Leadership strain and role ambiguity in assertive community treatment teams and their association with workforce functioning

Health systems depend on workforce capacity, role clarity, and leadership support to sustain implementation of complex, team-based service delivery models. Assertive Community Treatment (ACT) is an evidence-based intervention for individuals with serious mental illness that relies on intensive multidisciplinary coordination and high-fidelity implementation. While ACT research has emphasized outcomes and fidelity measurement, less attention has been given to leadership and workforce experiences that shape implementation processes at the organizational level. This mixed-methods study examines leadership and workforce challenges influencing ACT implementation within a publicly funded mental health system. Staff from a single urban ACT program completed surveys and provided qualitative responses addressing role clarity, supervision, training, and implementation strain. Quantitative analyses found no significant associations between staff background characteristics and perceptions of role clarity or preparedness. Qualitative analysis identified five interrelated themes: role ambiguity, supervision gaps, inconsistent training, tension between fidelity standards and real-world practice conditions, and implicit leadership strain. Leadership frequently absorbed unresolved structural gaps by assuming additional responsibilities and managing ongoing operational demands under constrained conditions. Findings suggest that ACT implementation challenges are driven less by individual staff characteristics and more by organizational and leadership strain arising from structural ambiguity. Strengthening leadership support, supervision infrastructure, and training systems may enhance workforce functioning and promote more sustainable implementation fidelity in team-based mental health service delivery models.