The Organizational Social Context of Mental Health Medicaid Waiver Programs with Family Support Services: Implications for Research and Practice

Abstract

Introduction

Peer family support specialists (FSS) are parents with practical experience in navigating children’s mental health care systems who provide support, advocacy and guidance to the families of children who need mental health services. Their experience and training differ from those of formally trained mental health clinicians, creating potential conflicts in priorities and values between FSS and clinicians. We hypothesized that these differences could negatively affect the organizational cultures and climates of mental health clinics that employ both FSS and mental health clinicians, and lower the job satisfaction and organizational commitment of FSS.

Method

The Organizational Social Context (OSC) measure was administered on site to 209 FSS and clinicians in 21 mental health programs in New York State. The study compared the organizational-level culture and climate profiles of mental health clinics that employ both FSS and formally trained clinicians to national norms for child mental health clinics, assessed individual-level job satisfaction and organizational commitment as a function of job (FSS vs. clinician) and other individual-level and organizational-level characteristics, and tested whether FSS and clinicians’ job attitudes are differentially associated with organizational culture and climate.

Results

The programs’ organizational culture and climate profiles were not significantly different from national norms. Individual-level job satisfaction and organizational commitment were unrelated to position (FSS vs. clinician) or other individual-level and organizational-level characteristics except for culture and climate.

Conclusions

Organizational culture and climate are not related to the employment of FSS. Both FSS’ and clinicians’ individual-level work attitudes are associated similarly with organizational culture and climate.

Peer family support specialists (FSS) provide support, advocacy and guidance to families with children who need mental health services. FSS are typically parents of children who have received mental health care and have experience in navigating the institutional, bureaucratic and social hurdles encountered by families caring for children with chronic mental health problems. FSS are rarely formally trained mental health professionals and the credentials they bring to their work are rooted more in life experience and a passion for advocacy and helping families with similar mental health care needs than in formal education and traditional clinical training. Several states such as New York recognize the value of FSS and have implemented policies that support the integration of FSS in mental health clinics that serve children and families.

There is a belief among some advocates that FSS are not fully integrated into the mental health clinics in which they work and that their skills and experience are not uniformly appreciated by all formally trained clinicians (Donner, 2003; Parson & Lambert, 2012; Stroul, 1996). A lack of integration and appreciation of FSS services could affect a clinic’s organizational culture and climate, and result in FSS becoming alienated from their work environment and experiencing more negative work attitudes (e.g., lower levels of job satisfaction and organizational commitment) than found among clinicians. Organizational culture and climate may also play different roles in the formation of work attitudes among FSS and clinicians who work in the same clinic. That is, individual-level differences in experience and priorities that distinguish FSS from clinicians could be expected to moderate the effect of organizational-level culture and climate on their own individual-level work attitudes.

Several studies have confirmed relationships between individual-level perceptions of organizational culture and climate, on the one hand, and individual-level work attitudes on the other; however, there is less information about cross-level relationships where culture and climate are measured at the organizational level and work attitudes are measured at the individual level (Carr et al., 2003; James et al., 2008). Most importantly, there has been very little research on the differences in work attitudes among different groups of mental health service providers and almost none on the relationship of individual-level work attitudes with organizational-level culture and climate between professional and non-professional service providers in the same service system. Here, we begin to address these gaps by comparing: (a) the organizational-level culture and climate profiles of clinics that employ FSS with national norms for mental health clinics; (b) the individual-level work attitudes of formally trained clinicians and FSS; and, (c) the association of organizational-level culture and climate with individual-level work attitudes for FSS and clinicians working within the same mental health clinic.

The Organizational Culture and Climate of Mental Health Clinics that Provide Family Support Services

Organizational culture and climate define the social context of an organization, but each construct has a unique history in the organizational research literature (Ashkanasy, Wilderom & Peterson, 2000; Carr et al., 2003; Glisson & James, 2002; James et al., 2008; Reichers & Schneider, 1990; Verbeke, Volgering, & Hessels, 1998). Both constructs have been associated with critical criteria in mental health settings such as staff turnover, new program sustainment, receptivity to evidence-based practices, service quality and youth outcomes (Aarons et al., 2012; Aarons & Sawitzky, 2006; Glisson & Green, 2006, 2011; Glisson & Hemmelgarn, 1998; Glisson, Hemmelgarn, Green & Williams, 2013; Glisson & James, 2002; Glisson, Schoenwald et al., 2008). Although some writers use the two terms interchangeably, there is evidence that the two constructs are, in fact, distinct.

Organizational culture.

Organizational culture is an organizational-level construct assessed as the behavioral expectations that members of an organization are required to meet in their work environment (Verbeke et al., 1998). These expectations prescribe work behavior and socialize new employees in the priorities that are most important to the organization. Organizational culture is often described as including values (Rousseau, 1990) and several studies indicate that culture is developed and maintained in a workforce through behavioral expectations that reflect values (Ashkanasy, Broadfoot, & Falcus, 2000; Hofstede, 1998; Hofstede, Neuijen, Ohayv, & Sanders, 1990).

In children’s mental health service programs, for example, proficient organizational cultures expect that service providers will maintain the skills and expertise required for optimal outcomes and place improvements in client-wellbeing as the highest priority. Other dimensions of positive cultures within children’s mental health settings include expectations such as openness to change and flexibility. These positive cultural characteristics (proficiency, openness to change and flexibility) should complement the efforts of FSS by establishing expectations for all employees to: (a) excel in their work, (b) support the exploration of new techniques and ideas, and (c) foster less formalized divisions of labor and less centralized hierarchies of authority.

To the degree that family support services present an innovative approach to serving families, FSS working in negative cultures characterized by rigidity versus flexibility and by resistance to change versus openness to change could experience both passive and active opposition to new ideas and behaviors that require alterations in institutionalized program protocols. Active opposition might include critical responses to ideas and efforts associated with family support services while emphasizing rationales for resisting change that undermine the FSS’ efforts. Similarly, passive opposition could occur with superficial agreement to collaborate coupled with poor availability or follow through regarding suggestions and requests from FSS.

Organizational climate.

Psychological climate (as distinct from organizational climate) is assessed as individual employees’ perceptions of the psychological impact of their work environment on their own functioning and well-being. For example, individuals may experience their work climate as highly stressful (James & James, 1989). When members of the same organizational unit agree on their perceptions, their perceptions can be aggregated to describe the organizational climate of their work environment. When aggregated, the organization’s work environment would be characterized as stressful if the members of the unit shared the experience of high levels of stress (Jones & James, 1979; Joyce & Slocum, 1984).

Those who work in functional climates perceive their work environment as providing the cooperation and role clarity they need to be successful in their jobs. In negative, less functional climates, both FSS and clinicians would perceive minimal cooperation from colleagues and a lack of clarity regarding their mutual roles. Negative climates that are high in stress and low in functionality contribute to detachment among coworkers and attributions of blame for failures and problems. Reduced cooperation and clarity in less functional climate creates service barriers through conflicts over incongruent service goals and strategies, as well as service providers withholding information needed for improving services.

Those who work in positive climates characterized by engagement perceive a sense of involvement and personal accomplishment in their work. A potential asset that FSS bring to youth mental health care is their empathy and shared experiences with client families that aid in developing working relationships. In a program characterized by an engaged climate, FSS and the experiences they bring to the service team are expected to be valued and perceived by clinicians as critical to successful outcomes. In contrast, the efforts of FSS might be viewed as less important by service team members in less engaged clients.

Models of Work Attitudes

Work attitudes are most often assessed as the job satisfaction and organizational commitment of individual employees. The definitions of job satisfaction and organizational commitment have remained consistent over several decades of research and there is agreement that they are distinct but related individual-level constructs (Glisson & Durick, 1988; Glisson, Landsverk et al., 2008; Judge, Thoresen, Bono, & Patton, 2001; Rosen, Levy, & Hall, 2006). Job satisfaction is defined as a positive emotional state resulting from the appraisal of one’s job tasks (Locke, 1976). Organizational commitment is defined as a strong belief in an organization’s goals, a willingness to exert considerable effort on behalf of the organization, and a strong desire to remain a member of the organization (Mowday, Porter &Steers, 1982). The distinction between the two constructs is that commitment is a response to beliefs about the organization while job satisfaction is a response to the experience of specific job tasks. Although the two constructs are distinct, it has long been argued that the morale of a workforce depends on both— an attachment to the organization (i.e., commitment) and a positive reaction to one’s specific job (i.e., satisfaction) within the organization (Viteles, 1953). Job satisfaction and organizational commitment are important because of their association with employee behavior and performance in a range of organizational settings (Judge et al, 2001; Rosen et al, 2006).

Theoretical models developed to explain individual differences in work attitudes have focused on characteristics of the individual, characteristics of the individual’s job, or characteristics of the organization as critical antecedents to an employee’s job satisfaction and organizational commitment (Glisson & Durick, 1988). Theories that focus on characteristics of the individual focus on differences in either disposition or socioeconomic factors such as education which contribute to differences in individuals’ critiques of their job and organization. For example, individuals with more education are more critical because they have more alternatives for employment and are less likely to be satisfied with a specific job or committed to a specific organization. Theories focused on job characteristics argue that differences such as the level of autonomy, skill variety, and task significance associated with a job are important for explaining work attitudes because different jobs have different capacities for satisfying employees’ intrinsic needs. In those programs that fail to integrate family support services, FSS would be expected to experience less autonomy, skill variety and task significance than formally trained clinicians. Theories focused on characteristics of organizations argue that the organizational social context within which work occurs (e.g., organizational culture and climate) is the major determinant of variation in individuals’ work attitudes. Theories emphasizing social context draw on social information processing theory to argue that individual worker attitudes are constructed through social interaction with other workers in the same work context, relatively independent of the characteristics of the individual worker or their jobs (Glisson & Durick, 1988).

A growing body of research supports social context theories that explain differences in individual work attitudes as a function of differences in organizational culture and climate (Carr et al., 2003; Hartnell, Ou &Kinicki, 2011; James et al., 2008). In the area of children’s mental health services, there is evidence that organizational-level culture and climate are more closely related to individual-level work attitudes than are other individual-level and organizational-level characteristics (Glisson & James, 2002; Glisson, Landsverk et al., 2008) and that work attitudes form a mediating link between organizational culture and climate and staff behavior (e.g., turnover) (Aarons & Sawitsky, 2006).

Although studies of mental health service providers suggest that organizational social context (i.e., organizational culture and climate) may be a key predictor of employees’ work attitudes, these studies have typically included only mental health clinicians with formal mental health training and have not examined the unique circumstances surrounding the integration of peer advocates into work environments that are predominantly staffed by formally trained clinicians. Because of the unique job characteristics of the FSS role and because the individual-level characteristics of this workforce differ from traditional mental health clinicians, organizational-level culture and climate may play less of a role in shaping the individual-level work attitudes of this workforce. As a result, the association of organizational culture and climate with individual work attitudes may differ between FSS and clinicians.

Objectives of the Study

The present study describes the organizational-level culture and climate profiles of a sample of outpatient youth mental health Medicaid waiver programs in New York that provide both clinical treatment and peer-delivered family support services. We hypothesized that these programs’ culture and climate profiles would be more negative than those found in a national sample of outpatient youth mental health programs. Next, we examine the individual-level work attitudes of job satisfaction and organizational commitment of FSS and clinicians who provide mental health services in the same participating programs as a function of their job position (FSS vs. clinician), their individual-level characteristics, and organizational-level characteristics. We hypothesized that FSS would have more negative work attitudes. Finally, we examine the interactions between organizational-level culture and climate on the one hand and job position (FSS vs. clinician) on the other, and hypothesized that the association of organizational-level culture and climate with individual-level work attitudes would differ for FSS and clinicians.

Method

A cross-sectional on-site survey was conducted of New York State Office of Mental Health-funded Home and Community Based Services (HCBS) Medicaid Waiver Programs that serve children with serious emotional disturbance (SED) and provide family support services. Of 33 programs statewide, 30 met the eligibility requirement of having at least one peer family support specialist (FSS) on staff. Twenty-one programs (64% of 33) agreed to participate in the survey. These 21 programs are representative of the HCBS programs across the state in terms of program capacity (number of families that can be served ranged between 12 and 144, mean = 48.9, SD = 37.5) and urban (24 % in New York City) versus non-urban (76 % in the Hudson Valley and Western region) location.

Participants

The Organizational Social Context (OSC) measure was administered in person to 223 HCBS staff from 21 programs. All frontline staff employed at least half-time were included; no supervisors were present during the OSC administration; and response rates were 80 percent to 100 percent of the staff in each program. The number of respondents per program ranged from 4 to 27. Out of the 223 OSCs, 14 surveys were deemed invalid due to inconsistent ratings and/or insufficient data (more than 10% missing data). All data were collected on site between May and October, 2011. As shown in Table 1, the 209 service providers included 172 clinicians and 37 FSS; participants from each of the 21 programs included at least one family support specialist (FSS).

Table 1.

Characteristics of clinicians and peer family support specialists (FSS)

		Clinicians (n = 172)				FSS (n = 37)
	Min.	Max.	Mean	SD	Min.	Max.	Mean	SD
Number of participants per site	3	22	8.19	5.60	1	5	1.76	1.14
Age of participants	22	66	36.12	10.32	25	66	47.73***	10.87
Years of experience	0	36	10.00	6.74	0	40	10.27	9.13
Years in agency	0	22	3.36	3.20	0	10	3.43	2.44
Participant	%				%
Gender
Female	81.4				94.4*
Ethnicity
African American	18.0				8.1
Asian American	2.9				.0
White	62.8				83.8*
Hispanic	14.8				11.1
Native American	.6				.0
Other	15.1				8.1
Education
High school	2.4				34.3***
Associate degree	5.4				31.4***
Bachelors degree	42.8				25.7*
Masters degree	49.4				8.6***

Note: Independent samples t-tests used to compare means; Likelihood ratio tests used to compare proportions.

^***p <.001

^*p < .05

Table 1 compares the demographic characteristics of the clinicians and FSS who participated in the study. There were at least two FSS in nine programs, at least three FSS in four programs, and two programs had four and five FSS, respectively. The clinicians and FSS ranged in age between 22 and 66 years. On average, clinicians were about 10 years younger (36 versus 48 years) than the FSS, less likely to be female (81 versus 94 percent), less likely to be white (63 versus 84 percent), and more likely to be college educated (92 versus 34 percent).

Measure of Organizational Social Context

The OSC assesses organizational-level social context (culture and climate) and the individual-level work attitudes of job satisfaction and organizational commitment. The OSC measurement model has been confirmed in two U.S. nationwide samples: mental health clinics that serve youth (Glisson, Landsverk et al., 2008) and child welfare systems (Glisson, Green & Williams, 2012). These samples provide national norms for the OSC that are used in constructing culture and climate profiles of organizations that provide mental health and child welfare services, respectively (Glisson, Landsverk et al., 2008; Glisson et al., 2012).

The scales composing the OSC measurement system were developed over three decades of research with mental health, child welfare and other social service organizations (e.g., Glisson, 1978; Glisson & Durick, 1988; Glisson et al., 2012; Glisson & Hemmelgarn, 1998; Glisson, Landsverk, et al., 2008). These scales are associated with service related criteria such as employee turnover, service quality and service outcomes (Aarons et al., 2012; Glisson & Green, 2006, 2011; Glisson et al., 2012; Glisson & James, 2002; Glisson, Schoenwald et al., 2008).

Organizational culture.

The OSC assesses organizational culture on three primary dimensions: rigidity, proficiency and resistance. Rigid cultures expect that service providers will have no flexibility in carrying out their jobs, provide limited input into key management decisions, and carefully follow a host of bureaucratic rules and regulations (alpha reliability in current sample = .81). Proficient organizational cultures expect that service providers will place the well-being of each client first, be competent and have up-to-date knowledge (alpha reliability = .89). Resistant cultures expect that service providers will show little interest in new ways of providing services and suppress any change effort (alpha reliability = .75).

Organizational climate.

The OSC measures organizational climate on three primary dimensions: engagement, functionality and stress. Service providers in engaged climates perceive that they are able to personally accomplish many worthwhile things and remain personally involved in their work and concerned about their clients (alpha reliability in current sample = .75). Service providers in functional climates perceive they have the cooperation and help they need from coworkers and administrators to do a good job and have a clear understanding of how they can work successfully within the organization (alpha reliability = .90). Service providers in stressful climates perceive they are emotionally exhausted from their work, overloaded in their work, and conflicted in their job responsibilities (alpha reliability = .93) .

Work attitudes.

The OSC also measures individual-level work attitudes with two scales measuring the individual’s job satisfaction and commitment to the organization (Glisson & Durick, 1988). Employees with high job satisfaction appraise their everyday job tasks positively (alpha reliability in current sample = .84) and employees with high organizational commitment are invested in their organization’s success and intend to remain as employees of their organization (alpha reliability = .91).

Results

Within-system Agreement and Between-system Differences

The aggregation of individuals’ responses by organizational unit is necessary for composing the organizational-level profile of culture and climate (Chan, 1998). Glisson and James (2002) provide a detailed explanation of the differences between the composition models for culture and climate, and specify within-group consensus or agreement as a precondition for using aggregation to compose a higher-level organizational construct from individual employee-level responses. Following these composition models, an OSC culture and climate profile is produced for each program by aggregating employee responses within each program.

The level of agreement in the responses of service providers in the same mental health program is assessed with an index of within-group consistency of responses, r_wg, computed for each of the scales measuring culture and climate (James, Demaree & Wolf, 1993). As shown in Table 2, the r_wg values for each scale in the present sample are high and range between .83 and .99 across all programs. Moreover, the average value for each scale across all programs range between .94 and .97 so these values as a group indicate a high consistency of responses within each of the sampled mental health programs.

Table 2.

Within-group consistency analysis of clinician and peer family support specialist (FSS) responses in 21 waiver programs (N=209)

Construct	r wg
	Minimum	Maximum	Average
Rigidity	.92	.98	.96
Proficiency	.95	.99	.97
Resistance	.83	.97	.94
Stress	.95	.99	.97
Engagement	.94	.98	.97
Functionality	.91	.98	.96

Between-program variance confirms that the homogeneity of responses within-systems is not a byproduct of homogeneity of responses across an entire sample of programs and establishes the presence of substantive differences between programs. Between-program differences are calculated using the intraclass correlation coefficient (ICC) and eta-squared (see Bliese, 2000; Cohen & Cohen, 1983; and Raudenbush & Bryk, 2002). As shown in Table 3, Type 1 ICC values are typically much smaller than eta-squared values (Bliese, 2000) and range in this sample between .07 and .28 and average .16. Eta squared values for all scales ranged between .16 and .37 (which correspond to correlations between .40 and .61, respectively). These analyses show that a significant proportion of the variance in OSC responses is a function of the mental health program in which the respondent worked.

Table 3.

Between-groups analysis of clinician and peer family support specialist (FSS) responses in 21 waiver programs (N = 209)

Construct	Program Variance	Residual Variance	ICC	MSBG	MSWG	Eta squared
Rigidity	13.17 ***	34.54	.28	187.67	34.70	.37 ***
Proficiency	4.25 **	45.46	.09	88.99	45.22	.17 **
Resistance	7.92 ***	34.75	.19	109.96	34.68	.25 ***
Stress	20.92 ***	131.30	.14	331.29	131.69	.21 ***
Engagement	1.39 *	18.04	.07	32.06	17.79	.16 *
Functionality	12.20 ***	66.16	.16	189.65	65.95	.23 ***

^*P < .05;

^**P < .01;

^***P < .001

Creating Norm-based OSC Profiles

Figure 1 provides examples of culture and climate profiles from this sample of mental health programs, using T scores based on the national sample (Glisson, Landsverk et al., 2008). The figure illustrates the variety of profiles across these mental health programs by providing examples of the best and worst profiles in the sample. As illustrated with one mental health program profile shown in Figure 1, programs with the best culture have proficiency scores that are substantially higher (here, two standard deviations) than the resistance and rigidity scores. Figure 1 also includes a profile from one mental health program that illustrates a worst culture in which the proficiency score is substantially lower (here, approximately three standard deviations) than the program’s resistance and rigidity scores.

Figure 1.

Examples of best and worst culture and climate profiles based on national norms

Figure 1 also provides examples of the best and worst climates in the sample. The criteria for a best climate require the mental health program’s scores on engagement and functionality to be substantially higher than its score on stress. In the best climate in this sample, engagement and functionality are one and two standard deviations, respectively, above the score on stress. An example of a worst climate is also provided in Figure 1, showing a mental health program’s scores on engagement and functionality are four and two standard deviations, respectively, below its score on stress.

Latent Profile Analysis (LPA)

Culture and climate program profiles are combined to compute a composite program OSC profile score using Latent Profile Analysis based on norms from the national sample of mental health programs (Vermunt, 2004). Latent profile analysis, also referred to as latent class cluster analysis (Vermunt & Magidson, 2002) and mixture model clustering (Hunt & Jorgen, 1999), is a special case of finite mixture modeling in which a categorical latent variable is used to model heterogeneity among a set of observed outcome indicators (Muthén & Muthén, 2008). Here, the categorical latent variable represents a set of subpopulations or classes of programs that explain programs’ patterns of scores on the six culture and climate dimensions. Parameter estimates from the LPA provide means and variances for each class as well as the probability of class membership for each program (Hunt & Jorgensen, 1999).

The LPA of culture and climate scores of children’s mental health clinics from the national sample identified a three class solution (Glisson, Landsverk et al., 2008). The three empirically derived classes from the national sample are labeled positive (29%), average (49%), and negative (22%) OSC profiles. The class with a positive OSC profile has culture scores that are high on proficiency and low on rigidity and resistance, and climate scores that are high on engagement and functionality and low on stress. The class with an average OSC profile is represented by scores that are closer to the national average on all six OSC dimensions. The class with a negative OSC profile has culture scores high on rigidity and resistance and low on proficiency and climate scores high on stress and low on functionality and engagement. The LPA parameters from the national sample were applied to the programs in the present study to determine the probability of class membership for each program in the present study.

The classification of organizational profiles of culture and climate for the current sample resulted in fewer classified as average (24%) and more classified as negative (43%) and positive (33%) as compared to national norms. However, these differences were not large enough to be significantly different from the national sample (χ² = 5.338; df = 2; p < .069).

A weighted class membership variable was derived for each program, calculated as the probability-weighted sum of class membership in the three classes with scores ranging from 1.00 to 3.00. Higher scores on the weighted sum represent greater likelihood of membership in the class with the most positive OSC culture and climate profile. The LPA OSC scores in the present sample ranged between 1.00 and 3.00 with a mean of 1.88.

Hierarchical Linear Models Analysis

Hierarchical linear models (HLM) analyses were conducted using restricted maximum likelihood estimation for mixed effects regression models with HLM 6 software (Raudenbush, Bryk, Cheong, & Congdon, 2004). Hierarchical linear models analyses with fully random intercepts and slopes were used to estimate the cross-level relationships between organizational-level predictors and two individual-level criteria (Hedeker & Gibbons, 2006; Raudenbush & Bryk, 2002). The HLM analyses estimate individual-level job satisfaction and commitment, respectively, as a function of job position (FSS vs. clinician), individual-level characteristics (education, age, job experience, gender, race) and organizational-level characteristics (LPA OSC classification of organizations, New York City versus non-urban location, size of program, budget to staff ratio).

Table 4 shows that the LPA OSC classification of programs by organizational-level climate and culture was significantly related to individual-level job satisfaction after controlling for other organizational-level constructs, the respondents’ job position (FSS vs. clinician), individual-level characteristics, and the random organizational effects. Individual clinicians and FSS who work in mental health programs with more positive culture and climate profiles reported higher levels of job satisfaction. No other characteristics of the individual respondents or programs predicted job satisfaction. There was not a significant cross-level interaction between job position and the LPA OSC score for organizational- level culture and climate.

Table 4.

Hierarchical linear models analysis of job satisfaction (n=209, programs =21)

	Variable	Coefficient	SE	t-ratio	P-value
Conditional	Constant	47.24	5.89	8.02	.000
	NYC location	2.03	2.61	.78	.447
Organizational level
	Number of clinicians	.03	.03	.89	.387
	Budget ratio	.00	.00	1.02	.326
	OSC profile	3.69	.99	3.74	.002
Individual level	FSS	.93	2.03	.46	.650
	Years of experience	−.11	.13	−.82	.423
	Age	−.06	.07	−.89	.387
	Educational level	−.89	.84	−.105	.305
	Black	2.14	2.07	1.05	.308
	White	2.53	2.02	1.25	.225
	Female	.87	2.07	.422	.677
	OSC profile × FSS	−.44	2.04	−.22	.831

As shown in Table 5, individual-level commitment was also significantly associated with the organizational-level classification of culture and climate profiles. Individual clinicians and FSS who work in mental health programs with higher OSC scores reflecting more positive organizational-level culture and climate profiles reported higher levels of individual-level commitment after controlling for job position, individual-level characteristics and other organizational-level characteristics No other characteristics of the individual respondents or organizations predicted individual-level commitment. Moreover, the cross-level association between individual-level commitment and organizational-level culture and climate did not vary between clinicians and FSS.

Table 5.

Hierarchical linear models analysis of organizational commitment (n=209, programs=21)

	Variable	Coefficient	SE	t-ratio	P-value
Conditional	Constant	51.58	5.08	10.15	.000
Organizational		−3.44	2.48	−1.39	.183
level	NYC location
	Number of clinicians	.01	.03	.19	.849
	Budget ratio	.00	.00	1.03	.318
	OSC profile	2.36	1.05	2.25	.039
Individual level	FSS	−1.26	2.12	−.59	.559
	Years of experience	−.04	.12	−.35	.733
	Age	.09	.06	1.34	.196
	Educational level	−1.26	.77	−1.64	.117
	Black	.43	1.93	.22	.828
	White	1.42	1.78	.80	.435
	Female	−.15	1.83	−.08	.935
	OSC profile × FSS	−1.37	2.06	−.666	.513

Discussion

A number of models have been proposed to explain variation in individual employee work attitudes in mental health and other work settings. Competing theories of work attitudes stress the importance of individual, job, and organizational characteristics, respectively, in explaining employee work attitudes and subsequent work behavior (e.g., turnover, performance). Because of the empirical link between employee work attitudes, performance, and turnover, these theories have important implications for the functioning and effectiveness of mental health services (Aarons & Sawitzky, 2006; Judge et al, 2001; Rosen et al., 2006).

Among mental health clinics that are implementing peer-delivered family support services, the job position of the respondent (FSS vs. clinician) was hypothesized to play a role in explaining the respondent’s work attitudes because of preliminary evidence that FSS may not be fully integrated into the mental health clinics that employ traditional formally trained mental health clinicians as service providers (Donner, 2003; Parson & Lambert, 2012). However, the clinic’s organizational-level culture and climate profile was the only significant predictor of work attitudes in the participating clinics, and FSS and formally trained clinicians had similar levels of job satisfaction and organizational commitment. Furthermore, organizational culture and climate did not interact with job position, suggesting that their effects operate similarly for both FSS and formally trained clinicians. Both FSS and clinicians reported higher individual levels of job satisfaction and organizational commitment in clinics characterized by more positive organizational cultures and climates. Results from this study suggest that organizational culture and climate rather than individual characteristics or job position are most important for shaping employees’ work attitudes. These findings suggest that although clinicians and FSS differ with respect to their training and primary job responsibilities, their work attitudes are similar and are similarly affected by their organizations’ cultures and climates.

Findings from this study also indicated that this sample of mental health programs, representing two-thirds of the providers implementing family support services in New York State, displayed OSC culture and climate profiles consistent with national norms across the six dimensions of culture and climate profiled by the OSC. The lack of significant differences between the sampled clinics and national norms suggests that the implementation of family support services is not associated with differences in organizational culture and climate. Rather, programs implementing family support services exhibit wide variability in their cultures and climates—independent of their implementation of family support services—and these organizational cultures and climates are the strongest predictor of individual-level work attitudes regardless of job.

Although the random effects of clustering by organization were controlled with HLM strategies, caveats regarding these findings include the relatively few FSS working in each of the participating programs and the failure to include all predictors (e.g., caseloads) that could explain individual differences in work attitudes. In addition, the sample is representative of only one state, New York, and although similar in organizational-level culture and climate to national norms, the extent to which findings can be generalized to other states which have promoted the use of FSS is unknown.

Implications for Research and Service Improvement Efforts

These findings are important for the development of organizational intervention strategies for improving the quality and outcomes of family support services. Possible ideological and operational differences between FSS and clinicians suggested by previous writers have raised the concern that FSS and clinicians may form different attitudes regarding their shared work environments as a result of different experiences and views of mental health treatment. However, these findings support the notion that FSS and clinicians have similar views of their work environments and may be able to identify common goals for program improvement. The findings of high within-unit agreement, the failure to find significant individual-level differences between FSS’ and clinicians’ work attitudes, and the primary role played by organizational-level culture and climate in predicting the work attitudes of individuals, regardless of job position, suggest that the implementation of organizational interventions that include both clinicians and FSS have a potentially valuable role in improving family support services.