The relationship between first-level leadership and inner-context and implementation outcomes in behavioral health: a scoping review

Despite advances in evidence-based practices (EBPs) to treat mental and behavioral health problems [1], efforts to transfer them from laboratory to public settings are often unsuccessful [2, 3]. Implementation frameworks suggest that leadership may function as a mechanism for improving EBP implementation [4‐7]. Empirical studies support this theoretical link between leadership and the innovation implementation in healthcare settings [8‐10]. While there is no universally adopted leadership definition, conceptualizations generally reflect a process of intentional efforts by an individual to motivate, influence, and enable a person or group of people with the aim of impacting group or organizational outcomes [11‐13]. Leadership across organizational levels—from top leaders who establish organizational policies and practices [14] to first-level leaders who directly supervise employees providing direct services—and their alignment with one another influence the success of implementation [15, 16]. Achieving organizational effectiveness, including effectiveness in EBP implementation, is complex and hinges on coordination across levels of leadership [16, 17]. Organizational leadership at the first-level may be particularly influential in supporting EBP implementation due to leaders’ access to and direct relationships with service providers. For instance, first-level leadership may function to support or hinder the realization of top-level leaders’ organizational policies that are favorable for EBP implementation. Conversely, first-level leadership may mitigate potential negative impacts of organizational policies instituted by top leaders that would hinder implementation.

First-level leaders are individuals who directly supervise and manage frontline employees who do not manage others [18]. In the context of behavioral health service delivery, first-level leaders tend to include clinical supervisors, program managers, and team leaders who supervise direct providers. Leaders at this lowest level enact their leadership influence through direct interaction with frontline employees, making decisions that concern day-to-day work, anticipating and solving current problems, and using practical judgment to address ongoing problems [19]. They engage and inspire staff at the frontline [17]. In the context of implementation, first-level leadership is theorized to improve general and strategic cultures and climates, provider attitudes, and implementation outcomes [4, 16, 20].

There have been calls for leadership to be studied within a particular organizational level and context because the antecedents, consequences, and dynamics of leadership change as a function of organizational level, structure, and complexity [19]. The role of first-level leadership differs from leadership at higher organizational levels. At the highest level, leaders are responsible for establishing a comprehensive direction for the organization, creating organizational policy, and crafting organizational strategy [19]. Mid-level leaders engage in coordination of multiple subunits, manage less directly, and are responsible for establishing operational practices and policies [19]. The success of innovation implementation relies on numerous complex factors, some of which include training, teaching and feedback, time requirements, reimbursement, resource allocation, and workflow integration [4, 5]. Leaders across organizational levels are differentially positioned to impact these factors, which has implications for their influence on implementation. Given the distinct responsibilities of first-level leaders focused on day-to-day decisions and problem solving, synthesis of the literature is needed to understand how first-level leadership influences implementation and what implementation determinants and outcomes they impact.

Empirical research examining leadership and training programs to develop effective leadership have lagged in behavioral health relative to health broadly. The number of studies examining the role of leadership in behavioral health innovation implementation has not matched that of health innovations broadly [8]. Moreover, first-level leaders within behavioral health tend to be promoted internally due to their effectiveness as providers, thus are often unprepared and lacking formal leadership training [21, 22]. While leadership training is a continued need in healthcare broadly, many examples of formal training programs have existed in medicine for upwards of 20 years [23‐26]. Efforts to train leaders in behavioral health, including those with a focus on EBP implementation, are limited (e.g., [27, 28]). Synthesis of the literature is needed to understand the type of leadership styles and behaviors those in behavioral health draw on to support implementation. Further, implementation determinants and outcomes are theorized to interact with innovation characteristics [4, 29]. Behavioral health has followed the lead of evidence-based medicine in using research evidence to standardize healthcare [30] yielding an abundance of beneficial EBPs. Attending to and measuring delivery of EBPs is one important method by which leaders can impact EBT delivery [16]. However, monitoring and evaluating the content and dose of complex behavioral health interventions is difficult [31]. Efforts to standardize delivery and maintain quality have included detailed treatment manuals, training, certification requirements, and fidelity criteria [32], yet modification of behavioral health interventions is common [33] and direct observation to monitor and support delivery is often unfeasible [34]. Further, many treatments are based on principles of practice rather than prescribed strategies (e.g., [35‐37]) posing additional challenges to defining and monitoring their adoption, fidelity, and sustained use. These characteristics of behavioral health interventions may shape which first-level leadership behaviors are most effective in impacting implementation and the degree to which first-level leadership is able to impact implementation. For instance, task-oriented leadership behaviors such as planning and monitoring performance [38] may be more effective in ensuring behavioral health interventions are adopted and used with high fidelity than change-oriented behaviors primarily concerned with providing vision and encouraging innovation [38].

First-level leaders may influence implementation through leadership that aims to impact performance outcomes generally (i.e., general leadership) and through leadership that is strategically focused on influencing implementation outcomes (i.e., strategic implementation leadership). The full range leadership model, one of the most studied models of general leadership, describes three primary forms of leadership, transformational, transactional, and laissez-faire leadership [39]. Transformational leadership describes how leaders inspire and motivate employees to perform beyond expectations. Transactional leadership functions through reinforcement and exchanges, where leaders reward employees who fulfill expectations [39‐41]. Passive-avoidant leadership is a style of non-leadership [42], characterized as taking a “hands off” approach by altogether avoiding making decisions or managing employees [43]. A recent systematic review found that managers engage in behaviors that are consistent with transformational and transactional approaches to support research use by clinical staff in nursing and allied health professionals [44].

Leadership that is strategically focused on EBP implementation is theorized to promote a positive climate for implementation and, in turn, foster positive attitudes toward EBPs that support implementation [45]. The implementation leadership theory [46] and theory of middle managers’ role in implementation [47, 48] describe leadership behaviors that strategically focus on implementation among first-level leaders. Implementation leadership describes first-level leadership that proactively anticipates and addresses implementation challenges, demonstrates a deep understanding of EBP implementation, perseveres through implementation challenges, and supports providers to adopt and use EBPs [46]. The theory of middle managers’ role in implementation is based on review and research on both first-level leaders and mid-level managers [47‐49]. It describes middle manager commitment to innovation implementation operationalized as four ways that managers can demonstrate their commitment for innovation implementation: obtaining and diffusing information about an innovation, adapting information and the innovation, mediating between strategy and day-to-day activities, and selling innovation implementation. In healthcare settings, there is some evidence suggesting that middle manager commitment to implementation—in conjunction with executive support for implementation and access to human resources administration—is associated with implementation effectiveness [50].

We followed Arksey and Malley’s [54] methodological framework for scoping reviews. A scoping review was conducted due to the broad, emerging state of literature that cannot be subject to the narrow systematic review criteria due to its heterogenous nature [55]. We followed the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (PRISMA-ScR) to enhance transparency. There is no registered review protocol. Additional file 1 includes the PRISMA-ScR checklist and Fig. 1 contains the PRISMA diagram.

The search yielded a total of 4337 articles. After excluding duplicates, 3207 titles and abstracts were reviewed for inclusion. Among those, 129 articles progressed to full-text review and 21 met criteria for data abstraction (Fig. 1). Thirteen additional articles met criteria for abstraction [68‐80], but combined their measurement of first-level and higher levels of leadership limiting conclusions about how first-level leadership specifically is related to implementation. Data were abstracted from these articles, but their results are not combined with the 21 primary articles and are listed in the supplemental materials for comparison (additional file 3 Tables 9–12).

This scoping review synthesized research examining the relationship between first-level leadership and inner-context and implementation outcomes in the context of behavioral health service delivery. Studies primarily relied on observational designs and were often cross-sectional. Studies most often examined general forms of first-level leadership, namely transformational leadership. Strategic implementation leadership was also the focus of over half of studies. Nearly equal attention was given to inner-context and implementation outcomes, and inner-context outcomes centered on organizational and individual characteristics. The greatest concentration of studies examined first-level leadership in relation to providers’ EBP attitudes and general implementation. Our synthesis revealed moderate conceptual overlap of leadership behaviors described in theoretical frameworks of strategic implementation leadership.

While the scope of the literature was broad, patterns emerged in the forms of leadership and outcomes studied across qualitative and quantitative investigations. Strategic leadership was more often the focus in qualitative studies, while quantitative studies commonly focused on general leadership. This likely reflects that quantitative measures of strategic implementation leadership have only recently been developed [46] while measures of general leadership have long been available [100]. Among outcomes studied, there was nearly equal representation of inner-context and implementation outcomes. However, over half of the literature informing our understanding of the relationship between first-level leadership and implementation measured general implementation, limiting our knowledge of the precise domains of implementation that are influenced by leadership. Further, of the five studies that measured a specific implementation outcome, three were self-reported. One notable exception was the use of independent observation to measure fidelity.

Few leadership-outcome relationships were examined across multiple studies; however, one exception was the focus on providers’ EBP attitudes. Studies primarily found positive associations in the direct and indirect relationships between transformational leadership and providers’ EBP attitudes, although there were exceptions. This finding aligns with a comprehensive synthesis of studies across occupational settings and leadership levels that support transformational leaderships’ positive relation to employee attitudes [42]. In the implementation literature, theory suggests positive EBP attitudes are a necessary precursor to the EBP adoption decision [101], yet the evidence linking providers’ attitudes and behavior is mixed. Studies conflict in their conclusions regarding providers’ EBP attitudes and EBP implementation-related behaviors, with some finding positive associations [102, 103] and others—including the most rigorous among these [104]—finding mixed or no associations [104‐106]. What remains to be studied is whether the relationship between transformational leadership and providers’ EBP attitudes has implications for providers’ implementation behaviors. For instance, attitudes may modify the relationship between transformational leadership and adoption, such that transformational leadership may only predict adoption when providers have positive EBP attitudes.

Theory and research suggest general climates form a foundation for strategic climates, and these strategic climates function as a more proximal predictor of individual and organizational performance [58]. Ample evidence suggests that strategic climates mediate the relationship between leadership and employee performance [107, 108]. Further, strategic leadership has shown a stronger effect on strategic climate than general high-performance leadership [107]. Theory within implementation also posits that leadership influences organizational characteristics, including culture and climate, which then shape provider adoption and sustainment of EBPs [4, 5, 109]. While the relationship between first-level leadership and various organizational characteristics was a primary focus of the reviewed studies, variability in the specific outcomes measured and inconsistent findings offer limited conclusions about the nature of this relationship. Studies revealed some consistent, yet sparse, support for general and strategic implementation leadership positively relating to general [84, 88, 98] and strategic organizational climates [82, 97]. Studies demonstrated that general and strategic organizational climates mediated the relationship between positively framed leadership and other inner-context outcomes; however, only one study examined its mediating role on an implementation outcome. Williams and colleagues [97] provide initial evidence that the relationship between implementation leadership and EBP adoption is mediated by implementation climate. Extending from organizational theory and research, more evidence is needed to determine (1) whether strategic implementation leadership is associated with better strategic implementation climate, (2) whether general leadership and general climate are necessary precursors for positive implementation leadership and implementation climate, and (3) the mediating role of organizational characteristics in the relationship between leadership and implementation outcomes.

Leadership has shown a positive relationship with employees’ performance outcomes across industries [110]; however, the evidence linking leadership to implementation outcomes in behavioral health remains sparse. The qualitative evidence in this review indicates that first-level leadership, particularly strategic implementation leadership, facilitated general implementation. Yet it provides limited evidence regarding the influence of leadership behaviors on specific implementation outcomes. The studies involving mixed levels of leadership provide further support for the facilitating impact of strategic implementation leadership on implementation outcomes, although they preclude us from fully attributing that effect to first-level leadership. There were notably few studies that quantitatively examined the direct or indirect relationship between first-level leadership and implementation outcomes, limiting generalizations about these relationships. Findings suggest that implementation leadership and leader characteristics may support EBP adoption [89, 97], although additional research is needed as conflicting results exist [15]. Furthermore, measurement of EBP adoption has relied solely on provider report, dampening confidence in estimates of the leadership-adoption relationship [111].

This review offers a synthesis of the current state of the literature examining how first-level leadership shapes implementation. The findings suggest that the impact of leadership in shaping inner-context outcomes, most notably providers’ EBP attitudes and the organizational context, has been a primary focus in quantitative analyses. In contrast, the facilitating and hindering role of strategic implementation leadership on general implementation have comprised much of the qualitative examinations. Our synthesis documents an important conceptual overlap in the theories of implementation leadership and middle managers’ role in implementation that should be disentangled, as these forms of strategic leadership appear to hold promise in supporting EBP implementation. We identified gaps in the literature and provide recommendations to advance our understanding of the relationship between first-level leadership and inner-context and implementation outcomes.