-org.proxy-
library.ashford.edu/10.1007/s40617-018-00328-z
Maier, C. T. (2016). Beyond Branding: Van Riel and Fombrun’s
Corporate Communication Theory in the Human Services
Sector. Qualitative Research Reports in Communication, 17(1),
27–35. https://doi-org.proxy-
library.ashford.edu/10.1080/17459435.2015.1088892
Ricciardi, J. N., Rothschild, A. W., Driscoll, N. M., Crawley, J.,
Wanganga, J., Fofanah, D. A., & Luiselli, J. K. (2020). Social
validity assessment of behavior data recording among human
services care providers. Behavioral Interventions, 35(3), 458–
466. https://doi-org.proxy-library.ashford.edu/10.1002/bin.1730
Jaramillo, E. T., Willging, C. E., Green, A. E., Gunderson, L.
M., Fettes, D. L., & Aarons, G. A. (2019). “Creative financing”:
Funding evidence-based interventions in human service
systems. The Journal of Behavioral Health Services &

Research, 46(3), 366–383. https://doi-org.proxy-
library.ashford.edu/10.1007/s11414-018-9644-5
Alicea, C. C. M., & Johnson, R. E. (2021). Creating Community
Through Affinity Groups for Minority Students in
Communication Sciences and Disorders. American Journal of
Speech-Language Pathology, 30(9), 2028–2031.
Prince, J. D., Mora-Lett, O., Lalayants, M., & Brown, A.
(2021). Wanna grab some dinner? Social relations between
helping professionals and members of community mental health
or other human service organizations. American Journal of
Orthopsychiatry, 91(4), 545–557. https://doi-org.proxy-
library.ashford.edu/10.1037/ort0000552.supp (Supplemental)
The Experiences of Human Service Managers in Contexts of
Change and Uncertainty
Lynelle Wattsa, Michele Schoderb, and David Hodgsona
aSchool of Arts and Humanities, Edith Cowan University,
Bunbury, Western Australia, Australia; bSchool of
Business and Law, Edith Cowan University, Bunbury, Western
Australia, Australia
ABSTRACT
Against a background of rapid and widespread changes to the
delivery of human services and social welfare, this paper
reports
on a study into the experiences of managers of human services
organisations. Within an interpretive methodology, the research
utilised focus group and interview methods to examine the
relevance and need for business, finance, and management skills
from the perspective of managers in the human services. Results

indicate that managers of human service organisations need
advanced business, management, and finance skills to deal with
change and uncertainty in contemporary and competitive service
environments.
IMPLICATIONS
. Human service organisations in Australia are subject to change
and uncertainty with new models of funding and increased
accountability.
. Social workers employed as managers are under pressure to
lead
sustainable and accountable services, while still holding to
social
work principles.
. Social workers who manage organisations face a challenge of
how to integrate business, management, and finance skills with
the values and mission of social work.
ARTICLE HISTORY
Received 19 July 2017
Accepted 27 November 2017
KEYWORDS
Social Work; Human Service
Organisations; Management;
Neoliberalism
This paper reports on a study into the practices of business,
management, and finance
skills in human service organisations (HSO) and situates these
within a context of rapid
and widespread changes to the delivery of human services and
social welfare. Human

service workers employed as managers are required to possess
and demonstrate business
skills and knowledge in their work in managing and
coordinating human services. This
impetus has been building for some time, as many public and
not-for-profit services
were forecasted for privatisation as far back as the early 1990s
(O’Connor & Sacco,
1993) and have since then undergone significant change under
the weight of new
public management (NPM) (Webber, 2013) and market models
in public and not-for-
profit institutions (Berands & Crinall, 2014). HSOs operate in a
competitive and increas-
ingly accountable practice environment (Connell, Fawcett, &
Meagher, 2009). What this
© 2018 Australian Association of Social Workers
CONTACT David Hodgson [email protected] Senior Lecturer,
School of Arts and Humanities, Edith Cowan
University, South West Campus, Robertson Drive, Bunbury,
WA 6230, Australia
AUSTRALIAN SOCIAL WORK
2018, VOL. 71, NO. 3, 306–318
https://doi.org/10.1080/0312407X.2018.1448093
means for workers with a professional background in clinical
practice entering into man-
agement and leadership roles is only recently being examined.
The research aim was to understand the role of business,
finance, and management

skills and knowledge in the delivery and management of HSOs
from the perspective of
a sample of managers from the South West region of Western
Australia, who have a
prior background in direct practice with service users. The
research question was: What
business, financial, and management skills and knowledge are
relevant in human
service management practice?
Contexts of Change and Uncertainty
Welfare states encompass “ … education, health care, income
maintenance, housing, and
personal care” (Hills, 2011, p. 590). It is common to discuss
welfare as a mixed economy
that has four different sectors: public (government institutions),
commercial (for-profit
enterprises), not-for-profit (charities, self-help groups, faith
groups), and informal
(friends, families, households) (Brejning, 2016). Many human
services in Australia are
delivered “at arm’s length [from government] … through largely
autonomous and infor-
mal charities” (Murphy, 2006, p. 449), while employment and
wage arbitration are the
main mechanism for delivering universal welfare benefits.
However, the welfare states of many countries have undergone
substantial and contin-
ual changes over the last 40 years (Healy, 2002), which has
been ascribed to the adoption
of neoliberalism (Connell et al., 2009) and its impact on service
provision and pro-
fessionals within these systems (Wallace & Pease, 2011).
Connell et al. (2009) described

neoliberalism as “the project of economic and social
transformation under the sign of
the free market” (p. 331). All welfare states across the world
bear the brunt of a neoliberal
market economy that impacts national options for the
arrangement and delivery of ser-
vices (Esping-Andersen, 1996; Evans, 2011), such as:
reductions in tax; defunding of
social programs, particularly universal programs; and, shifting
responsibility for welfare
service delivery to nongovernment organisations (Abramovitz &
Zelnick, 2015). The
result has been that the welfare states of many countries have
witnessed a diminished
funding environment from government, putting pressure on
already scarce resources
(Abramovitz & Zelnick, 2015; Germak, 2015).
In Australia, this represented a marked change that began as
early as the 1970s
(Murphy, 2010) and social workers and services have been
grappling with these
changes since. These arrangements changed further with the
opening up of the Australian
economy in the 1980s leading to deregulation and downward
pressure on wages (Capling,
Considine, & Crozier, 1998; Murphy, 2006). Government
involvement in welfare delivery
(through funding) and noninvolvement (through contracting and
outsourcing to not-for-
profit providers) significantly changed the Australian welfare
landscape (Wright, Marston,
& McDonald, 2011).
Acknowledging the operating differences between the private
and public sector gave

rise to the term new public management (Healy, 2009). With
NPM came the adoption
of practices from business to the human service sector,
heralding a “shift from confor-
mance to performance” (Seden, Matthews, McCormick, &
Morgan, 2010, p. 18). The
adoption of neoliberalism led to the widespread economisation
of social life, where the
boundaries between state and private capital interests have
blurred (Whitehead &
AUSTRALIAN SOCIAL WORK 307
Crawshaw, 2014, p. 28). A generally accepted concept of
neoliberalism as antithetical to
the development of a well-resourced and functioning social
service sector poses significant
challenges for social workers who may seek to creatively resist
its impact on social and
economic life (Gray, Dean, Agllias, Howard, & Schubert, 2015).
Social workers inhabiting
these “operating spaces” (Whitehead & Crawshaw, 2014, p. 28)
often find themselves in
relationships characterised more by commodification than
ethics. Whitehead and
Crawshaw (2014, p. 29) suggested that “What is being played
out and affecting the
social and moral substance of organisational existence is the
transference of legitimate
power from the public sphere into a marketised private domain
where capital is the
driving force of change”. Marketisation is “the political and
socio-economic process
whereby whole areas of social life that were once kept beyond

the reach of the market
by governments have been opened up to market forces” (Wilson,
Ruch, Lymbery, &
Cooper, 2008 cited in Lawler & Bilson, 2010, p. 12). The effect
of these changes is that
the Australian welfare sector has had to engage—albeit with
reluctance and some resist-
ance—the influence of business management practices in the
human services.
By the 2000s this trend was well underway in Australia’s mixed
welfare economy with
the growing emergence of profit-motivated enterprises into what
was traditionally a pro-
tected not-for-profit sector. The welfare sector experienced
increasing government budget
rationalisation, changes in funding models, and aggressive
competition from new profit-
motivated businesses occurring in the context of an ageing and
predominately female
workforce (Fitzgerald, Rainnie, Goods, & Morris, 2014; Healy
& Lonne, 2010). More
recent changes include the prevalence of user-pays models of
service, and social entrepre-
neurialism. Berzin (2012) noted that these models emerge from
closer relationships
between business and social policy, pointing out that while
impacted, social work is
largely absent from shaping this development. Yet, Germak and
Singh (2009) argued
that social work is in a unique position to pursue a “hybrid of
social work macro practice
principles and business innovation activities” (p. 79). Dees and
Anderson (2003, p. 16)
contend that there is significant “sector-bending”, which blurs
the lines between commer-

cial, government, and non-profit enterprises and organisations.
In summary, business
acumen has become increasingly important to human services
managers across the sector.
Human Service Organisations
Given the mixed nature of the sector, it is important to define
the kinds of organisations
that are in focus here. Hughes and Wearing (2013) suggested
that human service organ-
isations (HSOs) are typically organised to meet human needs,
based in values and morals
about what is good and right, authorised by social policies, and
measured in relation to
interactions between “service users and workers” (p. 14). The
Australian human services
workforce is diverse in terms of profession and levels of
qualifications, because the welfare
sector is largely self-regulated, and in some areas unregulated
with regard to qualifications.
Social work, for example, represents a significant profession
within the welfare state
because it is one of only three distinctly human service
professions that require tertiary
qualifications (Healy & Lonne, 2010).
As the welfare sector has had to adapt to the changing
environment, so too have human
service workers and managers, who are experiencing an
increasing need to adapt to
business practices in order to compete for funding against
commercial for-profit
308 L. WATTS ET AL.

enterprises (Germak & Singh, 2009). It is not uncommon for
social work managers to be
recruited from practice roles, yet uncommon for managers to
have undertaken formal
postgraduate training in business. In light of this, recent
research has begun to explore
the transition of practicing social workers into management.
Knee (2014) found that
social workers who move to management roles face
considerable challenges in transition-
ing to new roles, such as integrating new perspectives,
responsibilities, and skills. Hurst
and Hurst (2017) contend that such transitions demand a
“paradigm shift” (p. 438) to
a different mindset, somewhat removed from the familiar
routines of direct practice.
Others (Austin, Regan, Gothard, & Carnochan, 2013) proposed
a conceptual model for
developing a management and leadership identity, one that
implies considerable identity
work as well as skills development and ongoing reflection and
learning.
Yet, business and management concepts and social
administration rarely feature in a
meaningful way in social work curricula (Gilliam, Chandler, Al -
Hajjaj, Mooney, &
Vakalahi, 2016). Goldkind and Pardasani (2013) suggest that as
the need for social
workers with these skills has become more urgent, the numbers
of students who
express an interest in careers in social administration has fallen.
Promoting from within
the field can be difficult due to a lack of investment in

succession planning as well as
the “high level of burnout among supervisory and case
management social workers”
(Gilliam et al., 2017, p. 334). There is also the question of
whether the practice skills of
human services professionals, including social workers, is
sufficient for general leadership
and managerial purposes (Shanks, Lundström, & Bergmark,
2014). It is from within this
context that this study is situated.
Methodology
This is an exploratory and interpretive study (Blaikie, 2004)
that explores the experiences
of human services managers about the role of business, finance,
and management skills
and knowledge in their practice. Theoretically, the study is
placed within a symbolic inter-
actionist perspective. It was guided by Blumer’s notions of
exploration and inspection
(Williams, 2008) and included different but overlapping stages.
Exploration refers to
the development of familiarity with the topic at hand (Williams,
2008). Familiarity was
developed through a number of activities. As a research team
we utilised reflexive discus-
sion (Gilmore & Kenny, 2015) to explore the different
disciplinary knowledges of the
topic. This was important as the research team was made up of
researchers from both
social work and business disciplines. Second, we engaged with
literatures from business
and social work to build familiarity with ways to conceptualise
business, management,
and finance skills and knowledge in the human services. Third,

we recruited six partici-
pants from the human services sector to participate in a single
focus group.
Participants in the focus group were asked to discuss and
exchange views on the three
key concepts in the research question (i.e., business, finance,
management). They were also
asked to identify and describe what skills and knowledge are
indicated in these areas, and
second, explore the reasons or contextual drivers for these in
their practice and in their
organisations. This resulted in data that produced a descriptive
account of certain skills
and knowledge domains, but also some critical commentary on
the nature and context
of HSOs generally, such as current tensions, complexities, and
uncertainties in practice.
Three of these participants completed a follow-up interview on
the basis that they had
expressed particular views considered by the research team as
warranting further explora-
tion. Given the small sample, the scope of the study is
necessarily exploratory, seeking to
identify key concepts and points of relevancy that could inform
the basis of larger studies.
Participants
Participants were recruited through the networks of the research
team based on predeter-

mined criteria (Emmel, 2013). These criteria included:
(1) Participants to be employed in an HSO that provides
community and social services.
HSOs may include government, nongovernment, not-for-profit,
and private practice.
(2) Participants to be employed in a management or leadership
role where they have sig-
nificant responsibility for the organisation’s operations.
Examples include director,
CEO, coordinator, or manager.
(3) All participants to have at least 5 years professional
background working in HSOs in
social work, welfare, community work, counselling, or
equivalent roles.
The study had institutional university ethics approval and
participants gave their
consent to participate in writing. Six participants were recruited
for the focus group,
which was recorded and transcribed. Three individual
unstructured qualitative interviews
were undertaken with participants who had participated in the
focus group. The inter-
views averaged 45 minutes and were transcribed. The six—four
male and two female—
participants represented nongovernment, government, not-for-
profit, and for-profit
organisations. Participants from the sample were (1) CEO (large
NGO), (2) operations
manager (government department), (3) team leader (large NGO),
(4) private practitioner
(manager of private practice), (5 and 6) site managers (from
different multisite NGOs).

The minimum qualification held by participants was a
bachelor’s degree; three of the par-
ticipants had a masters qualification. Four were social work
qualified and two held quali-
fications in a cognate discipline (psychology and theology).
Data Analysis: Inspection
The second aspect of Blumer’s (Williams, 2008, p. 6) phases
involves inspection of data
collected during the exploration phase. Data included notes
from meetings between the
research team, transcripts of interview data, and spreadsheets
used for coding. All
members of the research team were included in the exploration
and inspection phases
of the research.
Definitions for business, management, and finance were
established as part of the
exploration phase. Business skills were defined as knowledge
aimed at the allocation of
resources to achieve specific outcomes for an enterprise
(Branagan, 2009). These
include strategy, using delegations and authority, sourcing
funding, networking, and col-
laborating. Management refers to the attainment of
organisational goals through: plan-
ning, organising, leading and controlling organisational
resources (Samson & Daft,
2015). Finance skills are defined as the “art and science of
managing money” (Gitman,
Juchau, & Jack, 2011, p. 4). This includes making decisions
about money and understand-
ing and tracking cash flow and its relation to organisational
objectives.

310 L. WATTS ET AL.
Data analysis proceeded with each team member reading and
undertaking open coding
(Saldaña, 2012) with the transcripts of the focus group and
interviews. The resulting open
codes were discussed by the research team. Notes were taken of
this discussion and agree-
ment was reached on the focus for a second cycle of coding,
which included coding for
business, management, and finance skills directly. Two team
members coded the
second stage under these categories and then the whole team
met again to discuss the
results. The results of the analysis are reported below.
Findings and Discussion
We’re about to undergo some of the most significant changes in
the human services in the
next 5 years with the introduction of large for profit [services].
(Comment from focus group)
Bring out any graduate of any human services course that is
business savvy, they’re going to
be in demand. (Comment from focus group)
This section summarises the results by highlighting the skills
that participants reported on
when asked about business, management, and finance in the
context of their management
roles in HSOs. Key skills identified as codes from the data are
presented in Table 1.

Participants went beyond reporting on the skills in Table 1 and
provided information
that contextualised these in relation to their work. A summary
of the reasons for the skills
and the context that drives them are outlined below. The results
and discussion are organ-
ised under the three main concepts of this study and we consider
the implications in
relation to other literature.
Business
When asked about what business means in relation to their work
and their roles, partici-
pants articulated the need to build and maintain effective and
well-functioning services.
This idea relates back to the concept of business discussed
earlier, which concerns orien-
tating efforts and resources towards achieving specific
outcomes. In this respect, the
business impetus here is not so much to create profit, but to
meet increasing levels of
Table 1 Concepts of Business, Management and Finance Skills
Business Management Finance
Strategic thinking, vision, developing
new services
People skills, communication, conflict
resolution
Understanding the funding
environment

Tender writing, procurement Self-awareness (reflection)
Financial planning
Understanding governance, legislation Emotional intelligence,
social
intelligence
Generating and managing financial
resources
Working with boards and committees Recruitment skills, staff
development
and training
Developing and managing budgets
Due diligence, delegations, proper
process
OSH knowledge Connecting budgets to strategic
purposes
Marketing, networking, collaboration Time management
Utilising others’ expertise (finance,
administration)
IT skills
Flexibility, creativity, adaptability, open-
mindedness
Managing change
Leadership and innovation

accountability and to foster organisational functionality,
including financial sustainability
(Jones & Mucha, 2014) and meeting accreditation standards
(Carman & Fredericks, 2013).
Business skills translated to an HSO context include strategic
thinking, creating and
pursuing a coherent vision, and developing new services and
new initiatives. Relatedly,
marketing skills, networking, and collaboration with other
services and stakeholders
were argued as necessary for developing a service focus, and for
maintaining a sustainable
enterprise in an increasingly competitive environment. For
example:
… you’ve also got to understand marketing and work out “what
sort of marketing strategy
am I going to have, what sort of communication channels am I
going to push, what sort
of services am I going to develop and who am I going to target
these services to and
what’s a price point for these particular services?” (Comment
from focus group)
The participants noted that a business focus meant skills in
“good governance” and an
ability to “interpret and apply relevant legislation” to the
management and development of
services. For example:
… once you start to move into leadership positions, you need to
be able to understand
business. You need to be able to understand the legal IR
[industrial relations] implications
in a way we’ve never had to face before. (Interview participant)

At an applied level, this requires abilities to work with Boards
and Committees, and to
exercise due diligence in following delegations and procedural
accountability. The latter
was deemed particularly important for human resources (HR)
demands that arise from
increased casualisation and short-term employment churn. The
working life of a social
worker seems to be shorter than other health professions
(Curtis, Moriarty, & Netten,
2010), and supporting newly qualified workers is essential for
promoting “job satisfaction
and workforce retention” (Healy, Harrison, & Foster, 2015, p.
8). Hence, in a context of
workforce change, skills in managing staff recruitment,
retention, and turnover are needed.
Participants also outlined why these business skills are
demanded of human service
workers in management roles. The rationale concerned the need
to be more adaptable,
flexible, and responsive to widespread and far reaching changes
in the funding and
policy environment due to continual uncertainty and change.
These changes are the
result of the marketisation of the welfare state (Rainnie,
Fitzgerald, Gilchrist, & Morris,
2012; Spies-Butcher, 2014), which includes increasing targeted
eligibility testing
(Garthwaite, Bambra, Warren, Kasim, & Greig, 2014), the
transformative influence of neo-
liberalism on the state (Spies-Butcher, 2014), and the space–
time compression of late
modernity (Hughes & Wearing, 2013, p. 51). Participants spoke
of the pressure to gain

a competitive edge just to maintain financial viability and
sustainability of their services
and organisations. Further background to this is increased
competition, dwindling
resources, and increased levels of accountability from funding
entities. This includes out-
sourcing (Rainnie et al., 2012) and the push for not-for-profit
organisations to become
more businesslike (Considine, O’Sullivan, & Nguyen, 2014).
Management
When asked about management, participants framed their
responses in terms of “people
skills”, such as excellence in communication, conflict
resolution, and leadership to effec-
tively manage workplace conflict and grievances—including
managing the many
312 L. WATTS ET AL.
industrial problems that are generated by a casualised
workforce. Relatedly, participants
outlined the place of social and emotional intelligence, self-
awareness, and reflection
(Lawler & Bilson, 2010) as comprising subsets to
communication and management
skills. Reflective practice (Fook & Gardner, 2007) and social
and emotional intelligence
(Morrison, 2007) are attracting increasing interest in the social
work and organisational
and leadership literature (Cherniss, 2010). One interview
participant commented, “I see
that in myself or managers around the organisation and the ones

who actually have
that ability to self-reflect … so the ones who have higher
emotional intelligence or self-
awareness are much better managers”.
Participants reported that good management demands
knowledge and skills in the
areas of “occupational health and safety”, “information
technology”, and “time manage-
ment”. Furthermore, management requires knowledge and skills
in “staff recruitment”,
and “staff development” and “training”.
It was clear that there was pressure to “manage change,
complexity and uncertainty”.
For example, “ … it’s so turbulent though and we predict very
turbulent times through
maybe the next 5 maybe, 10 years. So if our staff can learn
anything it’s around change
management” (comment from focus group).
Lawler and Bilson (2010) argued that services are under
pressure to cope with the
uncertainty that is an artefact of widespread organisational
transformation amidst the
coalescing of “public services and private, corporate,
commercial and third sector inter-
ests” (Whitehead & Crawshaw, 2014, p. 26). Hence, the ability
to be flexible, creative,
adaptable, and open-minded was also reported by participants as
necessary requisites
for good management.
Change and uncertainty places demands on managers and
leaders to build a positive,
optimistic, and functioning work culture and climate

(Schneider, Ehrhart, & MacEy,
2013). Change also requires managers to develop effective and
well-functioning systems
to meet the demands for sustainability and viability. The
context of change was a key
force that necessitated strong communication, management, and
people skills and was a
significant theme overall.
Finance
Finance concerns making decisions about money and resources.
It was clear that questions
concerning finance exercises considerable mental energy of
HSO managers. This is
because financial management and accountability occupies a
substantial place in the
market models underpinning the operations of modern HSOs
(Rainnie et al., 2012). At
the same time, participants reported that they were neither
trained nor adequately pre-
pared for what would be demanded of them in comprehending
and responding to finan-
cial matters in their roles, “ … it’s a massive part of the job,
financial management, and I
have to admit I had no skills coming into it” (comment from
focus group).
Healy (2002) noted that social workers may be excluded from
occupying management
positions, which is “of concern because it compromises their
capacity to exercise pro-
fessional leadership and decision-making in the organizations
that employ them”
(p. 528). Yet, many HSO workers—including social workers—
receive little financial man-

agement training in their foundational education. Participants
had clear views on what
financial skills and knowledge are required of managers in
HSOs, saying that they
should at least know how to “develop, read and manage a
budget”. It was reported that
although HSO managers may utilise the financial expertise of
others, they still need finan-
cial literacy if they are to action critical financial decisions .
Participants contended that
HSO managers need to be able to “connect budgets and resource
allocation to strategic
and operational imperatives”, and engage in concerted
“financial planning”—the latter
of which demands skills in “understanding the funding
environment”. An interview par-
ticipant said, “ … in this role you wouldn’t be able to operate if
you were really not looking
at the bigger organisation and where it sits within a political
context and a financial
context.”
Sectoral change, funding uncertainty, and high levels of
governmental accountability
for fiscal reporting were seen as substantial drivers for well -
developed financial skills in
HSO management and leadership. This need for skills in
budgeting has been recognised
by the Network for Social Work Managers and the Council on
Social Work Education
(CSWE) (Gilliam et al., 2017). The move towards market-based

funding models and
increasing competition for scarce resources is said to drive
imperatives towards organis-
ational efficiency and financial sustainability (Fitzgerald et al.,
2014; Rainnie et al.,
2012). Participants noted the importance of developing an asset
and financial base that
may be protective during funding shortfalls or changes in policy
from different govern-
ment and social service priorities. For example:
… we’ll get paid on delivery, we’ll get paid on outcome, and it
was said probably 18 to 24
months ago that your best friend in a community organisation is
going to be your bank
manager, because you’re going to be highly reliant on lines of
credit, or you’re going to be
looking for for-profits or entities who are going to invest on a
guarantee of return. (Interview
participant)
This imperative towards asset building and financial surety
requires a depth of financial
modelling and planning. This responsibility tends to sit within a
relationship amongst
managers, …
RESEARCH ARTICLE
Utilizing Group-Based Contingencies to Increase Hand Washing
in a Large Human Service Setting
Lynn G. Bowman1,2 & Samantha L. Hardesty1,3 & Sigurdur O.
Sigurdsson3 & Melissa McIvor1 & Phillip M. Orchowitz1 &

Leaora L. Wagner1 & Louis P. Hagopian1,2
Published online: 23 January 2019
# Association for Behavior Analysis International 2019
Abstract
Hand washing is the most important preventative measure for
the reduction of contagious disease. Although hand washing is
easy
to perform, non-adherence is a ubiquitous problem. Several
studies have demonstrated the effectiveness of multi-component
intervention packages to improve hand washing among
employees; however, interventions are limited to acute settings,
are often
implemented for a short period of time, and rarely, if ever,
include information on long-term effectiveness. The purpose of
the
current study was to utilize a behavior analytic approach to
determine the stimulus conditions under which hand washing
should
occur, and to assess and then implement a long-term monitoring
system among direct care workers in a large, non-acute
inpatient
unit. A single-case repeated measures reversal design was used
to evaluate the effectiveness of two interventions aimed at
improving hand washing adherence. A lottery was found to be
effective in increasing hand hygiene for 2-years with 170 staff.
Keywords Hand washing . OBM . Lottery . Standard precautions
. Stimulus control
In human service and health care settings, the importance of
patient safety has received considerable attention, and one of
the highest priority goals set forth by the World Health
Organization (WHO) was to reduce hospital-acquired infections
(Gould, Drey, Moralejo, Grimshaw, & Chudleigh, 2008). Hand

washing is a relatively simple behavior to perform and is the
single most important preventative measure for the reduction of
contagious disease (Centers for Disease Control and Prevention
[CDC], 2016). A meta-analysis of the effects of hand hygiene
on infectious disease risk showed that improved hand-hygiene
resulted in decreased rates of gastrointestinal and respiratory
illnesses (Aiello, Coulbourn, Perez, & Larson, 2008). Despite
its importance, health care workers often fail to practice good
hand hygiene practices and adherence to best practice
guidelines
remain poor (e.g., Universal Precautions [UP] from
Occupational Safety and Health Administration [OSHA],
1999; Centers for Disease Control and Prevention, 2016; The
Joint Commission [TJC], 2009). A review of 96 empirical arti -
cles found the median adherence rate of healthcare workers to
be 40%, with lower adherence rates associated with high
activity
and those observations with which a physician was involved
(Erasmus et al., 2010). Given the importance of good hand
hygiene practices, and the consensus across studies that adher -
ence is poor, it is not surprising that hand hygiene continues to
be a focus of extensive research.
Antecedents for Hand Washing
Several studies have examined specific situations, sometimes
called indicators or critical antecedents that are likely to lead to
better hand hygiene practices in the absence of intervention
components. Across healthcare settings, antecedents identi-
fied by the CDC and WHO include: 1) before patient contact,
2) before starting an invasive procedure, 3) after contact with
blood, body fluids or excretions, mucous membranes, non-
intact skin, and wound dressings, 4) after removing gloves,
5) when moving from a contaminated patient body site to a
clean site during care, 6) after contact with inanimate objects

* Lynn G. Bowman
[email protected]
1 Neurobehavioral Unit, Kennedy Krieger Institute, 707 N.
Broadway,
Baltimore, MD 21205, USA
2 Johns Hopkins University School of Medicine, Baltimore,
MD, USA
3 University of Maryland, Baltimore County, Baltimore, MD,
USA
Behavior Analysis in Practice (2019) 12:600–611
https://doi.org/10.1007/s40617-018-00328-z
or medical equipment close to the patient, and 7) after patient
contact (TJC, 2009).
It is important to note that antecedents for hand hygiene are
likely to differ from setting to setting and that staff adherence
may differ across antecedents. This variation in setting and
across antecedents suggests the need for an individualized
approach to the measurement of hand washing. For
example, Raboud et al. (2004) observed hand washing in a
small group of nurses employed on a hospital unit and found
that nurses were more likely to wash their hands follow ing
high risk situations (e.g., contact with bodily fluid or patient
skin) than for other reasons (e.g., contact with equipment).
Creedon (2005) found that hand washing practices were better
prior to the initiation of an invasive procedure, and at the onse t
of patient care, while Mayer, Dubbert, Miller, Burkett, and
Chapman (1986) found adherence following patient contact
to be the highest. The identification of organizational-specific
antecedents can lead to a more targeted intervention, which is

ultimately more successful, efficient, and cost effective.
Although hand washing is an observable behavior amena-
ble to the principles of applied behavior analysis, most re-
search on this topic has been published in journals dedicated
to medical and infection control practices (e.g., American
Journal of Infection Control, Infection Control and Hospital
Epidemiology, American Journal of Public Health,
Epidemiology). Notable exceptions include a few small N
studies published in behavioral science journals (e.g.,
Journal of Organizational Behavior Management, Journal
of Applied Behavioral Analysis). There is some agreement
with respect to the effectiveness of certain intervention com-
ponents. Specifically, educational interventions were found to
have a very short-term influence on hand hygiene behavior
(Dubbert, Dolce, Richter, Miller, & Chapman, 1990), and the
use of strategically placed reminders, or prompts from patients
and staff, have had only a modest effect on hand hygiene
adherence (Khatib, Ghassan, Abdallah, & Ibrahim, 1999).
Arranging the environment to make hand washing easier
(e.g., automated sinks, moisturized soaps) led to minimal im-
provements (Larson et al., 1991). Feedback on performance
was found to be successful at increasing hand washing, but if
delivered intermittently the effect was not maintained over -
time (Conly, Hill, Ross, Lertzman, & Louie, 1989; Mayer
et al., 1986). Multi-component approaches which combined
education with written materials, reminders, and continued
feedback seemed to have the most impact on good hand hy-
giene practices (Naikoba & Hayward, 2001).
Feedback is an effective and frequently used intervention in
the field of Organizational Behavior Management (OBM)
(VanStelle et al., 2012). With respect to increasing hand hy-
giene behaviors, various types of feedback were found to be
effective. DeVries, Burnette, and Redmon (1991) improved
glove usage among nurses using bi-weekly feedback sessions

consisting of goal setting and graphic feedback. Babcock,
Sulzer-Azaroff, and Sanderson (1992) improved the feedback
of hand hygiene practices by supervisory nurses with training,
weekly feedback meetings with goal setting, and letters of
recognition. Stephens and Ludwig (2005) found training, set-
ting group goals, and posting individualized-graphic feedback
effective at improving nurses’ adherence to UP. Finally, Luke
and Alavosius (2011) demonstrated the effectiveness of per -
sonalized performance feedback consisting of a combination
of verbal and written feedback across 3 health-care workers
and improvement maintained for several months following
the intervention.
Although performance feedback has been demonstrated to
be effective, there are limitations to the long-term implemen-
tation of such components, particularly for a behavior that
needs to occur with such frequency as hand washing. For
example, the training, time, and resources necessary to sustain
individualized-level performance feedback systems are likely
to be too cumbersome for most facilities to implement. For
example, Luke and Alavosius (2011) estimated that it took
approximately 250-man hours over 6 months to create mate-
rials, complete observer training, conduct observations, and
provide feedback for only 3 participants. Implementing a sim-
ilar program across more individuals, or within in a large
facility, may not be feasible.
Despite the effective strategies identified within these
multi-component hand hygiene programs, several gaps con-
tinue to exist within both behavioral and non-behavioral liter-
ature. First, little is known regarding the maintenance or long-
term effectiveness of multi-component, hospital-wide pro-
grams as follow-up data are rarely, if ever published.
Secondly, although frequent feedback (delivered either verbal -
ly, graphically, or a combination of the two) has been found to

be effective, little to no discussion has been made regarding
the resources (time, personnel, or associated costs) needed to
implement such a program, especially in large human service
settings. Interventions that are equally or more effective as
frequent feedback, as well as those that require fewer re-
sources and maintain over time, are needed.
A lottery system can provide an organization with the abil -
ity to provide reinforcers (monetary or non-monetary) on a
lean schedule of reinforcement without deleterious effects on
the intervention. Mayer et al. (2011) evaluated the use of a
multi-component intervention that included 1) in-service pre-
sentations, 2) one-on-one discussions with staff, 3) convenient
positioning of soap dispensers and sanitizers, 4) the formation
of a hand hygiene committee that monitored progress, and
who generated catchy ideas for posters, jingles, and motiva-
tors, and 5) delivery of motivators identified by a committee
paired with feedback on hand hygiene practices. Specifically,
feedback and reinforcement components were embedded
within a series of programs in which employees, trained as
hand hygiene monitors, “caught (hand washers) in the act” pg.
61 and immediately distributed incentives (i.e., chocolate bars,
Behav Analysis Practice (2019) 12:600–611 601
pizza party, and entry into monthly drawings) to those staff
observed washing their hands following identified anteced-
ents. The authors noted long-term and sustained improve-
ments in hand washing practices following this program.
However, a component analysis was not conducted to deter-
mine which intervention(s) were responsible for hand washing
improvement, and there was a lack of sufficient detail on how
incentives were identified, how frequently incentives needed
to be delivered to maintain effects, and whether or not hand

washing occurred in the absence of monitoring. Although
Mayer et al. (2011) did not describe the incentive component
in these terms, entry into a drawing is analogous to a lottery.
Although incentives and lottery systems are not frequently
used in organizational settings (notable exceptions include
Iwata, Bailey, Brown, Foshee, & Alpern, 1976; Luiselli
et al., 2009 and Miller, Carlson, & Sigurdsson, 2014), they
have been shown to be a low-cost option for motivating be-
havior of individuals in large participant pools.
The purpose of the current study was to extend the research
on hand hygiene practices by implementing a long-term mon-
itoring system on hand washing adherence among direct care
workers in a large, non-acute human service setting. Hand
washing adherence was measured following antecedents
outlined in hospital policies, and based on those results, a
lottery system was implemented to increase and sustain hand
washing for almost two years. In addition, the effects of ob-
server presence and observer absence on hand washing adher -
ence was measured.
Method
Participants and Setting
Participants included approximately 170 direct care staff (full -
time and part-time) employed on a 16-bed inpatient unit with-
in a rehabilitation hospital from September 2009 through
August 2011. A minimum requirement for this position was
a high-school diploma or equivalent (i.e., GED); though most
staff had some college (some college or bachelor’s degree,
85%; working on graduate degree, 6%; unknown or no col-
lege, 9%). The inpatient unit provided services to children and
young adults diagnosed with an intellectual and developmen-
tal disability (IDD) who exhibited severe behavioral prob-
lems. Patients resided on the unit for approximately 4-5

months, and the unit functioned more like a school/home en-
vironment than a typical hospital environment as the patients
were not physically ill, but rather were admitted due to a
severe behavior disorder. Patient behavioral intensity necessi -
tated a minimum of one-to-one direct care staffing during all
waking hours and staff worked day shifts (7:00 a.m. to 3:30
p.m.), evening shifts (3:00 p.m. to 11:30 p.m.), and night shifts
(11:00 p.m. to 9:00 a.m.). Many other employees entered the
unit during the day as well (e.g., nursing staff, supervisors,
behavioral treatment teams, faculty, physicians, etc.), and it
was not uncommon for approximately 120-150 staff to visit
the unit on any given day. However, data were only collected
on hand washing adherence of the direct care staff.
The inpatient unit was approximately 6,000 square feet
(557.42 m2). It consisted of one large open room and two
smaller, classroom-sized rooms. These common areas were
connected by a long hallway that was lined with 4 bedrooms
and 4 bathrooms. Unit supervisors had an office at the main
entrance of the unit. Direct care staff and patient dyads were
not permitted in bedrooms outside patient scheduled sleep
times, unless otherwise indicated in the behavioral plan (i.e.,
behavioral safety or medical need for isolation). In the large
common area there were enough couches, tables, and chairs to
accommodate most staff and patients. To facilitate hand wash-
ing, 10 sanitizer dispensers and 9 sinks with soap dispensers
were on the unit and were predominately located in the hall -
way and the common areas.
Procedure
A single-case repeated measures reversal design (ABCAC)
was used to evaluate the effectiveness of two interventi ons
aimed at improving hand washing adherence. Prior to baseline
and throughout the study, a traditional hospital-wide hand

hygiene campaign was in place. This program consisted of
annual competencies related to good hand hygiene practices
and posters reminding staff to “wash your hands” strategically
placed in the hospital (e.g., in bathrooms, on elevators).
During staff orientation on the inpatient unit, staff received
additional training on the importance of hand hygiene, ante-
cedents when hand washing was necessary, and staff respon-
sible for training new employees modeled appropriate hand
hygiene behavior.
Dependent Variable and Measurement
Data were collected by trained observers on staff adherence
with hand hygiene. Hand hygiene adherence was defined as:
1) using sanitizer (wall-mounted or portable), or 2) using soap
and water to wash hands. Five antecedents of hand washing
were identified based on hospital infection control policy prior
to the start of data collection, and hand washing adherence
was only monitored and documented following one of the
identified antecedents. Critical antecedents included: 1) enter -
ing the unit, 2) exiting the unit, 3) patient-to-patient contact
(before making contact with a new patient if contact was pre-
viously made with another patient), 4) after taking a patient to
the bathroom, and 5) before providing a patient with his or her
meal. During some antecedents (e.g., taking a patient to the
bathroom) staff was required to wear gloves; however, they
602 Behav Analysis Practice (2019) 12:600–611
were still required to wash their hands following glove
removal.
Codes were created on the data sheet to indicate the type of
hand washing observed (sanitizer, soap and water, portable

sanitizer, or none), and which of the 5 critical antecedents
was observed. If hand washing occurred within 3-5 s of one
of the antecedents, or before another antecedent occurred
(whichever came first), the staff person was scored as adhering
to hygiene policy (and specific type recorded). If hand wash-
ing did not occur, “none” was recorded. Given the large num-
ber of direct care staff that could potentially be observed dur -
ing an observation period, data were aggregated across obser -
vations of employees, and the percentage of adherence was
calculated by dividing the number of observations where ad-
herence was observed by the total number of observations
during each observation period. In addition, covert data col -
lectors recorded whether a supervisor associated with the lot-
tery program was within eyesight of an employee who en-
gaged in hand washing (supervisor present) or not within eye-
sight (supervisor absent).
Data were collected during planned observation periods
conducted at variable times and locations on the unit between
the hours of 7:30 a.m. and 10:30 p.m. Observation periods
ranged from approximately 15 min in duration to a maximum
of one hour. Data were only included if the data collector(s)
observed five or more critical antecedents within an observa-
tion period. On average, 10.22 critical antecedents were
scored (range 5–37 critical antecedents) per observation
period.
Observation Procedure Throughout the study, overt and co-
vert data monitoring was conducted on hand washing adher-
ence. During overt observation periods, data were collected by
one (or two when reliability data were collected) of three
trained observers, all of whom were supervisors of the direct
care staff. During these observations, the supervisors walked
around the hospital unit holding clipboards while collecting
data on direct care staff’s hand hygiene. During covert obser -
vation periods, data were collected by one (or two when reli -

ability data were collected) of four trained observers who were
not supervisory staff. Covert data collectors discretel y collect-
ed data while they were seemingly performing an assigned
task on the unit (e.g., interacting with a patient, replacing unit
materials, reviewing protocol changes, cleaning, and helping
with patients). Probably due to the large number of employees
on the unit at any given time, there was no indication that
direct care staff were aware that their hand hygiene behavior
was being observed covertly. During covert monitoring obser -
vations, supervisors who conducted overt data collection were
purposefully not present on the unit.
Because of the physical layout of the unit (a straight, wide
hallway lined with sinks and sanitizers connecting three large
common areas), all data collectors (overt and covert) were
easily able to view each other as well as observe the hand
washing behavior of multiple staff, often simultaneously.
Reliability Observations For both overt and covert observa-
tions, two observers made independent and simultaneous re-
cordings of hand washing across critical antecedent condi -
tions. To ensure data were collected on the same employee,
observers discretely signaled to each other (e.g., made eye
contact, nodded, or gestured) to indicate the onset of an ob-
servation. These observations were compared to establish ob-
servation reliability. Agreement was scored if both observers
denoted the: 1) same type of adherence or “none”, 2) the same
critical antecedent observed, 3) for the same individual and the
same observation time, 4) and whether the supervisor was
present or absent. A percentage was then calculated by divid-
ing the total number of observations in which agreement was
achieved by the total number of observations. Due to sched-
uling conflicts among the overt data collectors and many ob-
servations resulting in no data recorded (given five or more
critical antecedents were not observed), total reliability was

assessed for only 19% of overt observations and 26% of co-
vert observations. Agreement averaged 93% for hand hygiene
adherence (across all types of antecedents) during overt ob-
servations and 99% during covert observations.
Critical Antecedent Analysis It was hypothesized by the au-
thors that hand washing was likely to occur more often fol -
lowing some critical antecedents (e.g., after assisting a patient
in the bathroom) than following others (e.g., entering the unit).
Therefore, an analysis was conducted to measure adherence
following each critical antecedent. In total, 280 observations
were conducted across all antecedent conditions. All critical
antecedent analysis observations were conducted by the overt
data collectors. The purpose of this analysis was to inform
intervention planning. Standard hospital and unit practices
were in place during this phase as well as all subsequent
phases. In addition, prior to collecting data on hand washing,
a memo was read at all shift changes to direct care staff
reminding them of the importance of hand washing as well
as describing when staff should wash their hands.
Baseline Data obtained during the critical antecedent analysis
served as the initial baseline observations. During a return to
baseline phase, all direct care employees were informed by
memo that the lottery was no longer in effect. Staff was con-
gratulated for their improved hand hygiene adherence follow -
ing the critical antecedents. In addition, staff was encouraged
to keep up the good work and reminded of the critical ante-
cedents in which hand washing should occur.
Antecedent-Based Intervention The antecedent-based inter-
vention involved the provision of portable hand sanitizer bot-
tles to direct care staff. Bottles were distributed to staff during
Behav Analysis Practice (2019) 12:600–611 603

randomly assigned shifts. The purpose of this arrangement
was to compare hand washing adherence across shifts with
and without hand sanitizer bottles. This intervention was cho-
sen based on discussions with supervisory staff and anecdotal
observations made during the critical antecedent analysis. It
was hypothesized that staff was engaged in several competing
responsibilities (e.g., maintaining the safety of a difficult pa-
tient, holding data sheets and patient materials, etc.) that might
make walking to a sink or wall sanitizer cumbersome.
Portable bottles were selected in an effort to: 1) increase ac -
cessibility of a cleaning agent, 2) reduce response effort asso-
ciated with hand washing, and 3) help prompt staff to wash
their hands. The sanitizer bottles were 2 oz. (59.18 ml) and
clipped onto break-away lanyards that staff already wore.
Covert data collection began during this phase.
Group-Based Lottery Due to the large size of the participant
group, it was not feasible or economical to implement an
individualized reinforcement schedule for each staff member.
As an alternative, a lottery system was devised. To determine
lottery prizes, a survey was administered to all direct care staff.
On the survey, three monetary prizes were listed including $25
gift cards to local restaurants and stores (e.g., coffee, depart-
ment stores), as well as three non-monetary prizes (e.g.,
selecting a patient to work with for multiple shifts, choosing
break times, and being drawn to go home). Staff then ranked
prize preference for all six items. Results indicated the most
preferred item was a $25 gift card to popular department
store©. Two days prior to starting the lottery, a memo was
distributed to all staff describing the details of the lottery, a
reminder of the critical antecedents, what constituted adher -
ence with hand hygiene (i.e., using soap and water, or
sanitizers), and the rules associated with administration of
the lottery prize. Specifically, staff members were told 1) they

would be entered into the lottery drawing each time they were
observed washing their hands following a critical antecedent,
2) they could be entered into the lottery multiple times during
an observation, and 3) lottery drawings were to be conducted
on pre-determined, randomly selected shifts. Participants were
only entered into the lottery during overt observations.
During the initial lottery phase, drawings were randomly
scheduled to occur across the day shift, evening shift, and
night shift approximately every two monitoring periods (i.e.,
approximately once per week). Numbers were generated for
all lottery participants eligible for the prize, and one number
was randomly selected by a supervisor otherwise not involved
in the study. To ensure hand washing continued for the re-
mainder of the shift, drawings were conducted no more than
1 h prior to the end of the shift. One of the three overt data
collectors was responsible for announcing the winner (in the
presence of other co-workers), providing verbal praise to the
winner, and delivering the gift card. Throughout the lottery
phase, the memo detailing the procedures was read before
each shift. Current winners (those that won within the last
two weeks) were announced and congratulated during shift
changes, and names of recent winners were also posted on
the main hospital unit.
Following a return to baseline and while a steady trend of
hand washing was observed, the number of times the lottery
distribution schedule was reduced to approximately every
third monitoring period (i.e., approximately once every 2
weeks) to minimize costs.. All other procedures remained
the same. Overt and covert hand hygiene observations contin-
ued for 10 months. Overt observation data suggested that ad-
herence improved and that improvements were observed fol -
lowing each of the five critical antecedents. However, covert
observation data suggested that adherence had not improved

beyond baseline levels.
Generalization of Lottery To increase hand hygiene adherence
when overt data collectors were not present, 13-unit supervi-
sors who were routinely present on the unit across all 3 shifts
were recruited to hand out prizes for hand washing. During
this phase, data continued to be collected by the overt and
covert data collectors (to ensure integrity and to minimize
added duties); however, each of the 13 supervisors was sys-
tematically selected to participate in the drawing and trained
by one of the overt data collectors to provide verbal praise in
front of co-workers, and deliver gift cards to winners in the
same way the overt data collectors delivered gift cards.
Social Validity and Infection Control Data
A short treatment acceptability questionnaire was adminis-
tered to direct care staff following the antecedent-based inter-
vention assessing their acceptance of the portable hand
sanitizers. Within this survey, staff’s knowledge of critical
antecedents was also examined, and suggestions for additional
intervention strategies were requested (see Appendix).
Concurrent to this study, data were collected quarterly across
the entire hospital (including the inpatient unit) on staff hand
hygiene behavior by “secret shoppers” who served on the
hospital's Infection Control Advisory Board. It is important to
note that these personnel had no knowledge of the current study,
and the authors had no knowledge of the identity of the secret
shoppers. Data were summarized each quarter for the respective
units and were distributed via e-mail to administrators. When
indicated, administrators were urged to address adherence
issues
with their staff; however, no specific guidance was provided on
how to improve hand washing behavior.

Results
Figure 1 shows the percentage of opportunities with hand
hygiene adherence during observation periods across baseline,
604 Behav Analysis Practice (2019) 12:600–611
the antecedent-based intervention, and lottery phases. During
baseline, hand washing was low across all critical antecedents
(see Fig. 2), making it necessary to target all 5 antecedents.
Initiation of the antecedent-based intervention (portable hand
sanitizers) did not improve adherence. Hand washing in-
creased and remained high with the initiation of the group-
based lottery (consequent intervention) and remained high
during schedule thinning and generalization of lottery phases.
Baseline During the initial baseline phase, hand washing ad-
herence averaged 11% (range 0% to 25%). When the lottery
was removed during the return to baseline phase, levels of
hand washing adherence immediately returned to low levels
(M =15%, range 0% to 29%).
Antecedent-Based Intervention Hand washing adherence
remained low during shifts in which portable hand sanitizers
were distributed to staff (M= 17%, range 0% to 29%).
Group-Based Lottery Following the initiation of the lottery
(consequent intervention), hand washing adherence imme-
diately increased across all situations and remained high
(M = 63%, range 50% to 80%) throughout the initial
phase in which gift cards were distributed following ap-
proximately every 2 observations. Following the return to
baseline phase, the lottery was reinstated and hand wash-
ing adherence again increased (M =76%, range 50% to

100%). Hand washing adherence remained high, even
when the density of reinforcement was thinned from fol-
lowing approximately every 2 observations to following
approximately every 3 observations (M =72%, range 38%
to 100%).
Intervention Results Figure 3 depicts the averaged percentage
of opportunities with hand hygiene adherence across baseline,
the antecedent-based intervention, the overt observations from
the group-based lottery, and the covert observations (supervi -
sor absent and supervisor present). A total of 3097 observa-
tions of hand washing were observed throughout the study
(2332 overt and 765 covert observations). Data were aggre-
gated within each phase.
Figure 4 …
B R I E F R E P O R T
Social validity assessment of behavior data
recording among human services care providers
Joseph N. Ricciardi1 | Allison Weiss Rothschild2 |
Natalie M. Driscoll2 | Jillian Crawley2 | Joshua Wanganga2 |
David A. Fofanah2 | James K. Luiselli3
1Seven Hills NeuroCare, Worcester, MA, USA
2Seven Hills Community Services, Middleton,
MA, USA

3Melmark New England, Andover,
Massachusetts, USA
Correspondence
Joseph N. Ricciardi, PsyD,ABPP, BCBA-D,
CBISTAssistantVice President/Director of
Clinical Services, Seven Hills NeuroCare, 81
Hope Avenue, Worcester, MA 01603
Email:[email protected]
Care providers within human services organizations have
many job responsibilities and performance expectations. In
the present study, we conducted social validity assessment
with 78 care providers concerning their attitudes and opin-
ions about behavior data recording with adults who had
intellectual disability and lived in community group homes.
Specifically, the care providers responded to a written ques -
tionnaire that inquired about the practicality, training/
supervision, and value of behavior data recording in the
context of service delivery. Results indicated generally high

approval of behavior data recording practices, purposes,
and approaches to training. We discuss implications of
these findings for implementing data recording by care pro-
viders and the contribution of social validity assessment to
training and performance management within human ser-
vices organizations.
K E Y W O R D S
behavior data recording, care provider training, human services
organizations, performance management, social validity
1 | INTRODUCTION
Training and performance management of care providers are
critical objectives within human services organizations
serving persons who have intellectual disability (ID)
(DiGennaro Reed, Hirst, & Howard, 2013; Lerman, LeBlanc, &
Valentino, 2015; Luiselli, 2018). Effective training and
performance management produces a more competent work-
force which leads to improved outcomes for service recipients,
higher job satisfaction, reduced turnover, and profes-
sional growth (Britton Laws, Kolomer, & Gallagher, 2014; Ejaz,
Noelker, & Menne, 2008; Firman, Orient, Steiner, &
Received: 16 March 2020 Revised: 12 June 2020 Accepted: 15

June 2020
DOI: 10.1002/bin.1730
458 © 2020 John Wiley & Sons, Ltd Behavioral Interventions.
2020;35:458–466.wileyonlinelibrary.com/journal/bin
Firmin, 2013). Notably, several approaches to training and
performance management within applied behavior analy-
sis (ABA) and organizational behavior management (OBM)
have good evidence support such as behavioral skills
training (BST), pyramidal training, and performance feedback
(Arco, 2008; LeBlanc, Gravina, & Carr, 2009; Parsons,
Rollyson, & Reid, 2012; Shapiro & Kazemi, 2017).
Social validity is a facet of care provider training and
performance management concerned with acceptance and
approval of objectives, methods, and outcomes (Gravina et al.,
2018; Luiselli, 2020; Schwartz & Baer, 1991;
Wolf, 1978). Typically, social validity is assessed through
questionnaires and surveys that elicit care provider atti-
tudes and opinions about the types of training and performance
management they received (Gravina & Austin, 2018;
Luiselli, Bass, & Whitcomb, 2010; Miller, Carlson, &
Sigurdsson, 2014), procedural preferences (Reed, DiGennaro
Reed, Campisano, Lacourse, & Azulay, 2012), and motivational

incentives (Wine, Reis, & Hantula, 2014). Through
social validity assessment, human services organizations are
able to align the perceptions of care providers with val -
ued operations, identify common themes that impact
programming, and consider alternative systems-wide practices.
Among many responsibilities, care providers are frequently
required to record data in order to objectively mea-
sure the effects of service delivery with persons who have ID
(Mayer & DiGennaro Reed, 2013; Rehfeldt, Baker, &
Grannan, 2014). For example, data recording by care providers
has targeted how often service-recipients complete
care routines (Burg, Reid, & Lattimore, 1979), initiate and
respond to social interactions (Doerner, Miltenberger, &
Bakken, 1989), and demonstrate challenging behavior (Flood &
Luiselli, 2012). However, training and performance
management of care provider data recording has infrequently
assessed social validity. In illustration, Gerald, Keeler,
Mackey, Merrill, and Luiselli (2019) evaluated the effects of a
self-management intervention on behavior data record-
ing by educational care providers followed by social validity
assessment of how the intervention was conducted, the
skills acquired through intervention, and recommendation of the
intervention to other staff. Similarly, Mishra, Grasso,
Essien, and Luiselli (2019) had educational care providers rate

their preference for environmental cuing and perfor-
mance monitoring interventions to improve data recording of
activity completion by students. Given the emphasis
many human services programs place on objective measurement,
social validity assessment of data recording should
be more fully integrated within training and performance
management as well as other operations that apply to care
providers (Ferguson et al., 2018; Gravina et al., 2018).
The present paper reports a social validity assessment study
with human services organization care providers to
identify their attitudes and opinions about behavior data
recording they were required to complete with adults who
had ID. We describe development of a social validity
questionnaire, summarize care provider responses, and discuss
implications of the findings for conducting training and
performance management. The study illustrates how human
services organizations can adopt social validity assessment as
an approach to evaluate and improve operations
through collaborative teamwork with and recommendations
from employees (Laffel & Blumenthal, 1989).
2 | METHOD
2.1 | Participants and setting
The participants were 78 care providers (61% female, 39%

male) who were employed at a human services organiza-
tion for adults with ID. The average age of the participants was
40.6 years (SD = 11.6 years) with an average of
9.5 years (SD = 7.3 years) working in the field of intellectual
and developmental disabilities. With regard to level of
education, the participants had a high school or general
education diploma (34.7%), associate degree (27.8%), under-
graduate college degree (27.8%), and graduate school degree
(9.7%).
The participants were assigned to 13 community group homes
that served a total of 48 adults with ID (22–
80 years old). Between two to five adults lived in each group
home and received habilitation services 24 hours per
day 7 days per week. In their roles as care providers, the
participants generally worked 8-hr daily shifts in the group
homes, 40 hours per week, and occasionally overtime hours
when additional shifts were available. Participants
RICCIARDI ET AL. 459
conducted many activities with the adults, including but not
limited to teaching adaptive living, self-care, communica-
tion, and leisure skills, arranging community events, dispensi ng
approved medications, planning group home sched-

ules, and coordinating visits with families.
All of participants consented to the study following meetings
with the authors at which time they were informed
about a project to sample their “opinions and feedback about
recording behavior data.” They were told further that
the project entailed completing a brief questionnaire, was
voluntary, did not represent a performance appraisal, and
would not affect their current and future employment. None of
the participants declined the request to complete
the questionnaire.
2.2 | Data recording responsibilities
Approximately 48% of the adults living in the group homes had
written procedural guidelines or intervention plans
that addressed challenging behavior such as aggression, self-
injury, property destruction, environmental disruption,
and non-compliance. During their assigned shifts, the
participants were required to record several types of behavior
data associated with these guidelines and plans. The behavior
data were recorded as frequency counts or occurrence
intervals on adult-specific forms contained in program binders
at the group homes. These were paper-and-pencil
forms that also specified the timeframes for data recording
(e.g., end of a shift).

The participants had been trained to record behavior data
immediately following their assignment to a group
home. Training conducted by an assigned clinician generally
consisted of explaining behavior data recording respon-
sibilities, the format of recording forms, and behavior
definitions specific to each adult. Clinicians also used instruc -
tions, demonstration, and performance specification during
training interactions. Participants were able to pose
questions during training and subsequently affirmed their
comprehension of expectations and procedures by signing
a confirmation document. Following initial training, clinicians
continued to consult with participants during scheduled
meetings and observations that addressed behavior data
recording guidelines.
2.3 | Questionnaire construction and distribution
The authors formed a research team at the human services
organization comprised of clinicians, behavior analysts,
and group home supervisors who designed, distributed, and
evaluated results from the social validity assessment
questionnaire. The questionnaire had three categories pertaining
to (a) practicality/ease of use, (b) training/supervi -
sion, and (c) importance/usefulness of behavior data recording
required of the participants as care providers in the
group homes. Each category included six statements that were

judged to be most relevant to the objectives of social
validity assessment (Table 1). Twelve of the 18 statements (six
statements per category) were worded positively such
as, “I know when I am responsible for recording behavior data,”
and six of the 12 statements (two statements per
category) were reverse coded in the form, “I have not been
trained to complete behavior data recording sheets in
the program.” For each statement on the questionnaire,
participants endorsed one numerical rating on a 5-point
Likert scale (1: strongly disagree, 2: disagree, 3: neither
disagree or agree, 4: agree, 5: strongly disagree).
Clinicians who were members of the research team distributed a
hardcopy of the questionnaire to the partici-
pants during a meeting at their respective group homes. While
following a standardized script, the clinician con-
ducting the meeting reminded the participants about the purpose
of the questionnaire and asked that they first fill-in
the demographic information requested on the first page (age,
sex, educational background, years of experience).
Next, the clinician explained that there were 18 statements on
the questionnaire and the participants should check
one of the five numerical ratings for each statement. The
clinician answered any inquiries from the participants, then
distributed the questionnaire while remaining present during the

time required for completion. The participants
responded to the questionnaire independently and anonymously
without conferring with each other, handing it to
460 RICCIARDI ET AL.
TABLE 1 Social validity questionnaire categories and
statements
Category Statement
Practicality/Ease of use The behavior recording data sheets are
easily accessible
There is enough time to record behavior data while on shift
Behavioral definitions are easy to understand
My other job tasks get in the way of recording behavior dataa
I know when I am responsible for collecting behavior data
Behavior recording data sheets are not easy to fill outa
Training/Supervision I have not been trained to complete
behavior data recording sheets in the programa
Additional training in behavior data recording would be helpful
Other staff and I record behavior data the same way
My supervisor teaches me how to complete behavior data
recording sheets

I do not have someone to contact if I need clarification
completing data recording sheetsa
Training in behavior data recording has happened on my shift
Importance/Usefulness Behavior data are important for my work
I do not find it helpful to review behavior data periodicallya
I understand how clinicians use behavior data after it has been
recorded
Behavior data I record are used to make decisions about the
people I serve
I have been shown graphs of the behavior data I record in the
program
Recording behavior data does not help the people I servea
aIndicates reverse coding.
TABLE 2 Rank ordered ratings on social validity questionnaire
Questionnaire statement Average rating
I know when I am responsible for recording behavior data 4.66
(SD = 0.75)
Behavior data I record are used to make decisions about the
people I serve 4.57 (SD = 0.91)
The behavior data recording sheets are easily accessible 4.57
(SD = 0.75)

Behavior data are important to my work 4.42 (SD = 1.03)
I do not have someone I can contact if I need clarification
completing behavior data recording sheetsa 4.38 (SD = 1.14)
I do not find it helpful to review behavior data periodicallya
4.24 (SD = 1.2)
Recording behavior data does not help the people I servea 4.23
(SD = 1.32)
Training in behavior data recording has happened on my shift
4.19 (SD = 1.18)
My supervisor teaches me how to record behavior data
recording sheets 4.18 (SD = 1.10)
There is enough time to record behavior data while on shift 4.10
(SD = 1.14)
I understand how clinicians use behavior data after it has been
recorded 4.03 (SD = 1.08)
I have not been trained to complete data recording sheets in the
programa 3.96 (SD = 1.45)
Behavior definitions are easy to understand 3.84 (SD = 1.12)
My other job tasks get in the way of recording behavior dataa
3.71 (SD = 1.38)
Behavior data recording sheets are not easy to fill outa 3.69 (SD
= 1.40)
Additional training in behavior data recording would be helpful
3.64 (SD = 1.26)

I have been shown graphs of the behavior data we record in the
program 3.54 (SD = 1.37)
Other staff record behavior data the same way 3.38 (SD = 1.33)
aIndicates reverse coding.
the clinician when finished, yielding 100% return rate.
Explanation, distribution, and completion of the questionnaire
during the group home meetings with participants lasted
between 15 to 20 min.
3 | RESULTS
Table 2 presents the rank ordered average Likert scale rating for
the 18 statements contained in the social validity
questionnaire. Eight of the 12 positively worded statements
(66.6%) received an average “agree” rating (4.0–4.9) and
the remaining four statements (33.3%) received an average
“neither disagree nor agree” rating (3.0–3.9). The stron-
gest endorsements from the participants were for their behavior
data recording responsibilities, understanding the
value of behavior data recording, and the training and
supervision to perform behavior data recording. More equivo-
cal ratings were documented for needing additional training,

reviewing graphed data, and understanding behavior
definitions.
Three of the six reverse coded statements (50%) received an
average “disagree” rating (4.0–4.9) and the
remaining three statements (50%) received an average “neither
disagree nor agree” (3.0–3.9) rating. On average, the
participants disagreed about not having a contact person for
clarifying completion of behavior data recording, finding
it useful to periodically review behavior data recording, and
behavior data recording not being helpful to the people
served. More equivocal ratings pertained to not having been
trained to record behavior data, other tasks interfering
with behavior data recording, and recording sheets not being
easy to fill out.
4 | DISCUSSION
The present study illustrates the contribution of social validity
assessment to issues of care provider training and per -
formance management within human services organizations
(Luiselli, 2020). Specifically, the study targeted partici-
pant opinions and attitudes about the behavior data recording
they were required to complete with adults who had
ID. As noted previously, many human services organizations
rely on data recording by care providers to measure and

evaluate learning progress of the individuals served.
Understanding how care providers perceive the practice, value,
and purposes of data recording informs organization
administrators and supervising clinicians about operations
prior-
ities, reasonable practices, and direction of future programming
with service recipients. Notably, social validity
assessment ranks high as practice and research objectives within
ABA and OBM (Ferguson et al., 2018; Gravina
et al., 2018).
The social validity assessment found that participants judged
behavior data recording as practical (e.g., “The
behavior data recording sheets are easily accessible”),
understood the objectives of behavior data recording (e.g.,
“Behavior data I collect are used to make decisions about the
people I serve”), and saw merit in behavior data record-
ing (e.g., “Behavior data are important for my work”). Further,
the participants endorsed high approval ratings for
behavior data recording training and supervision (e.g.,
“Training in behavior data recording has happened on my shift”
and “My supervisor teaches me how to complete behavior data
recording data sheets”). These findings suggest that
participants working in the group homes managed by the human
services organization were not negatively inclined

toward behavior data recording or would be expected to resist
efforts directed at performance management. The
positive ratings also suggest that the participants would perform
behavior data recording with good fidelity, that is,
consistently and accurately implement procedures they
understood and approved.
Other participant ratings suggested elements of behavior data
recording that group home supervisors could
focus on. For example, behavior data recording may at times be
difficult due to competing activities (e.g., “My other
job tasks get in the way of recording behavior data”), the results
of behavior data recording are not routinely shared
with care providers (e.g., “I have been shown graphs using the
behavior data we take in our program”), and behavior
recording data are performed inconsistently (e.g., “Other staff
and I record behavior data in the same way”). Relative
to these findings, post-assessment meetings could be convened
with participants in order to review how behavior
data recording could be improved through additional resources
and support to ongoing training and supervision.
Although the focus of this study was on behavior data
recording, the approach and format of social validity

assessment can be applied to many other areas of care provider
performance such as delivering skills instruction,
implementing behavior support plans, and completing daily
living routines. Questionnaires could also be developed
into surveys and checklists that measure implementation fidelity
and isolate procedural compliance problems similar
to instruments such as the Performance Diagnostic Checklist-
Human Services (PDC-HS) (Wilder, Cymbal, &
Villacorta, 2020).
We acknowledge that our social validity questionnaire included
only some of many possible inquiries concerning
behavior data recording. For example, questionnaire items that
judged the requirement of behavior data recording
compared to other participant job tasks or asked about
alternative methods of conducting measurement would have
been informative. Further, some of the items might not be
viewed as questions of social validation such as “I know
when I am responsible for recording behavior data” and
“Training in behavior data recording has happened on my
shift.” These items were intended to touch on behaviors,
conditions, and practical exigencies that impact direct con-
sumers and hence their ratings of social validity (Fawcett, 1991;
Schwartz & Baer, 1991).

Two other aspects of the social validity questionnaire should be
considered. First, the purpose of reverse coding
was to promote attentiveness from the participants by varying
content of the questionnaire and to control for unidi-
rectional response tendency that can occur when items are
worded similarly throughout (Swain, Weathers, &
Niedrich, 2008). Concerning the manner of distribution, a
clinician was present when participants completed the
questionnaire in order to maximize return rate. However, this
arrangement could have induced reactivity among the
participants and influenced their responses which to a large
degree were favorable. Recall that the participants com-
pleted the questionnaire anonymously and they were also
familiar with the clinicians, factors that may have lessened
possible reactivity. An alternative to this in-person format could
have been the participants completing the question-
naire online without other people present although this method
would not guarantee independent responding and
100% return rate.
The benefits of social validity assessment notwithstanding,
there are several qualifications applicable to a perfor -
mance objective such as behavior data recording and similar
competencies of human services care providers. On one
hand, social validity ratings by care providers may reflect

approval, acceptance, and preference for procedures and
strategies that are not necessarily the most effective or have
robust evidence support. It is also possible that social
validity ratings may not correlate with performance such as the
case of care providers who rank behavior data
recording an organizational priority but do not follow
established protocol or enter data reliably. In these situations,
observations of care providers would provide additional
information to better interpret results of a social validity
assessment, for example, do care providers actually implement
preferred procedures and demonstrate behavior that
conforms to their self-report?
Another consideration is evaluating care provider perceptions of
the effects of programmed interventions and
system changes that were informed through social validity
assessment. That is, how do care providers judge organi -
zation follow-up to questionnaire and survey data, post-
assessment focus groups, and respective recommendations?
Unfortunately, it was beyond the scope of the present study to
design and evaluate organization interventions
directed at behavior data recording policies, training, and
supervision based on the results of participant question-
naire ratings. Referencing the rank-ordered assessment findings
(Table 2), intervention efforts could focus on expan-

ding training in behavior data recording, teaching participants
how to interpret graphic presentation of behavior
data, and managing performance to ensure that behavior data are
recorded the same way. This process also high-
lights the need for human services organizations to assess social
validity at regular intervals that are tied to selected
initiatives, large-scale policy changes, and reoccurring events
such as hiring new staff (“onboarding”).
Generalization of our findings to other human services
organizations must be interpreted cautiously given differ-
ent types of behavior data recording, training, and supervision
conducted in those settings. As well, study results
should be qualified because this was a descriptive study with a
convenience sample that concerned a single
performance objective among care providers. Finally, it is
unclear how items in the social validity questionnaire corre-
lated or comprised separate domains because a test of sampling
adequacy (Kaiser-Meyer-Olkin Test) indicated insuf-
ficient data and sample size to perform a principal component
analysis.
In addition to the previously cited goals and benefits, social

validity assessment can contribute to care provider
professional development by demonstrating that human services
organizations seek and value their opinions (Hewitt
& Larson, 2007). Having input into organization operations
further enhances the self-image of care providers in the
demanding role of service delivery with persons who have ID
(Kessler & Troxel, 2019). The present study described
the process of designing and evaluating a social validity
questionnaire that focused on a performance priority of care
providers at a human services organization, described
implications of the findings, and supports the need for more
widespread application of social validity assessment in
behavioral practice and research (Ferguson et al., 2018;
Gravina et al., 2018).
ACKNOWLEDGMENT
The authors gratefully acknowledge the care providers at Seven
Hills Community Services for participating in the
study.
CONFLICT OF INTEREST
All of the authors declare that they have no conflict of interest.
INFORMED CONSENT
Informed consent was obtained from all participants included in

the study.
ETHICS STATEMENT
All procedures conducted in the study were in accordance with
the ethical standards of the institutional and/or
national research committee and with the 1964 Helsinki
declaration and its later amendments or comparable ethical
standards.
DATA AVAILABILITY STATEMENT
Research data not shared.
ORCID
James K. Luiselli https://orcid.org/0000-0001-6989-9155
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Journal of the …
Wanna Grab Some Dinner? Social Relations
Between Helping Professionals and Members of
Community Mental Health or Other Human Service
Organizations
Jonathan D. Prince, Olivia Mora-Lett, Marina Lalayants, and
Adam Brown
Silbmeran School of Social Work at Hunter College, City
University of New York
Purpose: Could practitioners and members (consumers) of
mental health or other organizations
interact socially by regularly going out for drinks or dinner
together, for example? The

American Psychological Association explicitly states for
example, “your psychologist
shouldn’t also be your friend.” However such social interactions
have occurred for decades
in certain clubhouse-modeled community mental healthcare, and
maybe research and a more
balanced perspective is warranted. Design/Method: We
interviewed six clubhouse staff that
interact socially with members and held three focus groups with
20 members. Results/
Conclusions: In relation to what we call a social interaction
policy, we herein highlight:
(a) four policy dimensions (e.g. activity types; relationship
closeness); (b) a spectrum of policy
challenges (e.g., dealing with romantic overture; feelings of
exclusion or hurt and effects on
mental health; symptom flare-up while out socializing; financial
constraints of members such as
dinner costs on limited incomes); and (c) a wide variety of
policy benefits such as: (a) learning
opportunities for members who can process with staff the ups
and downs of social relationships;
(b) social skill and network development; (c) enhanced
assessment across different times/
settings; (d) addressing stigma among staff who must grapple
with internal resistance to spend
free time with members; (e) enrichment of staff social life; (f)
reducing internalized stigma
among members when staff value them more holistically; and
(g) empowerment of members
when staff freely (and optionally) offer a valuable resource
(spare time). We offer suggestions
for certain types of agencies that may wish to implement social
interaction policies.
Public Policy Relevance Statement

Although dual (or multiple) associations between providers and
members (consumers) of
mental health service organizations have been explored
extensively over decades, this
exploration has covered random encounters (e.g., running into
members in grocery stores,
on one extreme) to close friendships on the other extreme. In a
more focused way, however,
researchers have yet to study regular social interactions (e.g.,
optional dinners or drinks)
between providers and members. We therefore studied these
interactions qualitatively
(interviews with providers and focus groups with members), for
both parties have actively
pursued such get-togethers for over 70 years in certain
clubhouses. In relation to this social
interaction policy, we highlight policy dimensions, challenges,
and benefits, and offer
suggestions for non-clubhouse agencies that can weigh policy
implementation against
maintenance of the status quo (e.g., in order to preserve
integrity of clinical relationships).
Supplemental materials:
https://doi.org/10.1037/ort0000552.supp
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Adam Brown https://orcid.org/0000-0001-5833-8811
We wish to thank Vicki Lens, PhD for her invaluable assistance
in reviewing
earlier drafts of this article. We have no conflicts of interest to
disclose.
Correspondence concerning this article should be addressed to
Jonathan
D. Prince, Silberman School of Social Work at Hunter College,
City
University of New York, New York, NY 10035, United States.
Email:
[email protected]
American Journal of Orthopsychiatry
© 2021 Global Alliance for Behavioral Health and Social
Justice 2021, Vol. 91, No. 4, 545–557
https://doi.org/10.1037/ort0000552
545

W hat would happen if practitioners (i.e., service provi -ders or
staff) and members (i.e., consumers or clients)of mental health
or other organizations started to
regularly socialize by going out for drinks together, for
example,
or going to baseball games or out to dinner? Such activates
(some-
times referred to as boundary crossings; Zur, 2020) do not
violate
codes of ethics or standards set by licensing boards (e.g.,
Sonne,
2007; Zur, 2020). In short, on a regular basis, could service
providers
spend free time with people under their care? The answer is yes
potentially, or at least yes maybe, for social lives have been
shared for
decades in some clubhouse-modeled community mental health
pro-
grams. Perhaps this is only possible in certain clubhouses, for
they
differ in important ways from other community mental
healthcare
(e.g., near-total equalization of power between staff and
program
members). Beyond clubhouses, the American Psychological
Association (2020), explicitly states for example, “your
psychologist
shouldn’t also be your friend.” Yet certain clubhouses operate
under a
different philosophy, and maybe research and a more balanced
perspective are warranted.
Surprisingly, social relations between clubhouse staff and mem-

bers have yet to be studied empirically. We therefore
interviewed six
clubhouse staff that spend free time with members, and held
three
focus groups with 20 clubhouse members in order to better
under-
stand from both perspectives (staff and members) what we
herein
refer to as a social interaction policy (an unwritten or informal
one,
in this case). Our two research questions include: (a) what are
the
dimensions of this policy? and (b) what are its challenges and
benefits? We conclude by questioning whether other agencies
could
adopt such a policy, perhaps in order to enhance care (e.g., by
building rapport outside of the office), or whether instead the
status
quo should be maintained (e.g., in order to preserve integrity of
clinical relationships). In relation to our rather contrarian idea
that
such a policy could indeed be considered elsewhere (e.g., other
forms of community mental healthcare, where having drinks
with
service recipients or sharing other social activities is often
prohib-
ited), we understand that we will be met with resistance. We
captured this resistance by recording an experienced clinician’s
response to the suggestion:
I am excited by innovative approaches to treatment but this
(social
interaction policy) makes me very uncomfortable. (There are
reasons)
why these boundaries haven’t been crossed : : : There is a
power

Week 4 journal start assignmentgroupthinkdefine groupthink.

Week 4 journal start assignmentgroupthinkdefine groupthink.

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Week 4 journal start assignmentgroupthinkdefine groupthink.