Mechanisms of Change in an Organizational Culture and Climate Intervention for Increasing Clinicians’ Evidence-Based Practice Adoption in Mental Health

Objective: Increasing the adoption of evidence-based practices (EBPs) is a focus of national and international efforts to improve the quality and outcomes of mental health services for youth; however, few studies have examined the multilevel change mechanisms that explain how successful implementation strategies increase EBP adoption. Identifying these mechanisms is necessary to develop more effective and efficient strategies. This study tested the multilevel mechanisms that link an empirically supported organizational implementation strategy called ARC (for Availability, Responsiveness, and Continuity) to increased EBP adoption.

Method: In a randomized controlled trial, 14 outpatient children’s mental health clinics in a large Midwestern city were assigned to a three-year ARC implementation strategy (k = 7) or control (k = 7). Measures completed by clinicians (n = 475) at baseline, mid-intervention, post-intervention, and 12-month follow-up assessed organizational culture, organizational climate, clinicians’ intentions to adopt EBPs, job-related barriers to EBP adoption, and clinicians’ EBP adoption.

Results: Clinicians in the ARC condition reported higher proficiency culture at mid-intervention, higher intentions to adopt EBPs at post-intervention, and fewer policy and procedure EBP barriers, higher odds of adopting a well-established EBP, and greater use of EBPs with clients at 12-month follow-up. Improvement in organizational proficiency culture mediated ARC’s effects on clinicians’ EBP intentions and together both variables serially mediated ARC’s effects on EBP adoption and use of EBPs with clients. Improvement in proficiency culture also mediated ARC’s effects on time and workflow barriers but not policy and procedure barriers to EBP adoption. Mediation and moderation analyses of EBP barriers suggested their most important role was to attenuate clinicians’ follow-through on positive EBP intentions.

Conclusions: Increasing EBP adoption in children’s mental health service systems requires attention to organizational culture as well as job-related policies and procedures. ARC increased clinicians’ EBP adoption by creating proficient organizational cultures that activated clinicians’ EBP intentions and by reducing policy and procedure barriers to intention enactment. Organizational proficiency culture and organizational policies represent viable targets for increasing EBP adoption in children’s service systems.