Providers’ Perceptions of Trauma-Focused EBT/EBP Implementation Fidelity: Implementation Process and Individual Influences

Providers’ Perceptions of Trauma-Focused EBT/EBP Implementation Fidelity: Implementation Process and Individual Influences | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Providers’ Perceptions of Trauma-Focused EBT/EBP Implementation Fidelity: Implementation Process and Individual Influences Stephanie Gusler, Ginny Sprang, Jessica Eslinger, Adrienne Whitt This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7060094/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Nov, 2025 Read the published version in Community Mental Health Journal → Version 1 posted You are reading this latest preprint version Abstract Implementation fidelity is the extent to which an intervention is delivered in the manner in which it was designed. Within randomized-controlled trials (RCTs), fidelity is often rigorously ensured through strategies out of reach for most organizations. This limitation may be of particular concern for trauma-focused evidence-based treatments/evidence-based practices (EBT/EBPs), as the needs of individuals and families seeking trauma-based treatment are often complex, with existing comorbidities that can complicate recovery. This contributes to concern about how or if EBT/EBPs are being implemented to fidelity. The present study used the Consolidated Framework for Implementation Research (CFIR) framework to examine implementation process and individual characteristics, as well as interactions among these factors in impacting provider’s perceptions of fidelity. Data came from 598 mental health providers, who completed an online survey regarding provider demographics, perceptions of personal effectiveness, work experiences such as secondary traumatic stress and compassion satisfaction, and organizational implementation strategies used for a trauma-focused EBT/EBP. Significant positive associations were found between perceptions of implementation fidelity and compassion satisfaction, implementation strategy use, and personal effectiveness. Further, STS was significantly negatively associated with implementation fidelity. Significant differences were found based on population served and use of consultation calls and in-person supervision. Within a regression model, a significant two-way interaction between STS and implementations strategy use was significant, along with a three-way interaction between STS, implementations strategy use, and personal effectiveness. This study advances our understanding of how fidelity is created, maintained and understood in implementation settings that provide EBT/EBPs to individuals exposed to trauma. Fidelity Trauma-Focused EBT/EBP Secondary Traumatic Stress Implementation Strategies Personal Effectiveness Compassion Satisfaction Figures Figure 1 Figure 2 Introduction Over the last two decades, there has been substantial growth in evidence-based treatments (EBT) and practices (EBP) for reducing traumatic stress and related symptoms for adults (Cusack et al., 2016; Lewis et al, 2020) and children (Gutermann et al., 2016). However, questions remain about the best way to disseminate these practices in ways that ensure fidelity to the EBT/EBP model, in real-world settings. Fidelity can be defined as the extent to which an intervention is delivered in the manner in which it was designed, involving provider knowledge and skill, as well as an ability to follow the prescribed elements of the intervention (McLeod et al. 2013; Schoenwald et al. 2011). Within randomized-controlled trials (RCTs), fidelity is often ensured through rigorous monitoring, supervision and consultation, and expert training (Hoagwood et al., 2024). These strategies are often out of reach for community-based organizations, who do not have the personnel, time, or funds for these fidelity enhancing procedures, contributing to concern about how or if EBT/EBPs are being implemented to fidelity, outside of controlled research protocols (Hoagwood et al., 2024). This limitation may be of particular concern for trauma-focused EBT/EBPs, as the needs of individuals and families seeking trauma-based treatment are often complex, with existing comorbidities that can complicate recovery (Bernhard et al., 2018; van Der Kolk, 2018). Therefore, symptom profiles may differ from RCT study samples, leading to potential challenges in providing the protocol as designed. Additionally, scheduling and billing requirements have been found to act as barriers to seeing children and families affected by trauma at the frequency recommended by the EBT developer (Eslinger et al., 2020). This can affect the course of the intervention with potential impacts to fidelity. The Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) can be a helpful implementation framework in further understanding the multitude of factors that may influence fidelity, and how to increase implementation fidelity in community settings. CFIR was developed to help operationalize the language used to define constructs and to identify components that were potentially missing from existing implementation theories (Damschroder et al., 2009). The CFIR framework consists of five domains that may influence implementation: intervention characteristics (e.g., complexity and adaptability of the intervention), outer setting (e.g., economic and political context), inner setting (e.g., structure of the organization), characteristics of the individuals (e.g., individual attitudes and interests), and the process of implementation (e.g., formal and informal implementation processes) (Damschroder et al., 2009). The individual characteristics and implementation process domains, in particular, may be the most proximal targets for intervention to help improve implementation fidelity. The implementation process domain, highlights multiple areas for implementation strategies (e.g., assessing needs, planning, learning, and doing). Implementation strategies that focus on learning and practicing the EBT/EBP, such as the type of training and availability of on-going supervision, are implementation process factors that can be targeted to support protocol fidelity. This is an important consideration, as the training process associated with RCTs is typically intensive, with knowledge and learning techniques involving a combination of instruction, demonstration, and hands-on practice with feedback. In fact, engagement in more intensive training models, such as a Breakthrough Series Collaborative (Kilo, 1998), has been associated with increased fidelity (Lang et al., 2015; Sprang et al, 2019). However, this approach is not feasible for most organizations, and more research is needed to identify achievable and cost-effect strategies that are most beneficial to increasing fidelity. Individual Characteristics as defined within the CFIR framework include factors such as an individual’s knowledge and skills specific to an EBT/EBP, their attitudes towards the practice, feelings of competence and self-efficacy in using the EBT/EBP, and their perception of the intervention as helpful and aligned with their own values (Aarons et al., 2011). Other individual factors, such as secondary traumatic stress (STS), have been found to lead to increased feelings of distress in the workplace. STS is the emotional duress that can arise from the exposure to the indirect trauma experiences of others (NCTSN, 2011). STS reactions align with symptoms of PTSD and can lead, to functional impairment (Sprang et al., 2022). Providers working with clients who have experienced trauma are at elevated risk of developing STS due to the indirect exposure inherent in their work. A recent study by Sprang et al. (2025) found that higher STS symptoms among trauma providers trained in EBT/EBPs were associated with lower provider perceptions of fidelity, suggesting that experiences of occupational distress may interfere with the way in which a provider may deliver intervention services. However, this is the only current study to examine this association and more research is needed to better understand the impact of STS on implementation fidelity. Compassion satisfaction (CS), is another potentially impactful individual characteristic, as it is the positive emotional experience that one gets from caring and supporting others (Stamm, 2005). While STS may serve as a risk factor, CS may serve as an individual characteristic that potentially enhances fidelity. Predictors of higher levels of CS have been found to include older age, spending more time engaging in research and development activities, perceived management support, and perceived supervisory support (Sodeke-Gregson et al., 2013). These findings suggest that strategies that target CS may play a key role in increasing fidelity. Lastly, the perceived effectiveness of an EBT/EBP is an additional individual characteristic that may play a role in fidelity. Provider satisfaction and perceived professional competence have been found to be associated with use of EBT. Specifically, provider ratings of satisfaction with an EBT have been found to be associated with protocol design (Chorpita et al., 2015). Use of trauma-focused strategies and use of training cases to practice skills have been found to be associated with higher ratings of perceived competence by providers (Marriott et al., 2023). Professional training has also been found to be associated with higher ratings of both general competence and task knowledge and problem-solving (Ben-Porat, et al., 2011). However, it is not currently known how a providers’ personal perception of effectiveness relates to the fidelity at which they deliver an EBT/EBP. The domains within the CFIR framework are understood to be transactional in nature. Thus, it is expected that there will be interactions between implementation processes and individual characteristics, but these interactions have seldomly been explicitly examined. Nonetheless, some evidence that does point to the combined influence of multiple domains comes from Jensen-Doss and colleagues (2009), who found that a provider’s attitude toward an EBT was influenced not only by other individual characteristics (e.g., attitudes towards co-workers) but also by implementation process factors such as quality of training. The current study aimed to examine the potential interactions between implementation process and individual characteristic factors and EBT/EBP fidelity. Specifically, identifying which factors are most influential in impacting perceptions of trauma-focused EBT/EBP implementation fidelity. It was hypothesized that factors from each domain (individual and implementation process) would significantly predict perceptions of fidelity. Further, the interaction effects between these variables were explored. Methods Study Sample A sample of 598 mental health providers responded to an online survey regarding their experiences with the implementation of a trauma-focused evidence-based treatment or practice (EBT/EBP). The average age of the providers was 43.3 years (SD = 11.9) and they reported an average of 14.2 years (SD = 11.1) of professional experience (post-Master’s). The most frequently endorsed practice setting was community mental health (32.1%) followed by other settings (27.9%), child advocacy centers (12.8%), hospitals (9.5%), private agencies (6.3%), university clinics (5.8%), juvenile justice facilities (3.5%), and private practice settings (2.1%). The most frequently endorsed professional discipline was social work (30.4%) followed by counseling (23.8%), psychology (22.1%), other disciplines (12.2%), marriage and family therapy (9%), and psychiatry (.9%). Participants were asked to select a trauma-focused EBT/EBP to reflect on for this survey. Approximately 76% reported that they had been using their selected intervention or practice for over one year. The most frequently reported EBT/EBP was Trauma Focused Cognitive Behavioral Therapy (29.9%) followed by Eye Movement Desensitization Reprocessing (10.4%), and Parent Child Interaction Therapy (7.2%). Procedure This survey was sent to two lists of mental health providers, one comprised of members of a national association that provides education and dissemination of practices related to child trauma, and the other consisted of trainees and affiliates of a university-based child trauma center. A snowball sampling method was employed due to some of the members of these lists forwarding the electronic survey to other providers. A response rate cannot be established due to the unknown number of participants invited from the original members of these lists versus those that received the survey from other providers. The confidential, online survey contained 85 questions regarding provider demographics, work experiences such as secondary traumatic stress and compassion satisfaction, and experiences with implementing an EBT/EBP. This study was approved by the university Institutional Review Board which determined that participation presented no more than minimal risks to human subjects. All data safety and storage procedures were sufficient to ensure privacy and confidentiality, and participation in the survey was sufficient to indicate informed consent after reviewing information provided in the cover letter. Measures Perceptions of Fidelity Providers perception of implementation fidelity was measured by asking, “To what degree is the EBT or EBP being implemented with fidelity?” This organizational level variable was measured on a 5-point Likert scale ranging from “not at all” to “a great deal.” Personal Effectiveness Participants were asked, “How effective would you rate yourself in delivering this EBT/EBP,” as a measure of their perception of their personal effectiveness in implementation. This provider level variable was measured on a 5-point Likert scale from “not at all” to “extremely.” Implementation Strategies Implementation strategy usage was measured by having participants rate the extent to which their organizations engaged in a series of implementation activities, drawn from a consolidated list of strategies from the Expert Recommendations for Implementing Change (ERIC; Waltz et al., 2015 ). Strategies used in the current study were seven items most directly connected to the learning and practicing of the EBT/EBP (e.g., provision of local technical assistance; provision of supervision, coaching or mentoring; involving, hiring, and/or consulting content experts to support implementation; providing initial training in the EBT/EBP that is dynamic and includes educational materials to assist in learning and utilization). Participants were asked to rate their usage of each item on a four-point Likert scale ranging from “to a large extent” to “not at all.” A sum score across was created, so that higher scores indicated greater strategy usage. There was excellent internal consistency for these items (𝛼 = .89). Population Served Providers responded to the question, “What best describes the population you serve? (please list age range),” which was then dichotomously coded into child only providers and child and/or adult providers. Training Method Participants also indicated if they received in-person training, consultation calls, and in-person supervision for the specified EBT/EBP. Secondary Traumatic Stress (STS) STS was measured using the total scale score from the Secondary Traumatic Stress Scale (STSS) for DSM-5. The STSS relies on self-reported experiences of intrusion, avoidance, alterations in mood and cognition, and arousal symptoms associated with indirect trauma exposures. The 21-item measure uses a 5-point Likert scale to assess symptoms in these domains ranging from “little or no STS” to “severe STS” (Bride, 2013 ). The STSS has been revised to reflect the DSM-5 criteria for PTSD and one item (“I felt discouraged about the future”) should be eliminated from score calculations to reflect this change. Total scores range from 20–100 with higher scores indicating higher STS. Prior research has established a clinically significant cutoff score of 46(Sprang et al., 2022 ). The Cronbach’s alpha was .959 for the total score in this sample indicating high internal consistency for this measure. Compassion Satisfaction Compassion Satisfaction was measured using the 10-item compassion satisfaction subscale from the 30-item Professional Quality of Life: Compassion Satisfaction and Fatigue Scale Version 5 (ProQOL) (Stamm, 2010 ). This widely used measure assesses secondary traumatic stress, burnout, and compassion satisfaction in helping professionals. Items from the compassion satisfaction subscale are rated on a 5-point Likert scale from “never” to “very often.” The ProQOL has established sound reliability and construct validity across studies (Stamm, 2002 & 2010 ). The compassion satisfaction subscale in this sample had a Cronbach’s alpha of .835 indicating good internal consistency. Data Analytic Plan Missing data ranged from 0–10% among study variables. To maintain the full sample size and reduce the risk of introducing bias, multiple imputation was used to address missingness (de Goeij et al., 2013 ). Fifty imputations were created and results presented are of pooled analyses across all 50 imputations. Bivariate correlations between perceptions of fidelity and other study variables were first examined, along with mean comparisons for dichotomous variables, such as if consultation calls or in-person supervision was utilized. Any dichotomous variables for which there was a significant mean difference in perceptions of fidelity were then included in the subsequent regression model as control variables. A hierarchical linear regression model, with perceptions of implementation fidelity as the outcome variable, was then conducted. In step one, variables included compassion satisfaction, STS, implementation strategy usage, perceptions of personal effectiveness, and control variables that were identified as significant in mean comparison tests. In step two, interactions among the primary study variables were explored. Step three, included any three-way interactions to be explored based on significant two-way interactions. Multicollinearity was examined in the regression model, and all VIF indexes were < 4 (Leech, 2005). All continuous variables were mean centered. Any interactions that were significant, once all three steps in the model were accounted for, were probed at low (-1 SD) and high (+ 1 SD) ends of variable means and were then plotted to visualize the pattern of results (Aiken & West, 1991 ). All analyses, including multiple imputation were conducted in SPSS 28. Results Correlations and Mean Differences Correlations, as shown in Table 1 , indicated significant positive associations between perceptions of implementation fidelity and compassion satisfaction, implementation strategy use, and personal effectiveness. Further, STS was significantly negatively associated with implementation fidelity, compassion satisfaction, implementation strategy use, and personal effectiveness. Compassion satisfaction, implementation strategy use, and personal effectiveness were all positive correlated. Table 1 Bivariate Correlations 1 2 3 4 5 1.Fidelity -- 2.CS .60** -- 3.STS − .53** − .60** -- 4.Implementation Strategies .68** .55** − .48** -- 5.Effectiveness .69** .59** − .58** .63** Means (SD) 3.6 (1.1) 40.6 (7.5) 46.4 (17.5) 2.5 (.8) 3.7 (1.1) Note. STS = Secondary Traumatic Stress, CS = Compassion Satisfaction, ** p < .01, *p < .05. Independent t-tests of mean differences are displayed in Table 2 . First, those that served only children had significantly lower perceptions of fidelity ( t = -3.9, p < .00), compassion satisfaction ( t =-3.4, p < .00), implementations strategy use ( t = -4.0, p < .00), and personal effectiveness ( t = -3.9, p < .00), and had significantly higher STS ( t = 4.7, p < .00) than those who provided services to children and adults. No significant mean differences were found among study variables for those who received training in the EBT/EBP in person versus virtually. Lastly, those who received consultation calls and in-person supervision had significantly lower STS symptoms ( t = -9.3, p < .00; t = -4.4, p < .00) and higher perceptions of fidelity ( t = 9.7, p < .00; t = .48, p < .00), compassion satisfaction ( t = 7.4, p < .00; t = 3.2, p < .00), implementation strategy use ( t = 10.9, p < .00; t = 7.0, p < .00), and personal effectiveness ( t = 11.8, p < .00; t = 7.4, p < .00). Table 2 Mean Differences Child (n = 347) Adult and/or Child (n = 251) In-Person Training (n = 358) Virtual Training (n = 240) Consultation Calls (n = 215) No Consultation Calls (n = 383) Supervision (n = 118) No Supervision (n = 480) Fidelity 3.4 3.8 ** 3.6 3.7 4.1** 3.3 4.0** 3.5 CS 37.8 41.9** 40.5 40.8 43.3** 39.1 42.4** 40.2 STS 49.3** 42.5 45.8 47.3 39.0 50.6** 41.1 47.7** Implementation Strategies 2.4 2.6 ** 2.5 2.5 2.9** 2.2 2.9** 2.4 Effectiveness 3.5 3.9 ** 3.7 3.6 4.3** 3.3 4.2** 3.5 Note. STS = Secondary Traumatic Stress, CS = Compassion Satisfaction, ** p < .01, *p < .05. Regression Analysis Unstandardized regression coefficients for the regression analysis are shown in Table 3 . In step one, compassion satisfaction, implementation strategy use, and personal effectiveness were all significantly positively associated with perceptions of implementation fidelity, and STS was significantly negatively associated with fidelity. In step two, with the addition of interaction terms, STS was no longer significantly associated with fidelity, but compassion satisfaction, implementation strategy use, and personal effectiveness remained significant. Further, two interactions were significant, one between STS and implementation strategy use and the second between STS and personal effectiveness. As such, a three-way interaction between STS, implementation strategy use, and personal effectiveness was explored in step three of the model. In this final step, 63% of the variance in perceived implementation fidelity was accounted for by the direct and interaction effects. Compassion satisfaction, implementation strategy use, and personal effectiveness all remained positively associated with fidelity, and STS was significantly negatively associated with fidelity. The interaction between STS and implementations strategy was also significant. This interaction is plotted in Fig. 1 , which shows that when implementation strategy use was greater, perceptions of fidelity were similar for those with high and low STS. However, when implementation strategy use was lower, those with high STS rated fidelity more poorly than those with low STS. Lastly, the three-way interaction between STS, implementations strategy use, and personal effectiveness was significant. This interaction, plotted in Fig. 2 , shows that implementation fidelity, generally, increased when there was greater use of implementation strategies; however, those with low personal effectiveness had the lowest ratings of perceived fidelity. Further, for those with high levels of personal effectiveness, high STS was associated with lower perceptions of fidelity, but only when fewer implementation strategies were used by the organization. Table 3 Regression Model Predicting Perceptions of Implementation Fidelity Step 1 R 2 = .61 Step 2 R 2 = .62 Step 3 R 2 = .63 B p B p B p CS .19** .00 .20** .00 .20** .00 STS − .09* .03 − .08 .08 − .11* .01 Implementation Strategies .40** .00 .40** .00 .45** .00 Effectiveness .38** .00 .40** .00 .43** .00 CS*STS -- -- − .03 .46 − .03 .46 CS*Strategies -- -- .00 .99 .01 .92 CS*Effectiveness -- -- .04 .43 .03 .52 STS*Strategies -- -- .10* .03 .12** .01 STS*Effectiveness -- -- − .12* .02 − .09 .08 Strategies*Effectiveness -- -- − .05 .35 − .08 .10 STS*Strategies* Effectiveness -- -- -- -- .12** .00 Note. STS = Secondary Traumatic Stress, CS = Compassion Satisfaction, Control variables of population served, consultation calls, and in-person supervision were included in step 1 of the analyses, but are not presented in the table as they were not significant. ** p < .01, *p < .05. Discussion This study examines implementation process and individual factors that could impact perceptions of fidelity to a range of trauma-focused evidence-based treatments and practices. Unique to this investigation was the exploration of STS and compassion satisfaction, individual factors that have only recently been included in research on EBT/EBP implementation (Sprang et al., 2025 ). To provide a more nuanced understanding of the role these factors play in fidelitious practice, the interactions between significant correlates of perceived fidelity were investigated. Accordingly, this study advances our understanding of how fidelity is created, maintained and understood in implementation settings that provide EBT/EBPs to individuals exposed to trauma. The context in which implementation is occurring is key to understanding these results. In this sample, mean STS total scores were moderate to high, with respondents in the child serving group reporting symptom rates that exceed clinical cut-offs (Sprang et al., 2022 ). The aggregate scores in the total sample population are consistent with findings from other studies that document levels of trauma symptoms at or above threshold levels in 19.2–70% in professionals (Henderson et al., 2025 ; Holmes et al., 2021 ; Velasco et al., 2025 ). Exposure to child maltreatment and other forms of trauma in childhood has been noted to be particularly stressful for professionals due to the need to respond to sometimes disturbing trauma-related behavior, difficulties securing safety for children living in chaotic conditions and within avoidant, dangerous or defensive families, and having to interface with dysfunctional service systems (Berger et al., 2023 ; Hupe & Stevenson, 2019 ; Weiss-Dagan et al., 2022 ). In this study, in addition to higher STS levels, respondents serving only children had lower perceived fidelity, compassion satisfaction, implementation strategy usage, and viewed themselves as less effective than those who treated adults and children. STS in its conceptual origins was derived from systems theory, and understood as a series of transactions between a professional and client that had the capacity to propel the latter towards recovery and transform the former in nuanced and complicated ways (Figley, 1983 ). In fact, Michael Christopher ( 2004 ) observes that both adaptive and maladaptive responses to trauma are physiologically and psychologically transformative, excluding no one from the group impacted by these encounters. McCann & Pearlman’s ( 1990 ) constructivist self-development theory may provide some insights into how STS may impact perceptions of fidelity in the organization, personal effectiveness, and adaptive behaviors such as the use of implementation strategies. These authors posit that indirect trauma exposure (and subsequent responses) can have a pervasive and negative impact on a professional’s assumptions, their interpretation of events and expectations of self, others, and the organization; and this may, in turn cause them to question the validity of cause and effect propositions in their work environments. On a practical level, the complexities of working with children, caregivers, and overburdened child serving systems calls for high levels of flexibility that may make fidelity more challenging (Kerig et al., 2010 ; Signorelli et al., 2017 ). Results of this study suggest that implementation efforts in child serving contexts may need to be supplemented with additional emotional supports to allow professionals opportunities to process and resolve assaults to their systems of meaning related to self-efficacy, organizational trust, and adaptive coping, as well as the realities of the work. Additional comparisons regarding mean differences between subgroups of respondents demonstrated that consultation calls and supervision functioned to improve perceptions of fidelity. These results are consistent with research that demonstrates that external supports of this type delivered post-training can be robust predictors of therapist fidelity to an EBT, regardless of the method of technology transfer (Beidas, et al., 2012 ). Of particular importance is the content of the consultation and supervision, with those encounters that are geared toward giving timely feedback, identifying emerging needs for re-training, and addressing barriers to implementation consistently highlighted as particularly salient (Nadeem et al., 2013 ; Schouten, et al., 2008 ). The utilization of consultation calls and in-person supervision was not only associated with greater perceived fidelity across the organization but also higher levels of compassion satisfaction, personal effectiveness, and lower STS at the individual level. Dehlin and Lundh ( 2018 ) found that supervision associated with high levels of reflection was associated with high degrees of compassion satisfaction, suggesting that the relational interaction between supervisor and supervisee may be facilitating positive references to the work, or alternatively, those with a high degree of compassion satisfaction may find it easier to engage in a reflective interchange during processing. These findings are further underscored by other research supporting the role of supervision in improving compassion satisfaction and decreasing STS; and the role of self-efficacy in mediating these relationships (Lagos et al., 2022 ; Laulita, 2020 ). Even so, the possibility of a non-linear, multifaceted association between these constructs is possible and warrants further investigation. To further explore this issue within the context of fidelity, a series of interaction terms were entered into a regression model to test whether STS, compassion satisfaction, perceived personal effectiveness at delivering the EBT/EBP, and the frequency of implementation strategies varied based on the value of the correlates. The results highlight the importance of implementation process and individual domains singularly, and in combination in the perception of fidelity. In the final model, compassion satisfaction, STS, implementation strategy use, and perceived personal effectiveness were all noted to be significant independent correlates of higher ratings of perceived fidelity. Significant interactions were also noted between individual domain factors (STS and personal effectiveness) and the implementation process domain factor of organizational use of implementation strategies. A two-way interaction revealed that when greater implementation strategies are used, individuals have similar levels of fidelity, regardless of STS symptoms; however, when fewer implementation strategies are used, those with higher STS symptoms report lower implementation fidelity. The three-way interaction provided further clarification and nuance, suggesting that for perceived fidelity to be high, a professional must believe they are personally effective at delivering the intervention, STS symptoms should be low, and the organization must be utilizing greater implementation strategies. In other words, it is not enough to just teach someone to deliver an EBT/EBP with fidelity, the organizational milieu must use active implementation strategies to promote perceptions of effectiveness, and individuals and organizations must lower STS for the evidence-based approach to be perceived as fidelitious to the model. An Interagency Collaborative Team model such as the one described by Hurlburt et al. ( 2014 ) may be one such effective strategy to increase fidelity, but would need to be modified to include STS reduction strategies to fully address these factors. The findings of this study advance the idea that successful implementation requires attention to the organizational context as host of an innovation, and to the professionals as actors who shepherd the EBT/EBP toward fidelitious sustainment. During trauma treatment delivery, professional use of self is at the core of the EBT/EBP, and new technologies will succeed only to the extent they are accepted, utilized correctly, and promoted by that implementor. The CFIR model (Damschroder et al., 2020 ) clearly acknowledges this dual responsibility but does not explicate the role of STS specifically in the process. The bifocal model of addressing STS (Sprang et al., 2021 ) explicates the roles of organizations and individuals working in concert to address the phenomenon, but does not speak to implementation specifically. To amalgamate these approaches, one might consider the following integrated course of action: 1) individual monitoring of STS and use of organizational assessments like the Secondary Traumatic Stress Informed Organizational Assessment (STSI-OA) (Sprang et al., 2017); 2) facilitating the acquisition of individual coping strategies and developing a continuum of organizational supports such as reflective supervision, peer support, learning and practice implementation strategies, and consultation prior to training in the EBT (during preparation activities), and further supported during technology transfer phase (especially for child serving professionals); and 3) creation of data-collection systems and quality improvement processes (put in place prior to implementation) to provide continuous feedback to the organization and individual practitioners to support learning, growth, and an improved sense of effectiveness during sustainment. Extrapolating from both models, it is clear that these activities should begin early in the implementation cycle to avoid depleting resources when trying to resolve internal problems later in the process. Future research aimed at testing this integrated model during an implementation study is an important next step. Limitations Although the present results advance our knowledge of factors influencing provider’s perceptions of trauma-focused EBT/EBP implementation fidelity, there are multiple limitations that are important to note. First, this study focused only on implementation process and individual domains of the CFIR model, and it did not include any variables directly related to the inner (e.g., organizational culture on infrastructure) and outer setting (e.g., policies and laws, sociocultural environment, or external networks; Damschroder et al., 2022 ). Factors related to these domains likely impact differences seen in the implementation process and individual domains, but were beyond the scope of the current investigation. Future research is needed to understand how factors such as organizational and local policies may interact with the implementation process (e.g., implementation strategy usage) and individual (e.g., STS) domains to influence EBT/EBP implementation fidelity. Second, the present results are limited to providers’ perceptions of fidelity. While this is an important variable to assess in capturing individual attitudes and views, it may not align with more objective measures of implementation fidelity such as fidelity checklists completed by outside observers (Schoenwald et al., 2011 ). Third, the sampling design of the current study, though resulting in a large sample of providers across the United States, did contribute to a large number of participants who served children. There were not enough providers who worked exclusively with adult populations to compare to those who worked exclusively with children. This may limit the generalizability of the current results. Lastly, due to the correlational nature of the present study, directionality and causality of relations between variables cannot be determined. Conclusions Results of the present study highlight the important interplay between implementation process and individual characteristics in understanding mental health providers’ perceptions of implementation fidelity. Demonstrating the need to attend to which implementation strategies an organization uses and which populations are served, as well has providers’ level of STS and perceived personal effectiveness. Thus, implying that achieving implementation fidelity is not only the responsibility of the individual provider, but is equally the responsibility of the organization at large. 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Psychological therapies for post-traumatic stress disorder in adults: Systematic review and meta-analysis. European journal of psychotraumatology , 11 (1), 1729633. https://doi.org/10.1080/20008198.2020.1729633 Kerig, P. K., Sink, H. E., Cuellar, R. E., Vanderzee, K. L., & Elfstrom, J. L. (2010). Implementing trauma-focused CBT with fidelity and flexibility: A family case study. Journal of Clinical Child & Adolescent Psychology , 39 (5), 713-722. https://doi.org/10.1080/15374416.2010.501291 Marriott, B. R., Peer, S., Wade, S., & Hanson, R. F. (2023). Therapists' perceived competence in delivering trauma-focused cognitive behavioral therapy during statewide learning collaboratives. The Journal of Behavioral Health Services & Research , 50 (4), 500-513. https://10.1007/s11414-023-09847-2 McCann, L., & Pearlman, L. A. (1990). Vicarious traumatisation: A framework for understanding the psychological effects of working with victims. Journal of Traumatic Stress, 3, 131–149. http://dx.doi.org/10 .1007/BF00975140 Nadeem, E., Gleacher, A., & Beidas, R. S. (2013). Consultation as an implementation strategy for evidence-based practices across multiple contexts: Unpacking the black box. Administration and Policy in Mental Health and Mental Health Services Research , 40 , 439-450. https://doi.org/10.1007/s10488-013-0502-8 National Child Traumatic Stress Network, Secondary Traumatic Stress Committee. (2011). Secondary traumatic stress: A fact sheet for child-serving professionals. Los Angeles, CA, and Durham, NC: National Center for Child Traumatic Stress. Schouten, L. M., Hulscher, M. E., van Everdingen, J. J., Huijsman, R., & Grol, R. P. (2008). Evidence for the impact of quality improvement collaboratives: systematic review. Bmj , 336 (7659), 1491-1494.https://doi.org/10.1136/bmj.39570.749884.BE Schoenwald, S. K., Garland, A. F., Chapman, J. E., Frazier, S. L., Sheidow, A. J., & Southam-Gerow, M. A. (2011). Toward the effective and efficient measurement of implementation fidelity. Administration and Policy in Mental Health and Mental Health Services Research , 38 , 32-43. https://doi.org/10.1007/s10488-010-0321-0 Signorelli, R. G., Gluckman, N. S., Hassan, N., Coello, M., & Momartin, S. (2017). Relationship building, collaboration and flexible service delivery: The path to engagement of refugee families and communities in early childhood trauma recovery services. Children Australia , 42 (3), 142-158. https://doi.org/10.1017/cha.2017.30 Sodeke-Gregson, E. A., Holttum, S., & Billings, J. (2013). Compassion satisfaction, burnout, and secondary traumatic stress in UK therapists who work with adult trauma clients. European journal of psychotraumatology , 4 (1), 21869. https://doi.org/10.3402/ejpt.v4i0.21869 Sprang, G., Eslinger, J., Silman, M., & Ascienzo, S. (2019). Predictors of evidence-based treatment implementation, sustainability, and fidelity. Best Practices in Mental Health , 15 (1), 41-48. https://doi.org/10.70256/099230pyebox Sprang, G., Gusler, S., Whitt, A., Eslinger, J., & Hood, C. O. (2025). The role of secondary traumatic stress and implementation strategies in successful adoption of evidence-based approaches to address traumatic stress. Traumatology. Advance online publication. https://doi.org/10.1037/trm0000588 Sprang, G., Lei, F., & Bush, H. (2021). Can organizational efforts lead to less secondary traumatic stress? A longitudinal investigation of change. American Journal of Orthopsychiatry , 91 (4), 443. https://doi.org/10.1037/ort0000546 Sprang, G., Whitt-Woosley, A., & Eslinger, J. (2022). Diagnostic and translational utility of the secondary traumatic stress clinical algorithm (STS-CA). Journal of interpersonal violence , 37, 21-22, NP19811-NP19826. https://doi.org/10.1177/08862605211044961 Stamm, B. H. (2002). Measuring compassion satisfaction as well as fatigue: Developmental history of the Compassion Satisfaction and Fatigue Test. In C. R. Figley (Ed.), Treating compassion fatigue (pp. 107– 119). New York, NY: Brunner‐ Routledge. Stamm, B.H. (2010). The Concise ProQOL Manual, 2nd Ed . Pocatello, ID: ProQOL.org. van Der Kolk, B., Ford, J. D., & Spinazzola, J. (2019). Comorbidity of developmental trauma disorder (DTD) and post-traumatic stress disorder: Findings from the DTD field trial. European journal of psychotraumatology , 10 (1), 1562841. https://doi.org/10.1080/20008198.2018.1562841 Velasco, J., Sanmartín, F. J., Cuadrado, F., & Moriana, J. A. (2025). Prevalence of Secondary Trauma, Compassion Fatigue and Burnout Among Trauma Therapists in Spain. Counselling and Psychotherapy Research , 25 (1), e12901.https://doi.org/10.1002/capr.12901 Waltz, T. J., Powell, B. J., Matthieu, M. M., Damschroder, L. J., Chinman, M. J., Smith, J. L., ... & Kirchner, J. E. (2015). Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. Implementation Science , 10 , 1-8. https://doi.org/10.1186/s13012-015-0295-0 Weiss-Dagan, S., Ben-Porat, A., & Itzhaky, H. (2022). Secondary traumatic stress and vicarious post-traumatic growth among social workers who have worked with abused children. Journal of social work , 22 (1), 170-187. https://doi.org/10.1177/1468017320981363 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 05 Nov, 2025 Read the published version in Community Mental Health Journal → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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However, questions remain about the best way to disseminate these practices in ways that ensure fidelity to the EBT/EBP model, in real-world settings. Fidelity can be defined as the extent to which an intervention is delivered in the manner in which it was designed, involving provider knowledge and skill, as well as an ability to follow the prescribed elements of the intervention (McLeod et al. 2013; Schoenwald et al. 2011). Within randomized-controlled trials (RCTs), fidelity is often ensured through rigorous monitoring, supervision and consultation, and expert training (Hoagwood et al., 2024). These strategies are often out of reach for community-based organizations, who do not have the personnel, time, or funds for these fidelity enhancing procedures, contributing to concern about how or if EBT/EBPs are being implemented to fidelity, outside of controlled research protocols (Hoagwood et al., 2024).\u003c/p\u003e\n\u003cp\u003eThis limitation may be of particular concern for trauma-focused EBT/EBPs, as the needs of individuals and families seeking trauma-based treatment are often complex, with existing comorbidities that can complicate recovery (Bernhard et al., 2018; van Der Kolk, 2018). Therefore, symptom profiles may differ from RCT study samples, leading to potential challenges in providing the protocol as designed. Additionally, scheduling and billing requirements have been found to act as barriers to seeing children and families affected by trauma at the frequency recommended by the EBT developer (Eslinger et al., 2020). This can affect the course of the intervention with potential impacts to fidelity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2009) can be a helpful implementation framework in further understanding the multitude of factors that may influence fidelity, and how to increase implementation fidelity in community settings.\u0026nbsp;CFIR was developed to help operationalize the language used to define constructs and to identify components that were potentially missing from existing implementation theories (Damschroder et al., 2009). The CFIR framework consists of five domains that may influence implementation: intervention characteristics (e.g., complexity and adaptability of the intervention), outer setting (e.g., economic and political context), inner setting (e.g., structure of the organization), characteristics of the individuals \u0026nbsp;(e.g., individual attitudes and interests), and the process of implementation (e.g., formal and informal implementation processes) (Damschroder et al., 2009). The individual characteristics and implementation process domains, in particular, may be the most proximal targets for intervention to help improve implementation fidelity. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe implementation process domain, highlights multiple areas for implementation strategies (e.g., assessing needs, planning, learning, and doing). Implementation strategies that focus on learning and practicing the EBT/EBP, such as the type of training and availability of on-going supervision, are implementation process factors that can be targeted to support protocol fidelity. This is an important consideration, as the training process associated with RCTs is typically intensive, with knowledge and learning techniques involving a combination of instruction, demonstration, and hands-on practice with feedback. In fact, engagement in more intensive training models, such as a Breakthrough Series Collaborative (Kilo, 1998), has been associated with increased fidelity (Lang et al., 2015; Sprang et al, 2019). However, this approach is not feasible for most organizations, and more research is needed to identify achievable and cost-effect strategies that are most beneficial to increasing fidelity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIndividual Characteristics as defined within the CFIR framework include factors such as an individual\u0026rsquo;s knowledge and skills specific to an EBT/EBP, their attitudes towards the practice, feelings of competence and self-efficacy in using the EBT/EBP, and their perception of the intervention as helpful and aligned with their own values (Aarons et al., 2011). Other individual factors, such as secondary traumatic stress (STS), have been found to lead to increased feelings of distress in the workplace. STS is the emotional duress that can arise from the exposure to the indirect trauma experiences of others (NCTSN, 2011). STS reactions align with symptoms of PTSD and can lead, to functional impairment (Sprang et al., 2022). Providers working with clients who have experienced trauma are at elevated risk of developing STS due to the indirect exposure inherent in their work. A recent study by Sprang et al. (2025) found that higher STS symptoms among trauma providers trained in EBT/EBPs were associated with lower provider perceptions of fidelity, suggesting that experiences of occupational distress may interfere with the way in which a provider may deliver intervention services. However, this is the only current study to examine this association and more research is needed to better understand the impact of STS on implementation fidelity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompassion satisfaction (CS), is another potentially impactful individual characteristic, as it is the positive emotional experience that one gets from caring and supporting others (Stamm, 2005). \u0026nbsp;While STS may serve as a risk factor, CS may serve as an individual characteristic that potentially enhances fidelity. Predictors of higher levels of CS have been found to include older age, spending more time engaging in research and development activities, perceived management support, and perceived supervisory support (Sodeke-Gregson et al., 2013). These findings suggest that strategies that target CS may play a key role in increasing fidelity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLastly, the perceived effectiveness of an EBT/EBP is an additional individual characteristic that may play a role in fidelity. Provider satisfaction and perceived professional competence have been found to be associated with use of EBT. Specifically, provider ratings of satisfaction with an EBT have been found to be associated with protocol design (Chorpita et al., 2015). Use of trauma-focused strategies and use of training cases to practice skills have been found to be associated with higher ratings of perceived competence by providers (Marriott et al., 2023). Professional training has also been found to be associated with higher ratings of both general competence and task knowledge and problem-solving (Ben-Porat, et al., 2011). \u0026nbsp; However, it is not currently known how a providers\u0026rsquo; personal perception of effectiveness relates to the fidelity at which they deliver an EBT/EBP.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe domains within the CFIR framework are understood to be transactional in nature. Thus, it is expected that there will be interactions between implementation processes and individual characteristics, but these interactions have seldomly been explicitly examined. Nonetheless, some evidence that does point to the combined influence of multiple domains comes from Jensen-Doss and colleagues (2009), who found that a provider\u0026rsquo;s attitude toward an EBT was influenced not only by other individual characteristics (e.g., attitudes towards co-workers) but also by implementation process factors such as quality of training.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe current study aimed to examine the potential interactions between implementation process and individual characteristic factors and EBT/EBP fidelity. Specifically, identifying which factors are most influential in impacting perceptions of trauma-focused EBT/EBP implementation fidelity. It was hypothesized that factors from each domain (individual and implementation process) would significantly predict perceptions of fidelity. Further, the interaction effects between these variables were explored. \u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cb\u003eStudy Sample\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA sample of 598 mental health providers responded to an online survey regarding their experiences with the implementation of a trauma-focused evidence-based treatment or practice (EBT/EBP). The average age of the providers was 43.3 years (SD\u0026thinsp;=\u0026thinsp;11.9) and they reported an average of 14.2 years (SD\u0026thinsp;=\u0026thinsp;11.1) of professional experience (post-Master\u0026rsquo;s). The most frequently endorsed practice setting was community mental health (32.1%) followed by other settings (27.9%), child advocacy centers (12.8%), hospitals (9.5%), private agencies (6.3%), university clinics (5.8%), juvenile justice facilities (3.5%), and private practice settings (2.1%). The most frequently endorsed professional discipline was social work (30.4%) followed by counseling (23.8%), psychology (22.1%), other disciplines (12.2%), marriage and family therapy (9%), and psychiatry (.9%). Participants were asked to select a trauma-focused EBT/EBP to reflect on for this survey. Approximately 76% reported that they had been using their selected intervention or practice for over one year. The most frequently reported EBT/EBP was Trauma Focused Cognitive Behavioral Therapy (29.9%) followed by Eye Movement Desensitization Reprocessing (10.4%), and Parent Child Interaction Therapy (7.2%).\u003c/p\u003e\u003cp\u003e\u003cb\u003eProcedure\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis survey was sent to two lists of mental health providers, one comprised of members of a national association that provides education and dissemination of practices related to child trauma, and the other consisted of trainees and affiliates of a university-based child trauma center. A snowball sampling method was employed due to some of the members of these lists forwarding the electronic survey to other providers. A response rate cannot be established due to the unknown number of participants invited from the original members of these lists versus those that received the survey from other providers. The confidential, online survey contained 85 questions regarding provider demographics, work experiences such as secondary traumatic stress and compassion satisfaction, and experiences with implementing an EBT/EBP. This study was approved by the university Institutional Review Board which determined that participation presented no more than minimal risks to human subjects. All data safety and storage procedures were sufficient to ensure privacy and confidentiality, and participation in the survey was sufficient to indicate informed consent after reviewing information provided in the cover letter.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMeasures\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003ePerceptions of Fidelity\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProviders perception of implementation fidelity was measured by asking, \u0026ldquo;To what degree is the EBT or EBP being implemented with fidelity?\u0026rdquo; This organizational level variable was measured on a 5-point Likert scale ranging from \u0026ldquo;not at all\u0026rdquo; to \u0026ldquo;a great deal.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003cb\u003ePersonal Effectiveness\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Participants were asked, \u0026ldquo;How effective would you rate yourself in delivering this EBT/EBP,\u0026rdquo; as a measure of their perception of their personal effectiveness in implementation. This provider level variable was measured on a 5-point Likert scale from \u0026ldquo;not at all\u0026rdquo; to \u0026ldquo;extremely.\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplementation Strategies\u003c/b\u003e\u003c/p\u003e\u003cp\u003eImplementation strategy usage was measured by having participants rate the extent to which their organizations engaged in a series of implementation activities, drawn from a consolidated list of strategies from the Expert Recommendations for Implementing Change (ERIC; Waltz et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Strategies used in the current study were seven items most directly connected to the learning and practicing of the EBT/EBP (e.g., provision of local technical assistance; provision of supervision, coaching or mentoring; involving, hiring, and/or consulting content experts to support implementation; providing initial training in the EBT/EBP that is dynamic and includes educational materials to assist in learning and utilization). Participants were asked to rate their usage of each item on a four-point Likert scale ranging from \u0026ldquo;to a large extent\u0026rdquo; to \u0026ldquo;not at all.\u0026rdquo; A sum score across was created, so that higher scores indicated greater strategy usage. There was excellent internal consistency for these items (\u0026#120572; = .89).\u003c/p\u003e\u003cp\u003e\u003cb\u003ePopulation Served\u003c/b\u003e\u003c/p\u003e\u003cp\u003eProviders responded to the question, \u0026ldquo;What best describes the population you serve? (please list age range),\u0026rdquo; which was then dichotomously coded into child only providers and child and/or adult providers.\u003c/p\u003e\u003cp\u003e\u003cb\u003eTraining Method\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants also indicated if they received in-person training, consultation calls, and in-person supervision for the specified EBT/EBP.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSecondary Traumatic Stress (STS)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSTS was measured using the total scale score from the Secondary Traumatic Stress Scale (STSS) for DSM-5. The STSS relies on self-reported experiences of intrusion, avoidance, alterations in mood and cognition, and arousal symptoms associated with indirect trauma exposures. The 21-item measure uses a 5-point Likert scale to assess symptoms in these domains ranging from \u0026ldquo;little or no STS\u0026rdquo; to \u0026ldquo;severe STS\u0026rdquo; (Bride, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). The STSS has been revised to reflect the DSM-5 criteria for PTSD and one item (\u0026ldquo;I felt discouraged about the future\u0026rdquo;) should be eliminated from score calculations to reflect this change. Total scores range from 20\u0026ndash;100 with higher scores indicating higher STS. Prior research has established a clinically significant cutoff score of 46(Sprang et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The Cronbach\u0026rsquo;s alpha was .959 for the total score in this sample indicating high internal consistency for this measure.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCompassion Satisfaction\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCompassion Satisfaction was measured using the 10-item compassion satisfaction subscale from the 30-item Professional Quality of Life: Compassion Satisfaction and Fatigue Scale Version 5 (ProQOL) (Stamm, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). This widely used measure assesses secondary traumatic stress, burnout, and compassion satisfaction in helping professionals. Items from the compassion satisfaction subscale are rated on a 5-point Likert scale from \u0026ldquo;never\u0026rdquo; to \u0026ldquo;very often.\u0026rdquo; The ProQOL has established sound reliability and construct validity across studies (Stamm, \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2002\u003c/span\u003e \u0026amp; \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2010\u003c/span\u003e). The compassion satisfaction subscale in this sample had a Cronbach\u0026rsquo;s alpha of .835 indicating good internal consistency.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData Analytic Plan\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMissing data ranged from 0\u0026ndash;10% among study variables. To maintain the full sample size and reduce the risk of introducing bias, multiple imputation was used to address missingness (de Goeij et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2013\u003c/span\u003e). Fifty imputations were created and results presented are of pooled analyses across all 50 imputations. Bivariate correlations between perceptions of fidelity and other study variables were first examined, along with mean comparisons for dichotomous variables, such as if consultation calls or in-person supervision was utilized. Any dichotomous variables for which there was a significant mean difference in perceptions of fidelity were then included in the subsequent regression model as control variables.\u003c/p\u003e\u003cp\u003eA hierarchical linear regression model, with perceptions of implementation fidelity as the outcome variable, was then conducted. In step one, variables included compassion satisfaction, STS, implementation strategy usage, perceptions of personal effectiveness, and control variables that were identified as significant in mean comparison tests. In step two, interactions among the primary study variables were explored. Step three, included any three-way interactions to be explored based on significant two-way interactions. Multicollinearity was examined in the regression model, and all VIF indexes were \u0026lt;\u0026thinsp;4 (Leech, 2005). All continuous variables were mean centered. Any interactions that were significant, once all three steps in the model were accounted for, were probed at low (-1 SD) and high (+\u0026thinsp;1 SD) ends of variable means and were then plotted to visualize the pattern of results (Aiken \u0026amp; West, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1991\u003c/span\u003e). All analyses, including multiple imputation were conducted in SPSS 28.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cb\u003eCorrelations and Mean Differences\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCorrelations, as shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, indicated significant positive associations between perceptions of implementation fidelity and compassion satisfaction, implementation strategy use, and personal effectiveness. Further, STS was significantly negatively associated with implementation fidelity, compassion satisfaction, implementation strategy use, and personal effectiveness. Compassion satisfaction, implementation strategy use, and personal effectiveness were all positive correlated.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eBivariate Correlations\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1.Fidelity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2.CS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.60**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3.STS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.53**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.60**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4.Implementation Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.68**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.55**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.48**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5.Effectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.69**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.59**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.58**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.63**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMeans (SD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3.6 (1.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e40.6 (7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e46.4 (17.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.5 (.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e3.7 (1.1)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cem\u003eNote.\u003c/em\u003e STS\u0026thinsp;=\u0026thinsp;Secondary Traumatic Stress, CS\u0026thinsp;=\u0026thinsp;Compassion Satisfaction, ** p\u0026thinsp;\u0026lt;\u0026thinsp;.01, *p\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIndependent t-tests of mean differences are displayed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. First, those that served only children had significantly lower perceptions of fidelity (\u003cem\u003et\u003c/em\u003e= -3.9, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00), compassion satisfaction (\u003cem\u003et\u003c/em\u003e=-3.4, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00), implementations strategy use (\u003cem\u003et\u003c/em\u003e= -4.0, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00), and personal effectiveness (\u003cem\u003et\u003c/em\u003e= -3.9, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00), and had significantly higher STS (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;4.7, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00) than those who provided services to children \u003cem\u003eand\u003c/em\u003e adults. No significant mean differences were found among study variables for those who received training in the EBT/EBP in person versus virtually. Lastly, those who received consultation calls and in-person supervision had significantly lower STS symptoms (\u003cem\u003et\u003c/em\u003e= -9.3, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00; \u003cem\u003et\u003c/em\u003e= -4.4, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00) and higher perceptions of fidelity (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;9.7, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00; \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.48, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00), compassion satisfaction (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.4, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00; \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.2, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00), implementation strategy use (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;10.9, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00; \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.0, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00), and personal effectiveness (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11.8, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00; \u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;7.4, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.00).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eMean Differences\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eChild (n\u0026thinsp;=\u0026thinsp;347)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAdult and/or Child (n\u0026thinsp;=\u0026thinsp;251)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eIn-Person Training (n\u0026thinsp;=\u0026thinsp;358)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eVirtual Training (n\u0026thinsp;=\u0026thinsp;240)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eConsultation Calls (n\u0026thinsp;=\u0026thinsp;215)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eNo Consultation Calls (n\u0026thinsp;=\u0026thinsp;383)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eSupervision (n\u0026thinsp;=\u0026thinsp;118)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eNo Supervision (n\u0026thinsp;=\u0026thinsp;480)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFidelity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.8 **\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4.1**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e4.0**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e3.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e41.9**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e40.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e40.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e43.3**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e39.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e42.4**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e40.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSTS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e49.3**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e42.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e45.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e47.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e39.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e50.6**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e41.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e47.7**\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImplementation Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2.6 **\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e2.9**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e2.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e2.9**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e2.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3.9 **\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e3.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e\u003cp\u003e3.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e4.3**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e3.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e4.2**\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c9\"\u003e\u003cp\u003e3.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eNote.\u003c/em\u003e STS\u0026thinsp;=\u0026thinsp;Secondary Traumatic Stress, CS\u0026thinsp;=\u0026thinsp;Compassion Satisfaction, ** p\u0026thinsp;\u0026lt;\u0026thinsp;.01, *p\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eRegression Analysis\u003c/b\u003e\u003c/p\u003e\u003cp\u003eUnstandardized regression coefficients for the regression analysis are shown in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. In step one, compassion satisfaction, implementation strategy use, and personal effectiveness were all significantly positively associated with perceptions of implementation fidelity, and STS was significantly negatively associated with fidelity. In step two, with the addition of interaction terms, STS was no longer significantly associated with fidelity, but compassion satisfaction, implementation strategy use, and personal effectiveness remained significant. Further, two interactions were significant, one between STS and implementation strategy use and the second between STS and personal effectiveness. As such, a three-way interaction between STS, implementation strategy use, and personal effectiveness was explored in step three of the model. In this final step, 63% of the variance in perceived implementation fidelity was accounted for by the direct and interaction effects. Compassion satisfaction, implementation strategy use, and personal effectiveness all remained positively associated with fidelity, and STS was significantly negatively associated with fidelity. The interaction between STS and implementations strategy was also significant. This interaction is plotted in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, which shows that when implementation strategy use was greater, perceptions of fidelity were similar for those with high and low STS. However, when implementation strategy use was lower, those with high STS rated fidelity more poorly than those with low STS. Lastly, the three-way interaction between STS, implementations strategy use, and personal effectiveness was significant. This interaction, plotted in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, shows that implementation fidelity, generally, increased when there was greater use of implementation strategies; however, those with low personal effectiveness had the lowest ratings of perceived fidelity. Further, for those with high levels of personal effectiveness, high STS was associated with lower perceptions of fidelity, but only when fewer implementation strategies were used by the organization.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eRegression Model Predicting Perceptions of Implementation Fidelity\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eStep 1\u003c/p\u003e\u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.61\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eStep 2\u003c/p\u003e\u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.62\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003eStep 3\u003c/p\u003e\u003cp\u003eR\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;.63\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003ep\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.19**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e.20**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e.20**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSTS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.09*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.11*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eImplementation Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.40**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e.40**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e.45**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEffectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.38**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e.40**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e.43**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCS*STS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.46\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCS*Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.92\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCS*Effectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.52\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSTS*Strategies\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e.10*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e.12**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSTS*Effectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026minus;\u0026thinsp;.12*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.02\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStrategies*Effectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSTS*Strategies* Effectiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e--\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e.12**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.00\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"9\"\u003e\u003cem\u003eNote.\u003c/em\u003e STS\u0026thinsp;=\u0026thinsp;Secondary Traumatic Stress, CS\u0026thinsp;=\u0026thinsp;Compassion Satisfaction, Control variables of population served, consultation calls, and in-person supervision were included in step 1 of the analyses, but are not presented in the table as they were not significant. ** p\u0026thinsp;\u0026lt;\u0026thinsp;.01, *p\u0026thinsp;\u0026lt;\u0026thinsp;.05.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study examines implementation process and individual factors that could impact perceptions of fidelity to a range of trauma-focused evidence-based treatments and practices. Unique to this investigation was the exploration of STS and compassion satisfaction, individual factors that have only recently been included in research on EBT/EBP implementation (Sprang et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). To provide a more nuanced understanding of the role these factors play in fidelitious practice, the interactions between significant correlates of perceived fidelity were investigated. Accordingly, this study advances our understanding of how fidelity is created, maintained and understood in implementation settings that provide EBT/EBPs to individuals exposed to trauma.\u003c/p\u003e\u003cp\u003eThe context in which implementation is occurring is key to understanding these results. In this sample, mean STS total scores were moderate to high, with respondents in the child serving group reporting symptom rates that exceed clinical cut-offs (Sprang et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). The aggregate scores in the total sample population are consistent with findings from other studies that document levels of trauma symptoms at or above threshold levels in 19.2\u0026ndash;70% in professionals (Henderson et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2025\u003c/span\u003e; Holmes et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Velasco et al., \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Exposure to child maltreatment and other forms of trauma in childhood has been noted to be particularly stressful for professionals due to the need to respond to sometimes disturbing trauma-related behavior, difficulties securing safety for children living in chaotic conditions and within avoidant, dangerous or defensive families, and having to interface with dysfunctional service systems (Berger et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Hupe \u0026amp; Stevenson, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Weiss-Dagan et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). In this study, in addition to higher STS levels, respondents serving only children had lower perceived fidelity, compassion satisfaction, implementation strategy usage, and viewed themselves as less effective than those who treated adults and children. STS in its conceptual origins was derived from systems theory, and understood as a series of transactions between a professional and client that had the capacity to propel the latter towards recovery and transform the former in nuanced and complicated ways (Figley, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e1983\u003c/span\u003e). In fact, Michael Christopher (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2004\u003c/span\u003e) observes that both adaptive and maladaptive responses to trauma are physiologically and psychologically transformative, excluding no one from the group impacted by these encounters. McCann \u0026amp; Pearlman\u0026rsquo;s (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e1990\u003c/span\u003e) constructivist self-development theory may provide some insights into how STS may impact perceptions of fidelity in the organization, personal effectiveness, and adaptive behaviors such as the use of implementation strategies. These authors posit that indirect trauma exposure (and subsequent responses) can have a pervasive and negative impact on a professional\u0026rsquo;s assumptions, their interpretation of events and expectations of self, others, and the organization; and this may, in turn cause them to question the validity of cause and effect propositions in their work environments. On a practical level, the complexities of working with children, caregivers, and overburdened child serving systems calls for high levels of flexibility that may make fidelity more challenging (Kerig et al., \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Signorelli et al., \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). Results of this study suggest that implementation efforts in child serving contexts may need to be supplemented with additional emotional supports to allow professionals opportunities to process and resolve assaults to their systems of meaning related to self-efficacy, organizational trust, and adaptive coping, as well as the realities of the work.\u003c/p\u003e\u003cp\u003eAdditional comparisons regarding mean differences between subgroups of respondents demonstrated that consultation calls and supervision functioned to improve perceptions of fidelity. These results are consistent with research that demonstrates that external supports of this type delivered post-training can be robust predictors of therapist fidelity to an EBT, regardless of the method of technology transfer (Beidas, et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). Of particular importance is the content of the consultation and supervision, with those encounters that are geared toward giving timely feedback, identifying emerging needs for re-training, and addressing barriers to implementation consistently highlighted as particularly salient (Nadeem et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2013\u003c/span\u003e; Schouten, et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2008\u003c/span\u003e). The utilization of consultation calls and in-person supervision was not only associated with greater perceived fidelity across the organization but also higher levels of compassion satisfaction, personal effectiveness, and lower STS at the individual level. Dehlin and Lundh (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2018\u003c/span\u003e) found that supervision associated with high levels of reflection was associated with high degrees of compassion satisfaction, suggesting that the relational interaction between supervisor and supervisee may be facilitating positive references to the work, or alternatively, those with a high degree of compassion satisfaction may find it easier to engage in a reflective interchange during processing. These findings are further underscored by other research supporting the role of supervision in improving compassion satisfaction and decreasing STS; and the role of self-efficacy in mediating these relationships (Lagos et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Laulita, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Even so, the possibility of a non-linear, multifaceted association between these constructs is possible and warrants further investigation.\u003c/p\u003e\u003cp\u003eTo further explore this issue within the context of fidelity, a series of interaction terms were entered into a regression model to test whether STS, compassion satisfaction, perceived personal effectiveness at delivering the EBT/EBP, and the frequency of implementation strategies varied based on the value of the correlates. The results highlight the importance of implementation process and individual domains singularly, and in combination in the perception of fidelity.\u003c/p\u003e\u003cp\u003eIn the final model, compassion satisfaction, STS, implementation strategy use, and perceived personal effectiveness were all noted to be significant independent correlates of higher ratings of perceived fidelity. Significant interactions were also noted between individual domain factors (STS and personal effectiveness) and the implementation process domain factor of organizational use of implementation strategies. A two-way interaction revealed that when greater implementation strategies are used, individuals have similar levels of fidelity, regardless of STS symptoms; however, when fewer implementation strategies are used, those with higher STS symptoms report lower implementation fidelity. The three-way interaction provided further clarification and nuance, suggesting that for perceived fidelity to be high, a professional must believe they are personally effective at delivering the intervention, STS symptoms should be low, and the organization must be utilizing greater implementation strategies. In other words, it is not enough to just teach someone to deliver an EBT/EBP with fidelity, the organizational milieu must use active implementation strategies to promote perceptions of effectiveness, and individuals and organizations must lower STS for the evidence-based approach to be perceived as fidelitious to the model. An Interagency Collaborative Team model such as the one described by Hurlburt et al. (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2014\u003c/span\u003e) may be one such effective strategy to increase fidelity, but would need to be modified to include STS reduction strategies to fully address these factors.\u003c/p\u003e\u003cp\u003eThe findings of this study advance the idea that successful implementation requires attention to the organizational context as host of an innovation, and to the professionals as actors who shepherd the EBT/EBP toward fidelitious sustainment. During trauma treatment delivery, professional use of self is at the core of the EBT/EBP, and new technologies will succeed only to the extent they are accepted, utilized correctly, and promoted by that implementor. The CFIR model (Damschroder et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) clearly acknowledges this dual responsibility but does not explicate the role of STS specifically in the process. The bifocal model of addressing STS (Sprang et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) explicates the roles of organizations and individuals working in concert to address the phenomenon, but does not speak to implementation specifically. To amalgamate these approaches, one might consider the following integrated course of action: 1) individual monitoring of STS and use of organizational assessments like the Secondary Traumatic Stress Informed Organizational Assessment (STSI-OA) (Sprang et al., 2017); 2) facilitating the acquisition of individual coping strategies and developing a continuum of organizational supports such as reflective supervision, peer support, learning and practice implementation strategies, and consultation prior to training in the EBT (during preparation activities), and further supported during technology transfer phase (especially for child serving professionals); and 3) creation of data-collection systems and quality improvement processes (put in place prior to implementation) to provide continuous feedback to the organization and individual practitioners to support learning, growth, and an improved sense of effectiveness during sustainment. Extrapolating from both models, it is clear that these activities should begin early in the implementation cycle to avoid depleting resources when trying to resolve internal problems later in the process. Future research aimed at testing this integrated model during an implementation study is an important next step.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAlthough the present results advance our knowledge of factors influencing provider\u0026rsquo;s perceptions of trauma-focused EBT/EBP implementation fidelity, there are multiple limitations that are important to note. First, this study focused only on implementation process and individual domains of the CFIR model, and it did not include any variables directly related to the inner (e.g., organizational culture on infrastructure) and outer setting (e.g., policies and laws, sociocultural environment, or external networks; Damschroder et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Factors related to these domains likely impact differences seen in the implementation process and individual domains, but were beyond the scope of the current investigation. Future research is needed to understand how factors such as organizational and local policies may interact with the implementation process (e.g., implementation strategy usage) and individual (e.g., STS) domains to influence EBT/EBP implementation fidelity. Second, the present results are limited to providers\u0026rsquo; perceptions of fidelity. While this is an important variable to assess in capturing individual attitudes and views, it may not align with more objective measures of implementation fidelity such as fidelity checklists completed by outside observers (Schoenwald et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). Third, the sampling design of the current study, though resulting in a large sample of providers across the United States, did contribute to a large number of participants who served children. There were not enough providers who worked exclusively with adult populations to compare to those who worked exclusively with children. This may limit the generalizability of the current results. Lastly, due to the correlational nature of the present study, directionality and causality of relations between variables cannot be determined.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eResults of the present study highlight the important interplay between implementation process and individual characteristics in understanding mental health providers\u0026rsquo; perceptions of implementation fidelity. Demonstrating the need to attend to which implementation strategies an organization uses and which populations are served, as well has providers\u0026rsquo; level of STS and perceived personal effectiveness. Thus, implying that achieving implementation fidelity is not only the responsibility of the individual provider, but is equally the responsibility of the organization at large.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u0026nbsp;\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAarons, G. A., Hurlburt, M., \u0026amp; Horwitz, S. M. (2011). Advancing a conceptual model of evidence-based practice implementation in public service sectors. \u003cem\u003eAdministration and policy in mental health and mental health services research\u003c/em\u003e, \u003cem\u003e38\u003c/em\u003e, 4-23. https://10.1007/s10488-010-0327-7 \u003c/li\u003e\n\u003cli\u003eAiken, L. S., \u0026amp; West, S. G. 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Use of concept mapping to characterize relationships among implementation strategies and assess their feasibility and importance: results from the Expert Recommendations for Implementing Change (ERIC) study. \u003cem\u003eImplementation Science\u003c/em\u003e, \u003cem\u003e10\u003c/em\u003e, 1-8. https://doi.org/10.1186/s13012-015-0295-0 \u003c/li\u003e\n\u003cli\u003eWeiss-Dagan, S., Ben-Porat, A., \u0026amp; Itzhaky, H. (2022). Secondary traumatic stress and vicarious post-traumatic growth among social workers who have worked with abused children. \u003cem\u003eJournal of social work\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(1), 170-187. https://doi.org/10.1177/1468017320981363 \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Fidelity, Trauma-Focused EBT/EBP, Secondary Traumatic Stress, Implementation Strategies, Personal Effectiveness, Compassion Satisfaction","lastPublishedDoi":"10.21203/rs.3.rs-7060094/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7060094/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"Implementation fidelity is the extent to which an intervention is delivered in the manner in which it was designed. Within randomized-controlled trials (RCTs), fidelity is often rigorously ensured through strategies out of reach for most organizations. This limitation may be of particular concern for trauma-focused evidence-based treatments/evidence-based practices (EBT/EBPs), as the needs of individuals and families seeking trauma-based treatment are often complex, with existing comorbidities that can complicate recovery. This contributes to concern about how or if EBT/EBPs are being implemented to fidelity. The present study used the Consolidated Framework for Implementation Research (CFIR) framework to examine implementation process and individual characteristics, as well as interactions among these factors in impacting provider’s perceptions of fidelity. Data came from 598 mental health providers, who completed an online survey regarding provider demographics, perceptions of personal effectiveness, work experiences such as secondary traumatic stress and compassion satisfaction, and organizational implementation strategies used for a trauma-focused EBT/EBP. Significant positive associations were found between perceptions of implementation fidelity and compassion satisfaction, implementation strategy use, and personal effectiveness. Further, STS was significantly negatively associated with implementation fidelity. Significant differences were found based on population served and use of consultation calls and in-person supervision. Within a regression model, a significant two-way interaction between STS and implementations strategy use was significant, along with a three-way interaction between STS, implementations strategy use, and personal effectiveness. This study advances our understanding of how fidelity is created, maintained and understood in implementation settings that provide EBT/EBPs to individuals exposed to trauma.","manuscriptTitle":"Providers’ Perceptions of Trauma-Focused EBT/EBP Implementation Fidelity: Implementation Process and Individual Influences","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 14:42:22","doi":"10.21203/rs.3.rs-7060094/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"bf5bd0df-4f7a-4984-9c81-c72fb875f08e","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-10T16:03:07+00:00","versionOfRecord":{"articleIdentity":"rs-7060094","link":"https://doi.org/10.1007/s10597-025-01553-x","journal":{"identity":"community-mental-health-journal","isVorOnly":false,"title":"Community Mental Health Journal"},"publishedOn":"2025-11-05 15:58:00","publishedOnDateReadable":"November 5th, 2025"},"versionCreatedAt":"2025-07-15 14:42:22","video":"","vorDoi":"10.1007/s10597-025-01553-x","vorDoiUrl":"https://doi.org/10.1007/s10597-025-01553-x","workflowStages":[]},"version":"v1","identity":"rs-7060094","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7060094","identity":"rs-7060094","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}