Organizational Adaptation: Bridging the Research to Practice Gap

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<ul><li><p>ORIGINAL PAPER</p><p>Organizational Adaptation: Bridging the Research to PracticeGap</p><p>William E. Reay</p><p>Published online: 9 February 2010</p><p> Springer Science+Business Media, LLC 2010</p><p>Abstract Currently, the childrens mental health system</p><p>appears dysfunctional and in need of serious attention. A</p><p>possible remedy for this disarray would be for researchers</p><p>and providers to establish integrated management systems</p><p>which include mutual, cross organizational learning, and</p><p>reciprocal feedback mechanisms. This type of adaptive co-</p><p>management to organizational governance would fully</p><p>integrate research and practice at the community level.</p><p>Using a public health service model, this organizational</p><p>management approach to research and practice would</p><p>harvest diverse scientific knowledge and disseminate that</p><p>knowledge through the natural occurring culture and</p><p>practice of each community. Organizational and clinical</p><p>knowledge acquisition, as well as practice improvements</p><p>would necessarily occur over time and across institutions.</p><p>Keywords Organizational adaptation Researchto practice</p><p>Context is Everything</p><p>Thirty years ago, childrens mental health services were</p><p>powerfully influenced by stories told about children and</p><p>adolescents being needlessly housed in restrictive settings</p><p>and inadequately treated by outpatient programs. At that</p><p>time, the number of children and youth placed in residen-</p><p>tial treatment centers (RTCs) was alarming. Knitzer (1982)</p><p>estimated the number of children in these residential</p><p>facilities or treatment centers (RTCs) to be more than</p><p>50,000. Government agencies were known to quickly place</p><p>children in RTCs because community-based alternatives</p><p>were not available in sufficient quantities. Even more</p><p>troubling were findings that children and adolescent mental</p><p>health functioning did not improve during their stay at</p><p>RTCs (Burns et al. 1998). At about the same time, reports</p><p>regarding the over-use of private hospitals for adolescents</p><p>with substance-abuse and mental health needs surfaced as</p><p>well (Jackson et al. 1987).</p><p>Jane Knitzers (1982) monograph Unclaimed Children</p><p>ushered in a new movement in the United States to develop</p><p>quality community-based services as an alternative to the</p><p>restrictive, costly, and uncoordinated services that domi-</p><p>nated the service system at that time. In 1984, the Child</p><p>and Adolescent Service System Program (CASSP), a</p><p>Federal initiative, was created to provide technical support</p><p>to states. This CASSP initiative provided the foundation for</p><p>the System of Care for Childrens Mental Health (Stroul</p><p>and Friedman 1986). The System-of-Care (SOC) provided</p><p>a conceptual basis to design mental health and other</p><p>necessary services which are organized into a coordinated</p><p>network to meet the multiple and changing needs of chil-</p><p>dren and adolescents with severe emotional disturbances</p><p>and their families (Stroul and Friedman 1986, p. 3). There</p><p>was a basic assumption that the mental health treatment</p><p>was effective and the real problems in childrens mental</p><p>health services were due to poor coordination of all ser-</p><p>vices, a general lack of collaboration between services, and</p><p>lack of parental involvement.</p><p>Over the next three decades, and as a direct result of</p><p>these initiatives, we witnessed tremendous efforts to</p><p>change mental health public policy; how organizations</p><p>structured and managed services; and how to conceptual-</p><p>ize, implemented, and evaluate services. The promise of</p><p>the SOC initiative, with over 20 years of expansive</p><p>W. E. Reay (&amp;)OMNI Behavioral Health and Northcentral University,</p><p>5115 F Street, Omaha, NE 68117-2807, USA</p><p>e-mail: breay@omnibehavioralhealth.com</p><p>123</p><p>Adm Policy Ment Health (2010) 37:9599</p><p>DOI 10.1007/s10488-010-0275-2</p></li><li><p>funding, program evaluation, and expenditures in excess of</p><p>1 billion dollars, has not eliminated the fragmentation or</p><p>resulted in sustainable large-scale reform (Hogan 2003).</p><p>Despite efforts of government, universities, providers,</p><p>and child and family mental health advocates, current</p><p>delivery systems continue to cost too much, services are</p><p>purchased in ways that defy common sense and are</p><p>inconsistent with sound business practice (Frank and Gar-</p><p>field 2007; Rhuel 2005; Stone 2004). Some mental health</p><p>services continue to be provided and coordinated in the</p><p>absence of informed reason, or basic science (Norcross</p><p>et al. 2006). This state of dysfunction is incontestable and</p><p>is seen in financing methodologies, poor service design,</p><p>inadequate and outdated training of professionals at all</p><p>levels (Baker et al. 2009; Lambert et al. 2005). There is</p><p>general agreement that the childrens mental health system</p><p>is in need of repair.</p><p>Twenty Hours at Vanderbilt</p><p>This paper expresses my perspective on the meeting upon</p><p>which this special issue is based. It is also a reflection of a</p><p>research-practitioner who began their career at the begin-</p><p>ning of the CASSP initiative and became intensely</p><p>involved in the SOC movement from the start. As one of</p><p>the original founding members of the National Federation</p><p>of Families for Childrens Mental Health, and a current</p><p>clinician and administrator, my perspective is shaped by</p><p>the stories and experiences of both children and parents.</p><p>With that caveat, I suggest that modest changes in research</p><p>efforts, training programs, and professional practice may</p><p>drastically improve the lives of children and families.</p><p>Approximately 20 h of work produced a discrete set of</p><p>recommendations that are described in the four action</p><p>agendas in this volume. For the most part, professional</p><p>differences were set aside in an atmosphere designed to</p><p>promote open discussion around the most important and</p><p>critical areas in childrens mental health services today.</p><p>Obviously, challenges and opportunities were discussed as</p><p>well as what the ultimate promise of providing higher</p><p>quality mental health care for children and families could</p><p>accomplish. However, it became equally clear that best</p><p>evidence varies by stakeholder group and those differ-</p><p>ences may be formidable.</p><p>The Problem with Evidence</p><p>Evidence includes not only research results but the context</p><p>in which they were achieved and the scientific values of the</p><p>researcher. The effort to acquire evidence is not precise.</p><p>The differential importance researchers and practitioners</p><p>place on two types of validity and how evidence is dis-</p><p>seminated are two related areas that need attention.</p><p>Researchers place a relatively high emphasis on the need to</p><p>maintain fidelity to program elements believed to be</p><p>responsible for targeted clinical outcomes. Practitioners, on</p><p>the other hand place a high emphasis on the need to</p><p>innovate and adapt program elements in their attempts to</p><p>serve diverse populations (external validity). Similarly,</p><p>there is a general lack of agreement on how scientific</p><p>knowledge should be disseminated to end users. Taken</p><p>together, these two important areas of production and</p><p>transfer of scientific knowledge represent serious ongoing</p><p>challenges for both researchers and practitioners. Clearly, a</p><p>new working model is in order.</p><p>Mental Health within a Public Health Framework</p><p>One of the four recommendations that resulted from the</p><p>meeting is to use a public health approach to childrens</p><p>mental health service (Stelk et al. this issue). Public Health is</p><p>defined as what we, as a society, do collectively to assure</p><p>the conditions for people to be healthy (Institute of Medi-</p><p>cine 1988, p. 6). A public health approach to mental health</p><p>must involve defining, measuring mental health problems,</p><p>identifying causes and risk factors for the specific mental</p><p>health problem, determining how to prevent and treat the</p><p>problem, and using effective strategies to evaluate the impact</p><p>(Centers for Disease Control and Prevention 2007). All of</p><p>this must take place at the community level.</p><p>In public health, the gap between research and practice</p><p>has not been reduced. However, it does appear that public</p><p>health researchers and practitioners have a better under-</p><p>standing of the reasons for the gap between research evi-</p><p>dence and practice. In public health models, dissemination is</p><p>not seen as an outcome, but as a process of reinventing the</p><p>scientific knowledge and adapting that knowledge in context</p><p>with the natural occurring influences of culture, practice,</p><p>organizational and community constraints (Green 2006).</p><p>As with public health, community-based mental health</p><p>treatments rarely consist of discrete interventions (Brownson</p><p>et al. 2009). The typical community-based program uses</p><p>multiple interdisciplinary interventions under the general</p><p>framework of mental health. In fact, many community</p><p>mental health organizations are required by accreditation</p><p>organizations and licensing or regulatory bodies to provide</p><p>services in such a manner. Like public health, community</p><p>mental health organizations rely on a variety of disciplines to</p><p>provide direct services (psychiatry, psychology, social work,</p><p>counselors, and human service therapists). This workforce</p><p>diversity, although considered by many to be a considerable</p><p>strength, guarantees substantial variation in clinical perspec-</p><p>tives, case conceptualization, epidemiological understanding</p><p>96 Adm Policy Ment Health (2010) 37:9599</p><p>123</p></li><li><p>and clinical decision making. Variation in professional train-</p><p>ing and socialization also produces a richness of conceptual</p><p>diversity and understanding of what is evidence and who</p><p>provides it. For example, to have evidence is to have some</p><p>conceptual warrant for belief or action (Goodman 2003,</p><p>p. 2). For science to advance in the practitioners world,</p><p>researchers must do a far better job at understanding the</p><p>subjective experiences of the practitioner, where science is</p><p>seen as assisting the practitioner at the clinical and admin-</p><p>istrative level.</p><p>The Need for Balance in Applied Research</p><p>In an effort to bridge the gap between science and practice,</p><p>public health approaches may have promise for childrens</p><p>mental health services. Several changes in professional</p><p>practices and training programs could lead to substantial</p><p>improvement in care:</p><p>1. Participatory approaches that actively involve academ-</p><p>ics, practitioners, and community members define</p><p>community and neighborhood problems, develop and</p><p>test strategies and interventions, and evaluate processes,</p><p>have shown tremendous promise (Kohatsu et al. 2004).</p><p>2. Dissemination and implementation of evidence-based</p><p>practices requires organizational leaders to place high</p><p>value on research-informed practices, time efficient</p><p>approaches to training and monitoring, and the practice</p><p>of clinical supervision (Dobbins et al. 2001).</p><p>3. Practitioners need assistance from researchers in</p><p>determining the most powerful components of each</p><p>evidence-based practice associated with the substantial</p><p>clinical improvement, iatrogenic effects, and no effect</p><p>(Kelley et al. 2001).</p><p>4. Organizational executives must become outspoken</p><p>advocates for science and the use of evidence.</p><p>Furthermore, they must be willing to abandon tradi-</p><p>tional organizational structures and promote bottom-up</p><p>governance approaches (Brownson et al. 2009).</p><p>The United States expends just short of $30 billion each</p><p>year on health science research (Office of Management and</p><p>Budget 2008). We must find a more efficient way of getting</p><p>health science research to end users. To move this agenda</p><p>forward, a possible vehicle would be to establish new</p><p>organizational governance structures.</p><p>Adapting Integrated Management Structures</p><p>One of the most promising models of research-practice</p><p>interaction is based upon mutual, cross organizational</p><p>learning (Van Kerkhoff and Lebel 2006). Based on the work</p><p>of Nonaka (1994), Nonaka and Toyama (2002) and Nonaka</p><p>et al. (2000), the model integrates the idea of organizational</p><p>reform with knowledge sharing, knowledge management,</p><p>cross organizational learning and co-management. A key</p><p>element of this approach is to promote action with knowl-</p><p>edge. Innovation and change occur through specific actions</p><p>of persons within social systems (Leeuwis and Pyburn</p><p>2002). Within this model, management is about harvesting</p><p>knowledge from diverse sources and applying that knowl-</p><p>edge to practice in a bidirectional manner, i.e., research-to-</p><p>practice-to-research (Gunderson et al. 1995). System and</p><p>management processes that cause bidirectional learning,</p><p>knowledge and contextualized understandings become part</p><p>of the adaptive capacity of the system to change based upon</p><p>the demands and pressures of the environment.</p><p>Adaptive Governance is often used to describe rules</p><p>and coordinated action associated with decision-making</p><p>and sharing of power (Boyle et al. 2001). Governance</p><p>occurs through co-management mechanisms that inti-</p><p>mately involve nested networks and levels of leadership.</p><p>Management becomes an ongoing process of bringing</p><p>together existing knowledge from a variety of disciplines in</p><p>an effort to create novel perspectives and hypotheses</p><p>(Gunderson et al. 1995). In such systems, knowledge</p><p>acquisition and practice dissemination occur over time.</p><p>Therefore, adaptive co-management approaches are flexi-</p><p>ble community-based systems of management that are</p><p>specifically responsive to the diversity of individuals, sit-</p><p>uations and organization itself. Such management systems</p><p>help address the common problem that practitioners face</p><p>when deciding if the findings of an evidence-based treat-</p><p>ment apply to their specific context.</p><p>Organizational cultures and climates that support change</p><p>are unquestionably required for any organizational inno-</p><p>vation or rapid change (Simpson 2002). Part of that inno-</p><p>vative approach includes acquiring multi-trained generalist</p><p>and specialist practitioners, and multi-functioning para-</p><p>professionals. Adaptive organizations reject rigid policies</p><p>and procedures that maintain any organizational status</p><p>quo. Management strategies include incentives to improve</p><p>and/or reinvent the scientific bases of interventions and</p><p>management practices. Forging and maintaining continuous</p><p>relationships with e-based technicians assist the practitio-</p><p>ners in identifying new research that may be applicable to</p><p>general and specific social, clinical, and political problems.</p><p>For example, it is not uncommon for a community-</p><p>based provider to be called upon to treat a youth that has</p><p>juvenile diabetes; addicted to nicotine; considered to have a</p><p>conduct disorder; a verifiable learning disability and has</p><p>developmental delays. This clinical presentation, although</p><p>common, offers substantial challenges for even the best</p><p>trained, highly motivated and monitored practitioner,</p><p>regardless of guild (psychology, psychiatry, social work).</p><p>Adm Policy Ment Health (2010) 37:9599 97</p><p>123</p></li><li><p>The expertise required to adequately screen, evaluate,</p><p>manage, and directly treat these physical, emotional,</p><p>behavioral, and cognitive challenges is substantial and</p><p>beyond the abilities of most direct line practitioners.</p><p>In adaptive co-governance organizations that are co-</p><p>managed by practitioners and researchers from diverse</p><p>professions, the organization would harvest the available</p><p>treatment evidence in an effort to develop the best treatm...</p></li></ul>

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