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Advancing theory on the multilevel role of leadership in the implementation of evidence-based health care practices

Guerrero, Erick G.; Frimpong, Jemima; Kong, Yinfei; Fenwick, Karissa; Aarons, Gregory A.

doi: 10.1097/HMR.0000000000000213
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Background: Top managers’ transformational leadership is associated with significant influence on subordinates. Yet little is known about the extent to which top managers’ transformational leadership influences middle managers’ implementation leadership and, ultimately, frontline staff delivery of evidence-based health care practices.

Purpose: To test a multilevel leadership model examining the extent to which top managers’ transformational leadership, as mediated by implementation leadership of middle managers (i.e., those who supervise direct clinical services), affects staff attitudes toward evidence-based practices (EBPs) and their implementation.

Methodology/Approach: We used data collected in 2013 from 427 employees in 112 addiction health services programs in Los Angeles County, California. We relied on hierarchical linear models with robust standard errors to analyze multilevel data, individuals nested in programs. We conducted two path models to estimate multilevel relationships with two EBPs: contingency management and medication-assisted treatment.

Results: Findings partially supported our theory-driven multilevel leadership model. Specifically, results demonstrated that middle managers’ implementation leadership mediated the relationship between top managers’ transformational leadership and attitudes toward EBPs. At the same time, they showed the mediated relationship for delivery of contingency management treatment was only marginally significant (standardized indirect effect = .006, bootstrap p = .091). We did not find a mediation effect for medication-assisted treatment.

Discussion: Findings advance leadership theory in health care, highlighting the importance of middle managers’ implementation leadership in transmitting the influence of top managers’ transformational leadership on staff attitudes toward EBPs. The full path model shows the extent to which transformational leadership may influence staff implementation of innovative practices as mediated through staff attitudes toward EBPs and middle managers’ implementation leadership.

Practice Implications: Our findings have implications for developing a multilevel leadership approach to implementation in health care. Leadership development should build on different competencies based on managers' level but align managers' priorities on the same implementation goals.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

Erick G. Guerrero, PhD, is Associated Professor, Marshall School of Business and Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles; and Executive Director of the Integrative Leadership to End Addiction Disparities (i-LEAD) Institute. E-mail:

Jemima Frimpong, PhD, is Assistant Professor, Business School at John Hopkins University, Baltimore, Maryland.

Yinfei Kong, PhD, is Assistant Professor, Mihaylo College of Business and Economics, California State University, Fullerton.

Karissa Fenwick, MSW, is Student, Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles.

Gregory A. Aarons, PhD, is Professor, Department of Psychiatry, University of California, San Diego.

Funding for Erick G. Guerrero’s role in this study was provided by National Institute on Drug Abuse research (R01DA038608 and R33DA035634) and implementation fellowship training (R25MH080916) grants. Gregory A. Aarons’ participation was supported by National Institute of Drug Abuse (R01DA038466) and National Institute of Mental Health (R01MH072961 and R01MH092950) grants. Funders had no further role in study design; collection, analysis, and interpretation of data; writing of this report; or decision to submit for publication.

The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.

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