A mixed methods study of the relationship between organisational readiness to change, service user engagement and innovation adoption in community-based opiate substitute treatment services in Ireland

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Kelly, Peter
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University College Cork
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Introduction: While we know that treatment for opiate dependence, such as opiate substitution therapy and psychosocial interventions delivered in community settings are effective, we do not know exactly why they are effective. We do not know exactly what makes some services better than others at delivering treatment, and little is known about the attributes of services which can make them effective at improving service user outcomes or adopting new innovations. Organisational Readiness to Change (ORC) is a key concept from the field of organisational development and where it has been operationalised, it has helped to identify that some attributes of services within substance misuse treatment are important. ORC measurements have identified attributes of services which make some services more effective than others at adopting new innovations and delivering certain aspects of treatment such as service user engagement. No studies using ORC measures have been conducted in the context of Irish community treatment prescribing services and there is a dearth of qualitative studies which examine organisational aspects of addiction treatment services. Aim: The overall aim of this study was to identify and describe aspects of community-based opiate substitute treatment services which were perceived to make them more effective at adapting to change, and delivering treatment for people who are dependent on opiates. This was done by describing and exploring the relationship between staff perceptions of ORC and its relationship with (i) staff perceptions of innovation adoption (ii) service user engagement with treatment and seeking to understand the mechanisms which underpin those relationships. Method: The evidence base for this study was identified by conducting one systematic review (n=14 included studies) on the relationship between ORC and innovation adoption and one systematic review (n=8 included studies) on ORC and client outcomes in substance misuse treatment services. A cross-sectional study using a mixed methods study design which accessed both staff and services users was then conducted. Two separate quantitative studies were conducted concurrently in community-based opiate treatment prescribing services (n=12) across 10 geographic locations in Ireland. The first study, involving a range of staff who had direct contact with service users (n=132) measured the relationship between staff demographics, ORC and training adoption, and data was analysed at the individual level. The second study involved the same staff sample and additional sample of service users (n=262) from the same services. This study measured the relationship between staff and service user characteristics, ORC and client engagement, and data was analysed at the centre level. A concurrent qualitative study with staff, (n=12) was also conducted which explored the narratives of staff about the factors which influence the relationships between ORC and innovation adoption. Results: The systematic literature reviews showed that although the same tool was used to measure ORC across all of the included papers there was significant heterogeneity in study designs and outcomes measured. ORC is predictive of how effectively services can deliver treatment and adopt new innovations into practice. Better ORC ratings (resources, staff attributes, change drivers and in particular organisational climate), related to more effective innovation adoption and better client engagement. Having good organisational climate was of particular importance. The majority of studies were cross-sectional and there was a dearth of qualitative, interventional or quasi-experimental studies which involved the use of ORC measures. Little was known about how to address ORC deficits once they are identified, and generalisability of findings outside the US was not clear. In the first cross-sectional survey undertaken in Irish community opiate substitution treatment services, ORC and staff characteristics were shown to be predictive of training adoption. Staff who were longer in post and with higher levels of education were more likely to engage in a process of training adoption. In services where staff perceived there to be better resources, lower organisational needs, fewer pressures for change, less stress, and better influence with peers they reported higher engagement in a process of training adoption. Disciplines, such as counsellors, reported higher levels of training adoption than other professional groups. In the second cross-sectional survey, involving staff and service users, staff perceptions of ORC were also predictive of better service user engagement. In particular, in services where staff reported greater levels of autonomy, service users reported higher levels of treatment participation, better therapeutic relationships, and higher satisfaction with treatment. Service users who were the longest in treatment reported significantly poorer rapport with staff and were less likely to seek support from peers, while those in stable accommodation reported greater participation in treatment. Levels of peer support were not related to ORC measures, but those with lower levels of education and those in early treatment were more likely to seek support from peers. Findings from both these quantitative studies expanded results using ORC from the US to the Irish context. Concurrent qualitative inquiry with staff showed that change itself was described both in respect of how a service responded to immediate service user needs or supported planned change. Little distinction was made in respect of service attributes which facilitated a response in either context. Overwhelmingly, staff contextualised current service effectiveness, historical change, and desired change in how effectively their services met service user needs, which was also viewed as a significant motivation for change. Differences in operational standards across services in terms of practices, policy implementation, job roles, divisions between professional groups, and recruitment and retention of staff inhibited change adoption. Factors which were identified in terms of inhibiting or facilitating planned change were consistent with the wider literature on change implementation but provided unique insights in the context of substance misuse services. Consideration of the qualitative findings provided possible explanations for relationships identified in the quantitative inquiry in this mixed methods study. Qualitative data also identified aspects of organisations which were important to staff and relevant to ORC but were not identified as being important in quantitative inquiry. Analysis of quantitative and qualitative data within the context of the wider literature provided more understanding of the mechanisms which underpinned relationships between ORC, service user engagement, innovation adoption and helped to understand how some of these relationships might work in practice. Qualitative inquiry also identified organisational factors which were identified as being important to staff but were not captured by ORC measurements. This also helped to understand both currently and retrospectively how cultural factors, social factors and policy can influence staff and service user evaluations of services. These related to areas such as drivers of change, resources, staff recruitment and retention, governance and standardisation of practices and the organisation and planning of services. Conclusion: A wide range of complex but interdependent factors which influence how the ‘eco-system’ of services operate were identified. ORC measures provide valuable insights into the dynamics and process of treatment and these can be used to identify what aspects of services make a service more likely to adopt new innovations or more effectively engage service users. Qualitative inquiry provides rich information which can be used to understand how and why relationships might exist or not in quantitative inquiry. Evidence presented in this thesis, including primary research confirms the importance of assessing staff, organisational and service user attributes as part of an overall systemic approach to bolster policy and improve the quality of substance misuse treatment.
Organisational readiness to change , Service user engagement , Innovation adoption , Opiate substitute
Kelly, P. F. 2021. A mixed methods study of the relationship between organisational readiness to change, service user engagement and innovation adoption in community-based opiate substitute treatment services in Ireland. PhD Thesis, University College Cork.