Evidence-Based Practice in the Past

Evidence-Based Practice

In the past decade, evidence-based practice (EBP) has been consistently recommended for the helping professions (Proctor, 2004; Roberts & Yager, 2007). Trace the historical roots of evidenced-based practice. Evaluate the benefits and risks of its implementation in social work and community services.

Roberts, A.R., & Yaeger, K.R. (Eds.). (2007). Foundations of evidence-based social work practice. New York: Oxford University Press.

Proctor, E.K. (2004). Leverage points for the implementation of evidence-based practice. Brief Treatment and Crisis Intervention, 4(3), 227-242.

The nature of the social work profession is to assist people who are in need of services. People who chose to work in helping professions such as social work and community services are charged with the task of helping people overcome problems by providing a variety of resources. Commitment to the welfare of clients is one of the most important aspects of being a social worker and/or any other worker in a service profession. The emergence of the phenomenon that is Evidence-Based Practice (EBP) has caused a great deal of controversy in the world of social work as well as other service related professions. Therefore, it is important to exam the methods by which social workers assist clients using EBP and to more discretely define EBP and its various components. Despite these accepted facts, there is substantial evidence that across the varied settings in which many social workers are employed, including mental health, substance abuse, public health, child protection, and so on, large numbers of clients perhaps half or more who are offered treatment do not engage, and among those who begin treatment, many possibly another half or more drop out of treatment before any significant impact could be expected (Bellamy et. Al, 2008).

EBP can be applied to decisions that arise not just within clinical work with individual clients, but also in managing human service organizations, developing policy, or designing and administering educational programs to train social workers. Those who choose the route of research for the field argue that EBP is essential and must be taught and studied in order for the profession to thrive and come up with cutting edge, effective interventions for clients. However, many practitioners have no interest in research and have not been trained to seek out interventions tested by EBP. Many practitioners might even feel threatened by EBP as it requires a substantial educational investment, learning how to search and retrieve data, and then applying it to either new practice or related existing practice. To a large degree EBP is an essential marriage between the scholar and the practitioner, and though logically this marriage makes sense, as many would like to see the most current and cutting edge theory applied (without delay) to clinical practice the reality is that clinical and scholarly skills and desires are not always compatible in a single individual. Where one individual practitioner may see the value in the goal of publishing, researching and searching data sets, others are more likely to seek out more time to actually interact directly with patients, not study subjects. (Grinnell & Unrau 2008)

Gambrill (2003) as strong advocate for EBP states that practitioners and clients will not have access to effective interventions, if researchers continue to utilize inadequate rigor, while others complain that scholarly rigor may not be the needed function of an equation in each and every clinical situation. Herbert et. Al.(2001) discern that the overwhelming strength of the evidence-based approach to clinical practice is that it takes full advantage of the only potentially unbiased estimates of effects of therapy those which are derived from carefully conducted clinical research (pp. 210).

While conversely, many opponents of EBP, social work practitioners will spend more money and time accessing, reading, and analyzing a lot of social work books and journal articles, even though the information in the books and journal articles may not be relevant to their practice. Unless social workers' time constraints and heavy workload can be reduced, adopting EBP will increase social workers' stress, workload, and possibly even their personal resource allocation. This will likely force many social workers to leave the social work profession and look for other jobs (McNeill, 2006).

What is Evidence-Based Practice (EBP)

Roberts and Yeager (2006), cite Gibbs (2003) when defining EBP as a systemic approach to evaluate problems, formulate answerable questions, gather and critically evaluate evidence, applying the evidence to the present situations, and evaluating the intervention. Over the past decade, there has been an increasing recognition that social work should be evidence based. The potential contribution of evidence-based practice to the effectiveness, efficiency, and accountability of social work education and practice has been emphasized.

All clinical practice to some degree is EBP, though often a vastly oversimplified one in which a practitioner first determines a client's diagnosis or condition, then consults a diagnostic criteria and works from there to aide the client in personal development or change, to better the situation. The National Association of Social Workers (NASW) defines EBP as interventions for which scientific evidence consistently shows that they improve client outcomes (NASW, 2009). It has been argued that EBP reflects a primarily positive, epistemology and that its ontological and epistemological assumptions are too narrow to embrace human behaviors and the metaphysical world that social workers strive to understand (McNeill, 2006).

Rosen (2003), states that EBP must include the client's individual circumstances in the decision process. Consideration of the client includes informing the client of the available interventions and explaining the research and findings associated with that intervention. EBP is again thought to be a means to bridge the gap between practice and research, and can be simple, i.e. related to a case by case process of research and application, yet it can also be highly scholarly and formal. McNeill (2006) stated that evidence is much more of a relative concept than proof; it can range from clinical observations to the results of both large-scale epidemiological studies and randomized control trials (p. 150).

What is Evidence?

This paper will explore EBP based on a fusion of the definitions mentioned above. In order to develop a greater understanding of EBP a more in-depth explanation of the terms must be offered. Zlotnik and Galambos (2004) define evidence as randomized controlled trials that support an intervention. In other words, phenomenon considered as evidence must be contrived as a result of some sort of research and/or trial. According to many the most essential aspect to learning, using and even teaching EBP is that not all information produced by studies can be considered good or credible evidence.

Christopher Weed describes evidence in a level system. Below are the levels listed from highest to lowest weight in credibility, where evidence is ranked according to its validity/repeatability. In level 1 evidence is gleaned from a true experimental design such as a randomized clinical trial, and is considered the best type of evidence. Level 2 evidence is that which is gleaned from quasi-experimental research designs, such as clinical trials that do not include randomization but do include all the other elements of a true randomized clinical trial. Level 3 evidence is that which is based on expert consensus, which can be anecdotal but is based on observation and experience of supposed experts en mass. Level 4 evidence is that which comes from qualitative literature reviews, and finally level 5 evidence which is simply gleaned from anecdotal experience. (Weed, 2007)

If these levels are to be trusted, much of the tradition of social work might be challenged, though the profession would seem much more "scientific" in nature. Another credible challenge to this hierarchy of information with regard to social work, is similar in concern to any thinking science as much of the work is un- recordable and unobservable, as it occurs within the mind, rather than the action of the individual. Here in lies another controversy surrounding EBP in social work, or any helping science involved with mental processes; defining individuals then, "are we what we think or are we what we do?" Yet, it is clear that defining evidence, taken separately from the term evidence-based practice is essential to the establishment of the whole of the definition of EBP and is certainly part of the learning curve for application. Certainly, practitioners and scholars, or any marriage of the two must be clear that when retrieving evidence, that not all research is "good," yet this also implies that much of the unspoken and undercurrent of what we do as social workers is not considered "good" by these standards.

Straus and Haynes (2009) in fact, warn those who seek interventions that claim to be EBP at any of the level must ensure that evidence is reliable by being aware of the methods used to generate, synthesize, discuss and summarize it. They should know that just because a resource has references does not mean that these reosuces are evidence- based. Or just because a resource uses the terms evidence-based in its title does not mean that it was derived through appropriate research methods and could potentially be a very well written review of anecdotal literature. In fact the inabilty of the sociall work profession to adequaelty and discretely define EBP, specifically the main goal of this work, may in part be to blame for scholalry blunders, such as the use of evidence-based practice in a title of a work that is highly qualitative, anecdotal or even based on a single or small set of case studies.

Just as Weed lists the various levels of evidence, The American Psychological Association (APA) went a step further by establishing a task force to judge good evidence for a range of psychological disorders. According to Rosen and Proctor (2003), as taken from the APA, the most basic criterion used by this task force is that well established and empirically validated data requires a design that involves two or more rigorous studies that support the proposed intervention.

History of EBP

Newly gained interest in EBP makes it appear as a fairly new phenomenon to the social work and social services field. In fact, EBP was derived from medicine in general. Some in fact argue that the application of a standard that is derived as a tool for something such as a drug trial may not be a reasonable fit for social work, as the outcomes and answers are rarely as discrete as say, the drug removed the pain, or lowered blood pressure, or the trial surgical procedure healed faster and had less risk of failure than an older procedure. Relapse is far less common in such discrete issues than it is in fields associated with the human mind driven to action or inaction, based on thoughts and feelings.

Rosen (2003) states that EBP has been advocated in a number of human services professions, first in medicine, and more recently in psychiatry, clinical psychiatry and now social work. Early scholars in the field of social work education such as Edith Abbott, Sophonisba Breckinridge, Porter Lee, and Gordon Hamilton have long advocated for research based on practice (Shoemaker, 1998). Conversely, the implied assumption is that such research would then be used to improve practice at a later date, or even in the present research group. Yet, it is also clear that for the most part the rigors of science and data set searches were not likely at the forefront of their minds. As early as the late 1800's, social welfare advocates Anna Dawes and Mary Richmond, began moving toward an organized method of training new social workers, when they did so they also implied that there was a way to train, that involved experience and application, again a simplified support for EBP, in its most rigorous form, and mostly a simple goal of attaining professionalism through at least some standardization of practice. In this quest schools were where applied philanthropy was taught (Shoemaker, 1998). Yet, it is likely that in these classrooms and clinical settings a great deal of "you will get a feel for it," was espoused by these "applied philanthropists."

Bridging health and human services with scientific research inquiry, emerged as a trend toward the end of the 20th century and spread world wide within the 21st century throughout major universities, treatment facilities and medical and mental health centers throughout the world (Roberts and Yeager, 2004). In today's world of technology, the research industry plays a major role in the perceptions that consumers have for products being advertised and delivered and accountability is the key to consumer driven thought. This holds true for the field of social work and supports the emergence of EBP and its importance to the field of social work and other community service fields. Yet, it also makes sense that such a system as EBP, as it applies to social work would emerge in a climate of "accountability" as in the development of a culture that sees only "raw" data as a real gage of success and/or failure of a system, individual or organization. This is certainly not to say the EBP is essentially in error, as this would be another invalid certainty, as it is clear that evidence and knowledge must be utilized to the best degree possible when developing client interventions and that to do so requires rigor, it is also fair to say that many practitioners would like to see a bit of converse flexibility.

Per Yunong and Fengzhi (2009), observe that many scholars in the field of social work utilize the five steps of EBP originally formulated by a seminal work by Satchell et al. In 2000. The five steps include; 1 Converting one's need for information into an answerable question. 2. Searching for the best evidence to answer that question. 3. Critically evaluating the evidence. 4. Integrating the critical expertise and with the patient's unique biology, values, and circumstances, and finally 5 Evaluating one's own effectiveness and efficiency in undertaking the previous steps and to strive for self-improvement. The core of these principles, themselves certainly do not seem to denote judgment, as they provide a clear sense that the "best" evidence can in some cases be dependant upon the individual, the case and the practitioner and that this flexibility is inherent within reason.

The five step process is said to be designed to engage practitioners in a continual process of evidence identification, evaluation, and application in partnership with clients to improve practice outcomes (Bellamy et. Al, 2008). Yet, you could also argue that any paradigm that invokes inquiry would be of greater assistance to the practitioner than none. In short, using EBP can be viewed as a learning what treatments and techniques work based on research, while integrating client views into determining what will work best for them. Thoughout this work have been hints at the various contentions of both advocates and opponents of evidence-based practice. The following section will further stress this trend as it applies to education and application.

Multiple Perspectives on EBP

EBP has several potential benefits to social work. First, social work has been obsessed with professional status for almost its entire existence and advocating and applying a system that stands up to scientific rigors would aide in the quest for professionalism and professionalization of the field. (Bellamy et. Al, 2008). In other words the emphasis of research and strict evidence in EBP social work could potentially enhance the credibility of the social work profession. Second, it has been argued that social workers seldom use research evidence in practice, which many find a disheartening reality of the field (Rosen, 2003). The emphasis of research evidence in EBP social work could promote the integration of research evidence into social work practice, helping even the most ardent opponent see how even reading a single well documented research article might give them insight and promote thinking about solutions for clients. The fear is that if practitioners fail to consider the effectiveness of their interventions, then it is possible that clients will leave agencies without getting adequate and helpful treatment for their concerns and when they do this the profession is degraded.

With new advancements in technology, the invention of and the wide spread usage of the internet, research studies and findings are more readily available and easier to access than in the past, though again the ability, time and learning curve for such research must be considered. There are many researchers who are passionate about the effectiveness and the need for EBP in the social services and medical fields. For example; Roberts and Yeager have produced a document: Evidence-Based Practice Manual: Research and Outcome Measures in the Health and Human Services; (2004) that offers evidence-based knowledge so that graduate students and practitioners in the medical and human services professions can have the latest research and evaluation guidelines and evidence-based protocols in a comprehensive manual. Such a document, though exceedingly helpful may need to be the type of document that gains annual status, i.e. producing a yearly digest with new and emerging EBP evidence scholarship. Other scholars and textbook authors in the social work field have begun to add EBP to educational materials in relatively comprehensive manner. (Grinell & Unrau 2008)

Indeed many practitioners are excited about EBP and devoted advocates for continuing research and even teaching courses pertaining to EBP to college students; however, as has been pointed out not all practitioners are in favor of EBP. Social work educators must include thoughtful discussion of multiple aspects of evidence-based practice in the curriculum, including both the opportunities evidence-based practices hold for social work as well as the potential limitations. This is needed in order to ensure that students do not oversimplify the process of identifying and using evidence- based practices, and to ensure that students remain vigilant to potential evidence-based practice misuses and inappropriate practices under the guise of evidence-based practice (Bellamy et. Al, 2008). Yet, probably most importantly EBP must be adequately and appropriately defined in some sort of standardized manner.

Teaching clinical skills is of course an important element in existing social work education and if social workers are to develop expertise in the EBP process, gaining skills in assessing evidence must not crowd out the acquisition of these more traditionally emphasized -- but still critical -- clinical skills (Haynes & Straus, 2009). Jenson (2005) points out that there is no consensus on, or regulation of, what exactly constitutes an evidence-based practice because of variations in fidelity and implementation issues. For example, a practice can have a plethora of evidence to support it, a detailed manual, and perform well with a variety of clients in controlled research studies, but still not meet practical considerations that determine its applicability to the field. More importantly, as Jenson (2005) states, untested interventions marketed as evidence based under such names as best practices or exemplary programs promotes a false sense of efficacy, erodes the basic principles of evidence-based practice, and dilutes commonly accepted definitions of evidence-based practice used in medicine and psychology. Herbert et. Al (2001), note the following as the biggest reasons why EBP faces criticism, EBP is to time consuming to be practical, there is not a good base of evidence already in existence and that evidence which does exist does not always qualify as rigorous, especially by the level standards associated with Weed and described above. Herbert et. al continue by stressing that the evidence is not generalizable from trial to treatment and that only patient centered research is viable for application in patient centered practice.

Regardless of an individuals' opinion regarding EBP it is completely undeniable that research, publishing and therefore dissemination of such research is crucial to the social work field. The only manner in which any practitioner can provide useful and applicable interventions that are timely is through continuous research occurrence and practitioners must be abreast to it. In short this is the greatest argument for EBP, and yet really the strict sense of accountability and controlled blind studies does seem to be a lot for many practicing clinicians to adopt in any real practical way. Most scholars will have a curriculum vita that contains 10-20 published sources, but try doing this when you are not a scholar and work within a practice that requires accountability for billable hour as well as positive patient outcomes.

The Benefits of EBP

With the increased interest in EBP, it is important to consider its potential benefits. Preparing social workers to be competent with EBP requires teaching them how to collaborate with clients in determining needs, in selecting treatments, and in monitoring outcomes, this is of course a positive paradigm. As mentioned earlier in the paper, research enhances the credibility of those interventions used to help clients. Gambrill (2003) supports the idea that it is of the utmost importance that professional social workers advocate for clients by helping them to discern the good from the bad, when it comes to intervention. The ethic of medicine is do no harm, the same goes for social work. Concerns that practitioners were continuing to use methods that were harmful was a key reason for the development of EBP. EBP calls for candid descriptions of limitations of research studies and use of research methods that critically test questions addressed (Gambrill, 2003, pp. 5 & 6).

Furthermore, NASW acknowledges the importance of EBP as it relates its importance to the mental health profession. According to NASW, due to the numerous services that social workers provide to persons with serious mental illness, social workers working with persons with mental health disorders should also be exposed to relevant EBP (NASW, 2009). While EBP is not the cure all for unanswered, undiscovered questions about interventions and treatments in the field of social services, it certainly provides a way to research and test theory and then potentially disseminate it to colleagues farther away than the office across the hall.

Charles Schwartz describes EBP as beneficial because it provides a series of steps that may be used in difficult situations, where evidence for new practices may be lacking or where current practices appear to be ineffective (EBP in Social Work). In a time when many are plagued with economic hardship, EBP can be used to determine high quality, cost effective interventions that work, rather than allowing clients to continue to waste money using interventions that are less effective.

Medical doctors use extensive research and testing to validate medicines and procedures used in that field. The use of EBP in the field of social work could add that same validity and credibility to the methods used by social workers and other professionals in the service field. The social service field is one based in history and traditions; however, in order to remain viable and relevant, it would be wise to embrace the advances that EBP could potentially provide. It is possible that through direct communication between social work researchers and clients, a new approach toward social work practice that connects social work researchers directly to clients can be built.

Risks and Objections to EBP

In order to effectively discuss EBP both benefits and risks must be explored. Much of the research on EBP shows that practitioners in the field of social work have mixed reviews about the emergence of EBP. Although there is an array of information available supporting EBP, there are many who attest to the risks and barriers associated with the practice. According to Walsh (1997), time constraint is one of the major barriers of EBP. It may be difficult or impossible for social workers to take the necessary time away from direct care in order to effectively conduct research and monitor experiments. Let alone edit and publish works. Furthermore, those who work for agencies may find it difficult to get approval to take time off, in order to pursue research interests. Dr. Suman Bhusan Bhattacharyya in his article, Evidence-Based Medicine and Outcomes Analysis: An Evaluation listed several barriers to evidence-based practice. Some of those barriers include, unrealistic patient expectations, time constraints, resources constraints, learning curve for data and technology gathering and analysis, investment in education and a behavior change. Bhattacharyya also states that research currently available is not standardized or indexed or references in a universal fashion creating frustration for the efficient researcher. This scenario can create situations where research that could be directly applicable is simply out of the reach of the practitioner, who has only a limited amount of time to seek it. He then goes on to say that the system lacks flexibility, requires an individual a good knowledge of statistics, there is not enough evidence and most systems are not integrated to support EBP (2008).