Expert Recommendations for Designing Reporting Systems to Address Patient-Perpetrated Sexual Harassment in Healthcare Settings.

BACKGROUND: Patient-perpetrated sexual harassment toward staff and patients is prevalent in Veterans Affairs and other healthcare settings. However, many healthcare facilities do not have adequate systems for reporting patient-perpetrated harassment, and there is limited evidence to guide administrators in developing them. OBJECTIVE: To identify expert recommendations for designing effective systems for reporting patient-perpetrated sexual harassment of staff and patients in Veterans Affairs and other healthcare settings. DESIGN: We conducted qualitative interviews with subject matter experts in sexual harassment prevention and intervention during 2019. PARTICIPANTS: We used snowball sampling to recruit subject matter experts. Participants included researchers, clinicians, and administrators from Veterans Affairs/other healthcare, academic, military, and non-profit settings (n = 33). APPROACH: We interviewed participants via telephone using a semi-structured guide and analyzed interview data using a constant comparative approach. KEY RESULTS: Expert recommendations for designing reporting systems to address patient-perpetrated sexual harassment focused on fostering trust, encouraging reporting, and deterring harassment. Recommendations included the following: (1) promote a climate in which harassment is not tolerated; (2) take proportional, corrective actions in response to reports; (3) minimize adverse outcomes for reporting parties; (4) facilitate and simplify reporting processes; and (5) hold the reporting system accountable. Specific strategies related to each recommendation were also identified. CONCLUSIONS: This qualitative study generated initial recommendations to guide healthcare administrators and policy makers in assessing, developing, and improving systems for reporting patient-perpetrated sexual harassment toward staff and other patients. Results indicate that proactive, careful design and ongoing evaluation are essential for ensuring that reporting systems have their intended effects and mitigating the risks of inadequate systems. Additional research is needed to evaluate strategies that effectively address patient-perpetrated harassment while balancing patients' clinical needs.

A Mixed-method Evaluation of the Behavioral Health Integration and Complex Care Initiative Using the Consolidated Framework for Implementation Research.

BACKGROUND: Integrated behavioral health and primary care can improve the health of persons with complex chronic conditions. The Behavioral Health Integration and Complex Care Initiative (BHICCI) implemented integrated care across a large health system. Whether Behavioral Health Organizations (BHOs) and Federally Qualified Health Centers (FQHCs) implemented the BHICCI differently is unclear. OBJECTIVES: The objective of this study was to evaluate integration under the BHICCI and to understand implementation differences between BHOs and FQHCs. METHODS: We used a convergent parallel mixed-method design. Integration was measured quantitatively using the Maine Health Access Site Self-Assessment (SSA), which was completed by clinic teams at baseline and 24 months, and through n=70 qualitative interviews with initiative stakeholders, which were organized using the Consolidated Framework for Implementation Research. Results were compared to understand how qualitative findings explained quantitative results. RESULTS: Data were collected in 7 clinics (n=2 FQHC; n=5 BHOs). FQHCs reported greatest improvement in the client centered subscale, with a baseline score of 4.6 (SD=0.64) and 7.8 (SD=0.89) at 24 months. BHOs reported greatest improvement in the organizational supports for integration subscale, with a baseline score of 4.8 (SD=1.07) and 7.9 (SD=1.1) at 24 months. Our Consolidated Framework for Implementation Research analysis illustrates contextual factors, such as insurance plan supports and clinic-level challenges, that explain these scores. CONCLUSIONS: All clinical settings received support from the health plan, but differences between BHOs and FQHCs affected integration progress. Study results can help identify organizational practices that advance or undermine the delivery of integrated care across multiple clinical settings.

Challenges to Addressing Patient-Perpetrated Sexual Harassment in Veterans Affairs Healthcare Settings.

BACKGROUND: Patient-perpetrated sexual harassment adversely affects healthcare organizations, staff, and other patients, yet few institutions have clear policies to address it. Understanding the challenges to addressing patient-perpetrated harassment can inform development of institutional guidelines and interventions. OBJECTIVE: To identify challenges and stakeholder-driven recommendations for addressing patient-perpetrated sexual harassment of women staff and patients at Veterans Health Administration (VA) facilities. DESIGN: We conducted qualitative interviews with 24 staff, clinicians, and administrators across four VA healthcare facilities. PARTICIPANTS: We used snowball sampling to identify stakeholders with expertise in overseeing care environments, providing care to women patients, and/or managing disruptive patient behavior. APPROACH: We interviewed participants in-person or via phone using a semi-structured guide. Two members of the research team analyzed the interview data using the constant comparative method. KEY RESULTS: Participants identified challenges to addressing patient-perpetrated harassment of women staff and patients that were interrelated and spanned multiple levels. Perceived organizational-level challenges included a climate of tolerance for harassment, lack of formal policies, and insufficient leadership support. At the staff level, perceived challenges included ambiguity around defining harassment, fear of negatively impacting patient-staff dynamics, and competing priorities. Finally, participants identified patient-level challenges, including patient characteristics such as age, cognitive impairment, and psychiatric diagnoses that complicated assessments of intentionality and culpability. Participant recommendations focused on development and implementation of policies, reporting systems, public norms campaigns, staff and patient education, and bystander intervention training. CONCLUSIONS: VA offers unique opportunities for studying patient-perpetrated harassment of women staff and patients due to its majority-male patient population, culture informed by military gender norms, and commitment to reducing harassment at its facilities. Our findings highlight the complexity of addressing patient-perpetrated harassment and underscore the need for systemic, multilevel interventions.

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

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.

Acquisition of Information About Innovative Practices in Outpatient Mental Health Clinics.

This study uses qualitative interviews with leaders of 34 mental health clinics in the context of a statewide rollout of clinical and business innovations to explore how clinics first learn about innovations and which external sources of information they access. Clinic leaders reported accessing information about innovations mainly from government agencies, professional associations, peer organizations, and research literature. Leaders mentioned an average of two external sources of information. There was evidence of variation in how leaders accessed information and how information about innovations was communicated within clinics. Findings have implications for improving dissemination of information about innovations in mental health systems.

'It's Like You Do It Without Knowing That You're Doing It': Practitioner Experiences with ACT Implementation.

Using a case study approach, this study explores the experiences of providers at three organizations identified by county mental health executives as exemplar programs that have received continued and competitive funding to deliver assertive community treatment (ACT) in a large urban county in California. Interviews were conducted with 37 participants including program directors (n = 4), frontline staff (n = 31), and county mental health executives (n = 2). Frontline provider perspectives reveal that, in many ways, teams appear to be working within an ACT model in the absence of detailed explicit knowledge about ACT's core components, frequent or in-depth conversations about ACT, or awareness of fidelity monitoring. Integration of program director and county executive perspectives illustrates how inner and outer contextual information can explain these on-the-ground ACT implementation experiences. This study illustrates the nuanced ways that frontline staff might understand and define evidence-based practice (EBP) use and has implications for studying EBP implementation.

Stakeholder Perceptions of the Barriers to Receiving and Delivering Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings.

CBT is considered the first-line treatment for anxiety disorders, particularly when it involves gradual confrontation with feared stimuli (i.e., exposure); however, delivery of CBT for anxiety disorders in real-world community clinics is lacking. This study utilized surveys we developed with key stakeholder feedback (patient, provider, and administrator) to assess patient and provider/administrator perceptions of the barriers to delivering (or receiving) CBT for anxiety disorders. Providers/administrators from two counties in California (N = 106) indicated lack of training/competency as primary barriers. Patients in one large county (N = 42) reported their own symptoms most often impacted treatment receipt. Both groups endorsed acceptability of exposure but indicated that its use in treatment provided/received had been limited. Implications and recommendations are discussed.

A Preliminary Exploration of the Barriers to Delivering (and Receiving) Exposure-Based Cognitive Behavioral Therapy for Anxiety Disorders in Adult Community Mental Health Settings.

Despite the effectiveness of exposure-based cognitive behavioral therapy (CBT) for anxiety disorders, few individuals in need receive this treatment, particularly in community mental health settings serving low-income adults. The present study took a preliminary step to understand these barriers by conducting a series of key informant interviews and focus groups among patients, providers, clinical administrators, and policy makers. Several themes emerged as barriers to the delivery of exposure-based CBT in these settings, including therapist training and compentency issues, logistical issues, and funding stream issues. Clinical implications and future research that can build from these data are discussed.

Well-Being and Safety Among Inpatient Psychiatric Staff: The Impact of Conflict, Assault, and Stress Reactivity.

Psychiatric staff are faced with multiple forms of hostility, aggression, and assault at work, collectively referred to as workplace violence, which typically is activated by patients but can also come from coworkers and supervisors. Whether workplace violence adversely affects staff well-being may be related not only to its presence, but also to an individual's stress reactivity. At a large public psychiatric hospital, an online survey was completed by 323 clinical care staff, of whom 69.5 % had experienced physical assault in the previous 12 months. Staff well-being (depression, anger, and physical health) and staff safety concerns were adversely affected by conflicts with other staff members and by individual reactivity to social conflict and to assault. To improve staff well-being, in addition to safety protocols, interventions should target staff relationships, personal health maintenance practices, and individual coping skills for dealing with adverse workplace experiences.

Leadership, Organizational Climate, and Perceived Burden of Evidence-Based Practice in Mental Health Services.

The use of evidence-based practices (EBPs) is associated with favorable client outcomes, yet perceived burden of using EBPs may affect the adoption and implementation of such practices. Multilevel path analysis was used to examine the associations of transformational leadership with organizational climate, and their associations with perceived burden of using EBPs. Results indicated significant relationships between transformational leadership and empowering and demoralizing climates, and between demoralizing climate and perceived burden of EBPs. We found significant indirect associations of leadership and perceived burden through organizational climate. Findings suggest that further research is needed to examine the extent to which improving leadership and organizational climate may reduce perceived burden and use of EBPs with the ultimate goal of enhancing quality of care.

Organizational correlates of implementation of colocation of mental health and primary care in the Veterans Health Administration.

This study explored the role of organizational factors in the ability of Veterans Health Administration (VHA) clinics to implement colocated mental health care in primary care settings (PC-MH). The study used data from the VHA Clinical Practice Organizational Survey collected in 2007 from 225 clinic administrators across the United States. Clinic degree of implementation of PC-MH was the dependent variable, whereas independent variables included policies and procedures, organizational context, and leaders' perceptions of barriers to change. Pearson bivariate correlations and multivariable linear regression were used to test hypotheses. Results show that depression care training for primary care providers and clinics' flexibility and participation were both positively correlated with implementation of PC-MH. However, after accounting for other factors, regressions show that only training primary care providers in depression care was marginally associated with degree of implementation of PC-MH (p = 0.051). Given the importance of this topic for implementing integrated care as part of health care reform, these null findings underscore the need to improve theory and testing of more proximal measures of colocation in future work.

Addressing Pregnancy And Parenting In Mental Health Care: Perspectives Of Women With Serious Mental Illness.

Women living with serious mental illness (SMI) are at increased risk for adverse pregnancy and parenting outcomes. However, little is known about the experiences and preferences of women with SMI related to addressing pregnancy and parenting with their mental health providers. We conducted semistructured interviews with twenty-two reproductive-age cisgender women patients living with SMI. Participants characterized discussions about pregnancy and medication teratogenicity with their mental health providers as limited or unsatisfactory. Participants' openness to discussing pregnancy varied by topic and its perceived relevance to their individual circumstances, and it hinged on participants' trust in their providers. Participants characterized discussions about parenting with their mental health providers as helpful and identified additional opportunities for parenting support. Our findings highlight critical gaps in the delivery of information, support, and resources that can inform efforts to increase providers' capacity to address pregnancy and parenting with women living with SMI.

Acceptability of reproductive goals assessment in public mental health care.

OBJECTIVE: To assess patient and provider perspectives on the acceptability of reproductive goals assessment in public mental health clinics and inform potential tailoring for these settings. DATA SOURCES AND STUDY SETTING: Primary qualitative data from patients and providers at four clinics in an urban public mental health system serving individuals with chronic mental illness (collected November 2020-October 2021). STUDY DESIGN: This was an exploratory qualitative study with patients (English-speaking women of reproductive age, primarily Black or Latina) and mental health providers (psychiatrists, psychotherapists, case managers, nurses). We examined the acceptability of reproductive goals assessment within mental health care and obtained feedback on two reproductive goals assessment conversation guides: PATH (Pregnancy Attitudes, Timing, and How Important is Pregnancy Prevention) and OKQ (One Key Question). DATA COLLECTION: We conducted semi-structured telephone interviews with 22 patients and 36 providers. We used rapid qualitative analysis to summarize interview transcripts and identified themes using matrix analysis. PRINCIPAL FINDINGS: Perceptions of reproductive goals assessment were generally positive. Providers said the conversation guides would "open the door" to important discussions, support a better understanding of patients' goals, and facilitate medication counseling and planning. A minority of patients expressed discomfort or ambivalence; several suggested providers ask permission or allow patients to raise the topic. Additional themes included the need for framing to provide context for these personal questions, the need to build rapport before asking them, and the challenge of balancing competing priorities. Many participants found both PATH and OKQ prompts acceptable; some preferred the "conversational" and "open-ended" PATH phrasing. CONCLUSIONS: Participants perceived reproductive goals assessment as a promising practice in mental health care with unique functions in this setting. Areas of discomfort highlight the sensitivity of these topics for some women with chronic mental illness and suggest opportunities to tailor language, framing, and provider training to support effective and appropriate implementation.

Managers' and Leaders' Perceptions of Sexual and Gender-Based Public Harassment in the Veterans Health Administration.

PURPOSE: Managers and leaders have a critical role to play in sexual and gender-based harassment prevention within organizations. Although the Veterans Health Administration has committed to eliminating harassment through national directives and training programs, it is unclear how aware local-level managers and leaders are about public harassment at their facilities and how they perceive sexual and gender-based harassment. We examined middle managers' and leaders' views about whether harassment is perceived as a problem locally, and what policies and procedures (if any) are in place to address public harassment. METHODS: We conducted 69 semistructured telephone interviews with middle managers and facility leaders before implementation of an evidence-based quality improvement project designed to improve delivery of comprehensive women's health care. Transcripts were coded using the constant comparative method and analyzed for overarching themes. RESULTS: Perceptions of the prevalence of sexual and gender-based public harassment varied among middle managers and leaders. A little more than one-half of respondents were unaware of facility-level policies and procedures to address public harassment between patients. To decrease patient-to-patient harassment, both groups generally supported the creation of separate clinical spaces for women. However, middle managers also stated that education was needed to change patient harassing behavior, which they tied to male military culture. CONCLUSIONS: Aligning divergent perspectives of what constitutes sexual and gender-based harassment and how to address it is a necessary step towards tackling harassment at the local level. Managers and leaders should continue to assess environments of care and share findings widely among employees and leadership to improve awareness and inform a unified response.

Sources of Social Support After Patient Assault as Related to Staff Well-Being.

Patient assault is a serious issue for the well-being of staff in psychiatric hospitals. To guide workplace responses to patient assault, more information is needed about social support from different sources and whether those supports are associated with staff well-being. The present study examines social support after patient assault from work-based and nonwork-based sources, and whether inpatient psychiatric staff desires support from them and perceive the support received as being effective. Received support across sources was examined in relations to staff well-being (physical health, mental health, anger, sleep quality) and perceptions of safety. Survey data was collected from 348 clinical staff in a large public forensic mental hospital. Among the 242 staff who reported an assault in the last year, 71% wanted support and 72% found effective support from at least one source. Generally, effective support from supervisors, coworkers, and their combination was associated with better well-being. Support from nonwork sources was related to less concerns about safety, but not to other well-being measures. However, 28% of staff did not receive effective support from any source postassault. Gaps in support as reported in this study and as found by other investigators call for systematic programming by hospital organizations to enhance the well-being of clinical staff, which in turn has implications for patient care.

Women Veterans' Experiences of Harassment and Perceptions of Veterans Affairs Health Care Settings During a National Anti-Harassment Campaign.

PURPOSE: In 2017, Veterans Health Administration (VA) launched a social marketing and training campaign to address harassment of women veterans at VA health care facilities. We assessed women veterans' experiences of harassment, reported perpetrators of harassment, and perceptions of VA in 2017 (before campaign launch) and 2018 (1 year after campaign implementation). METHODS: We administered surveys to women veterans attending primary care appointments (2017, n = 1,300; 2018, n = 1,711). Participants reported whether they experienced sexual harassment (e.g., catcalls) and gender harassment (e.g., questioning women's veteran status) from patients and/or staff at VA in the past 6 months. They also indicated whether they felt welcome, felt safe, and believed the VA is working to address harassment. We compared variables in 2017 versus 2018 with χ2 analyses, adjusting for facility-level clustering. RESULTS: There were no significant differences in percentages of participants reporting sexual harassment (20% vs. 17%) or gender harassment (11% vs. 11%) in 2017 versus 2018. Men veterans were the most frequently named perpetrators, but participants also reported harassment from staff. Participant beliefs that VA is working to address harassment significantly improved from 2017 to 2018 (52% vs. 57%; p = .05). CONCLUSIONS: One year after campaign launch, women veterans continued to experience harassment while accessing VA health care services. Findings confirm that ongoing efforts to address and monitor both staff- and patient-perpetrated harassment are essential. Results have implications for future anti-harassment intervention design and implementation and highlight additional opportunities for investigation.

Staff and Patient Perspectives on Bystander Intervention Training to Address Patient-Initiated Sexual Harassment in Veterans Affairs Healthcare Settings.

INTRODUCTION: One in four women veteran patients experience public harassment by men veterans at Veterans Affairs (VA) health care facilities. Bystander intervention training-teaching bystanders to identify harassment, assess appropriate responses, and safely intervene before, during, or after an event-is a popular strategy for addressing harassment in military and education settings. We explored staff and veteran patient perspectives on bystander intervention training to address harassment of women veterans in VA health care settings. METHODS: We conducted 24 staff interviews and 15 veteran patient discussion groups (eight men's groups and seven women's groups) at four VA Medical Centers. We analyzed transcripts using the constant comparative method. RESULTS: Participants expressed divergent views about bystander intervention training to address harassment of women veteran patients at VA. Most participants supported training staff in bystander intervention, but support for training patients was mixed. Participants identified potential benefits of bystander intervention, including staff and patient empowerment and improvements to organizational culture. They also identified potential concerns, including provocation of conflict between patients, lack of buy-in among the VA community, and difficulty in identifying intervention-appropriate situations. Finally, participants offered recommendations for tailoring training content and format to the VA context. CONCLUSIONS: Bystander intervention training has the potential to raise collective responsibility for addressing harassment of women in VA and other health care contexts. However, our results illustrate divergent stakeholder views that underscore the importance of engaging and educating stakeholders, securing buy-in, and tailoring bystander intervention programs to local contexts before implementation.

Reflective writing: a tool to support continuous learning and improved effectiveness in implementation facilitators.

BACKGROUND: Implementation facilitators support the adoption of evidence-based practices and other improvement efforts in complex healthcare settings. Facilitators are trained to develop essential facilitation skills and facilitator effectiveness is typically evaluated post-implementation, but little is known about how facilitators apply and adapt didactic knowledge after training, or how learning and refining experiential knowledge occurs during the facilitation process. We propose the use of reflective writing as a tool to document and support facilitator learning and facilitator effectiveness. METHODS: Using an instrumental case study of the Coordination Toolkit and Coaching (CTAC) project, we explore the use of reflective writing by facilitators to support their learning and effectiveness. Six primary care clinics participated in weekly hour-long facilitation calls over a 12-month period to implement quality improvement projects related to care coordination. Two facilitators completed templated reflections after each facilitation call for their assigned sites, totaling 269 reflections. We used the declarative-procedural-reflective model, which defines the process of skill development in clinical practice, to qualitatively analyze the reflections. Two independent coders used content analysis principles to code text that captured facilitators' observations, evaluations, interpretations, and communication. Descriptive statistics were used to analyze reflections by facilitator and by code within and across reflections. RESULTS: CTAC facilitators primarily used the reflections to summarize the calls (observation), assess the facilitation process and the tasks and activities they used (evaluation), document their thoughts about how to improve their own effectiveness (interpretation), and describe their communication with implementing teams. Ninety-one percent of reflections included observations, 42% interpretation, 41% evaluation, and 44% facilitator communication. In total, we coded 677 segments of text within reflections: 39% represented observation, 20% interpretation, 18% evaluation, and 23% facilitator communication. CONCLUSIONS: The process of reflective writing allowed the CTAC facilitators the time and structure to evaluate their facilitation and to think critically about how to adjust their facilitation in response to their observations and interpretations. Reflective writing is a feasible and acceptable tool to support and document facilitator learning and effectiveness. TRIAL REGISTRATION: The project was registered with ClinicalTrials.gov ( NCT03063294 ) on February 24, 2017.

Contracting as a bridging factor linking outer and inner contexts during EBP implementation and sustainment: a prospective study across multiple U.S. public sector service systems.

BACKGROUND: Bridging factors are relational ties (e.g. partnerships), formal arrangements (e.g. contracts or polices) and processes (e.g. data sharing agreements) linking outer and inner contexts and are a recent evolution of the Exploration-Preparation-Implementation-Sustainment (EPIS) framework. Bridging factor research can elucidate ways that service systems may influence and/or be influenced by organizations providing health services. This study used the EPIS framework and open systems and resource dependence theoretical approaches to examine contracting arrangements in U.S. public sector systems. Contracting arrangements function as bridging factors through which systems communicate, interact, and exchange resources with the organizations operating within them. METHODS: The sample included 17 community-based organizations in eight service systems. Longitudinal data is derived from 113 contract documents and 88 qualitative interviews and focus groups involving system and organizational stakeholders. Analyses consisted of a document review using content analysis and focused coding of transcripts from the interviews and focus groups. A multiple case study analysis was conducted to identify patterns across service systems and organizations. The dataset represented service systems that had sustained the same EBP for between 2 and 10 years, which allowed for observation of bridging factors and outer-inner context interactions over time. RESULTS: Service systems and organizations influenced each other in a number of ways through contracting arrangements. Service systems influenced organizations when contracting arrangements resulted in changes to organizational functioning, required organizational responses to insufficient funding, and altered interorganizational network relationships. Organizations influenced service systems when contract arrangements prompted organization-driven contract negotiation/tailoring, changes to system-level processes, and interorganizational collaboration. Service systems and organizations were dependent on each other as implementation progressed. Resources beyond funding emerged, including adequate numbers of eligible clients, expertise in the evidence-based practice, and training and coaching capacity. CONCLUSION: This study advances implementation science by expanding the range and definition of bridging factors and illustrating specific bi-directional influences between outer context service systems and inner context organizations. This study also identifies bi-directional dependencies over the course of implementation and sustainment. An analysis of influence, dependencies, and resources exchanged through bridging factors has direct implications for selecting and tailoring implementation strategies, especially those that require system-level coordination and change.

Who Wants Feedback? Effects of Transformational Leadership and Leader-Member Exchange on Mental Health Practitioners' Attitudes Toward Feedback.

OBJECTIVE: The purpose of this study was to identify the mechanisms through which different aspects of leadership affect mental health practitioners' attitudes toward supervisory feedback. METHODS: Data were collected from 363 practitioners nested in 68 treatment teams in public-sector mental health organizations. A multilevel path analysis was conducted to examine the associations of transformational leadership (supervisor's ability to inspire others to follow a course of action) and leader-member exchange (quality of the supervisor-practitioner relationship) with practitioner attitudes toward feedback. RESULTS: Transformational leadership and leader-member exchange were directly and positively associated with practitioners' attitudes toward feedback. Transformational leadership was also indirectly associated with practitioners' attitudes toward feedback through the quality of supervisor-practitioner relationships. CONCLUSIONS: Study results contribute to the growing body of evidence suggesting that leaders play a key role in shaping mental health service delivery. Both leadership behavior and high-quality supervisor-practitioner relationships are important in supporting practitioners in delivering evidence-based mental health care. Policymakers, administrators, and researchers should consider an integrative approach when developing leadership training interventions.