From Concept to

Implementation: The
Challenges Facing Evidence-
Based Social Work
Faculty Research & Insights: A Series Featuring
CUSSW Faculty Research

Edward Mullen & Aron Shlonsky

September 22, 2004
 Evidence-Based Social Work Is A
Concept Awaiting Implementation
Much discussed Placing
Evidence-based
--- theconscientious,
the clientsmedicine
benefits has
first,
evidence-based
been defined practitioners
as --- the adopt
explicit
a process and
conscientious, judicious
of lifelong
explicit
learning
anduse
that
judicious
involves continually
use of currentposing
best
ofevidence
current best evidence
Required in EPAS specific in
practical
about the
questions
making decisions
importance
of direct
caredecisions
of individual
to clients,
in making
patients
searching
(Sackett,
objectively
et al., 1996,
and p.
regarding
71);
efficiently
and thefor the welfare
"integration
the current of
ofbest
best
evidence
research relative
evidence
to each
with question,
clinical
Not clearly Defined service-users
and
expertise
takingand and
appropriate carers
patient values"
action
guided
(Sackett,
by evidence
(Sheldon, Straus, Richardson,
2003, (Gibbs
p. et al.,
1).
Rosenberg,2003, & Haynes,
p. 6). 2000, p. 1).
Not yet implemented
in pure form
Origin of Evidence-Based Social
Work
Adaptation of evidence-based approaches found in
medicine and healthcare
Evolution from earlier attempts to join policy-practice-
research
Effectiveness research
Eclecticism
Empiricism & the scientist-practitioner model
Social intervention research
Outcomes measurement
Systematic review methodologies meta-analysis
Eileen Gambrill early translator (1999)
Leonard Gibbs first workbook-text (2003)
Aaron Rosen & Enola Proctor on guidelines (2003)
 The EBP Model

Practitioners Best
Individual Evidence
Expertise

EBP

Client Values and

Expectations

Sackett et al., 1997

Newest EBP Model

Clinical state
and
circumstances

Clinical
Expertise

Client
Research
Preferences
Evidence
and actions

Haynes, Devereaux, and Guyatt, 2002

 Steps of EBP
Become Motivated to Apply EBP
Step 1Convert information need (prevention,
assessment, treatment, risk) into an answerable question.
Step 2Track down current best evidence.
Step 3Critically appraise the evidence.
Step 4Integrate critical appraisal with practice
experience, clients strengths, values, and circumstances.
Step 5Evaluate effectiveness and efficiency in
exercising steps 1-4 and seek ways to improve them next
time.
Step 6Teach others to follow the same process

Gibbs, 2003
 The Cycle of EBP
Appropriate for
this client?
Clinical state
Contextual
and
assessment circumstances Actuarial
risk
assessment
Clinical Expertise
Other valid
Client Current assessment
Preferences and Best measures?
actions Evidence
Clients
preferred Effective
course or services
at least
willing to
try? Barriers (e.g., Adapated from Haynes, Devereaux, and
Guyatt, 2002; as presented in Shlonsky and
cultural conflict Wagner, in press.
 Hallmarks of EBP
Individualized assessment (strengths, needs,
values, preferences of client)
Well-formulated question (database query)
Well-executed search of research literature
Deciding its applicability to clients
Considering the evidence together with the
values and preferences of the client.

Sackett et al., 1997; Gibbs, 2003

 Origins of Evidence-Based
Healthcare & Public Policy
Used to inform health care policy at hospital, regional, &
national levels (Davies & Boruch, 2001; Romanow, 2002;
Gray, 2001; Davies, Nutley, & Smith, 2000)
Became component of New Labours modernizing
government strategy - extended to other sectors
including social care (Davies, 2004; Walker, 2001)
Facilitated by:
Cochrane & Campbell Collaborations
UK ESRCs evidence-based practice & policy centres
UK Social Care Institute for Excellence
Sweden Institute for Evidence-Based Social Work
Publications e.g., Evidence-based Policy: A Journal of
Research, Debate and Practice
 Policy Applications
An approach to policy that:
helps people make well informed decisions
about policies, programs & projects

EBPolicy contrasts with opinion-based policy

which relies heavily on either the selective
use of evidence (single studies irrespective
of quality)
untested views of individuals or groups

Philip Davies (2004), Director of Policy Evaluation in the Cabinet

Office of the UK Prime Ministers Strategy Unit
 What is evidence-based
healthcare?
Discipline centered on evidence-based
decision-making about:
-Groups of patients
-Populations
Evidence from wide range of disciplines
Use of scientific research findings and
logic
Healthcare problems
Health improvement
Decision-making in healthcare
Gray 2001
Evidence-Based Policy Definition

Decision-making process in
which policy-makers,
purchasers, managers, or
practitioners together with
key stakeholders make
decisions about problem or
need assessment, goals &
objectives, interventions &
outcomes
EBPolicy Process (Gray, 2001)

Getting Evidence Finding &

into Practice Appraising Evidence

Capacity
Building
Sources of Evidence in EBP

Impact
Evaluation
Attitudinal Implementation
Studies Evaluation

Ethical Descriptive
Analysis Studies

Economic Statistical
Analyses Modeling
 EBPolicy Steps
Finding and appraising evidence pertaining to the
decision at hand:
Assessment or intervention options
Intended outcomes
Research method
Developing organizational capacity
Getting the evidence into practice
Preparing a policy
Making cultural changes
Designing systems for implementation
Implementation
Monitoring
Audit
 Examples of Evidence-based
Policy Initiatives
EVIDENCE AND POLICY: A JOURNAL OF
RESEARCH, DEBATE AND PRACTICE
ESRC Evidence Network - UK Centre for
Evidence Based Policy & Practice
U.K. Cabinet Office
University of St. Andrews
Romanow Commission Canada
U.S. Implementing Evidence-based Practices
Project
 Arguments For Evidence-Based
Social Work (EBSW)
Enhances decision quality
Fosters learning of assessment skills
Incorporates client values and expectations
Fosters evidence search and appraisal skills
Makes best use of best evidence
Framework for self-directed, life-long learning
Identifies gaps in knowledge
Common interdisciplinary language

Sackett et al, 2000

 Arguments For Evidence-Based
Social Work (EBSW)
Eschews authoritarian practices and policies
Promotes SW ethics through:
Informed consent
Using effective services
Wisely allocating scarce resources
Involving clients in practice process
Individualizing & personalizing decisions

Gambrill, 2003
 Arguments For Evidence-Based
Social Work (EBSW)
Helping clients develop critical appraisal skills
Involving clients in design and critique of
practice and policy related research
Involving clients as informed participants who
share in decision making
Recognizing clients unique knowledge in terms
of application concerns
Promoting transparency and honesty
Encouraging a systemic approach for integrating
practical, ethical and evidentiary issues
Maximizing the flow of knowledge and information
about knowledge gaps
Gambrill, 2003
 Challenges Facing EBSW
Evidence-of-effectiveness
Authority
Conflicting hierarchy
Definition of evidence
Shortage of evidence
Variation by field of practice
Inflation of evidence
Small & transient effects
Assessment validity
Nomothetic versus ideographic knowledge
Efficacy versus effectiveness
Diffusion, adoption and implementation
Policy & system level issues
Training & sustaining
 Evidence-of-effectiveness
Challenge
A key assumption of EBP is that it results in
better outcomes than other forms of practice
Yet, this assumption is not empirically testable:
This proof is no more achievable for the new paradigm
(EBM) than it is for the old, for no long-term randomized
trials of traditional and evidence-based medicine are
likely to be carried out. (Evidence-Based Medicine
Working Group, 1992, 2424)
 Authority Challenge
As originally conceived the founders of
evidence-based medicine envisioned that
medical practitioners would seek out
evidence & appraise the quality of that
evidence, alone or in teams of practitioners
The new paradigm puts a much lower value
on authority. The underlying belief is that
physicians can gain the skills to make
independent assessment of evidence and
thus evaluate the credibility of opinions
being offered by experts (Evidence-Based
Medicine Working Group, 1992)
 Authority Challenge
Lack of evidence that EBM can be
transmitted into practice
Medical students have not shown an interest
in becoming evidence-based practitioners
only evidence users
As evidence users rather than independent
appraisers, practitioners are simply
replacing one authority with another
researchers are the new authorities!
 Authority Challenge
To date it has not been shown that average
practitioners can gain the skills needed to
conduct independent assessments of the
evidence
Practitioners can become evidence-users
not evidence-based practitioners say
Upshur & Tracy
Evidence-users accept evidence that has
been vetted by others thus replacing one
authority for another! But what is the basis
for the authority of the evidence appraisers?
Conflicting Hierarchy Challenge
Hierarchy of Evidence Ranked by Quality
N of 1 randomized trials
Systematic reviews/Meta-analysis of
randomized trials
Randomized Controlled Trials
Systematic review of observational studies
addressing patient-important outcomes
Physiological/Laboratory experiments
Unsystematic clinical observation
 Conflicting Hierarchy Challenge
Practice recommendations (e.g., practice
guidelines) are to be based on the soundness
of the evidence
Many evidence hierarchies have been
published & these hierarchies are not
commensurable (e.g., randomized, controlled
trials and meta-analysis versus well designed
epidemiological studies)
Fundamentally these hierarchies do not rest
on evidence but rather on the consensus of
experts the beliefs of the few!
Definition of Evidence Challenge
Because contemporary health care and
human services are multidisciplinary
there are many differing perspectives
that require consideration
Accordingly, the concept of a univocal
understanding of evidence is not
sustainable
A restrictive view of evidence is not
sustainable
Shortage of Evidence Challenge
The question that faces proponents of EBP is whether
there are enough high-quality studies so that evidence-
based decisions can be made.
Surprisingly for a field that places a high premium on
research, few studies have examined this.
The conclusion at this point, based on just a few studies,
is that there are still many decisions that are made that
are not based on good evidence, but the picture is not
nearly as bleak as opponents to EBP would have us
believe.
Professionals must remember, though, that when they
make decisions for which little or no evidence exists, that
they should exercise caution and perhaps be even more
vigilant in monitoring outcomes.
 Shortage of Evidence
Varies by field of practice
Confounded by inflation of evidence by
proponents and users
Clouded by dominance of small and
transient effects
Applies to assessment evidence as well
as intervention evidence
 Shortage of Evidence Varies by
Field of Practice
Adequacy varies considerably by field of
practice
Most robust is mental health
In other fields of practice much more of a
patchwork
Unevenness of the research base across
fields of practice looms as a major
challenge
 Inflation of Evidence Challenge
Bias in reported research due to:
Tendency for investigators or assistants to
give a leg up to interventions they favour -
expectation for improvement
Dependence on client self-report to measure
intervention outcomes which may reflect
social desirability, expectancy, & cognitive
dissonance effects
 Small & Transient Effect Size
Challenge
The rule is small effect sizes which may
not be clinically or social important
Gains frequently do not persist, especially
for complex and chronic problems such as
addressed by social workers
 Assessment Challenge
Reliable, valid, & relevant assessment tools are
needed to support evidence-based social work
practice
Rapid assessment measures have contributed
greatly (Corcoran & Fisher, 2000)
Social work practitioners generally do not use
any standardized assessment procedures to
guide their practice (Mullen & Bacon, 2004)
Shortage of Evidence Challenge
Evidence-based social workers must remember that
when they make decisions for which little or no evidence
exists, that they should exercise caution and perhaps be
even more vigilant in monitoring outcomes
Knowledge gaps point the way to needed research
Methodological corrections should be instituted to deal
with the inflation of evidence issue
Where interventions are found to have small with
transient effects of limited importance this should be
acknowledged and addressed
The underutilization of assessment instruments should be
corrected by enhance training in the use of appropriate
instruments & dissemination of information about
available instruments.
 Challenge of Applying Results to
Individuals
Results of RCTs are analyzed by comparing the mean
score of the experimental group against that of the
placebo or control group (or some comparable summary
statistic). This masks the fact that there is always
individual variability around the means, & overlap in the
distributions of scores for the two groups. The result of
this is that a proportion of people in the experimental
group actually do worse than some in the control group
and, conversely, some in the comparison group improve
more than some people in the active treatment group.
Practitioners cannot blindly apply a proven procedure
and assume that a particular individual receiving that
procedure will benefit
 Challenge of Applying Results to
Individuals
We are at least able to quantify the probability
with which an individual person will respond to a
given procedure (Number Needed to Treat)
Alternative to using evidence-based
interventions with their known rate of failure
is to use unproven procedures, based only on
the hope that they may work
Practitioners can and should view each case or
situation as an N = 1 study and collect data
 Efficacy Versus Effectiveness
Challenge
The efficacy versus effectiveness challenge requires a
careful consideration of the trade off between internal
and external validity
Claims to evidence-based practice typically must be
grounded in random, controlled trials which usually
translate into efficacy studies
Such studies do not address how effective such
interventions would be in real world contexts
At the present time there is a paucity of evidence of
relevance to social work based on effectiveness studies
conducted in real world contexts
it may be more efficient to begin with studies based on
conditions as realistic as possible so as to avoid the
misinformation that too frequently comes from
misinterpretations of efficacy studies
 Adoption & Implementation
Challenge
Two major challenges:
(1) adoption &
effective
implementation of
evidence-based
practice in social
agencies
(2) educating for
evidence-based
practice
Sisyphus
 Training, Time, Resources
Challenges
EBP requires:
Training in search
techniques
Training in critical
appraisal
Computer
resources
Electronic
resources
 Killer Bs
Low BASE rate
Incompatible client or
community BELIEFS
BAD BARGAIN in
terms of scarce
resources
BARRIERS too high
 Adoption & Implementation
Challenge
Motivate core group
Acceptance of EBP
Facilitate adoption
Implementation of effective services
Evaluate outcomes

2.5% 13.5% 34% 34% 16%

Innovators Early Early Late Laggards

Adopters Majority Majority
 Gira, Kessler and Poertner (2004)
Survey of reviews of
adoption of research
evidence medical practice
Educational outreach visits
and audit and feedback
showed weak to moderate
effects
Certain types of continuing
education and the use of
computers as decision aids
showed moderate effects
There are no magic bullets
(Oxman et al., 1995)
The literature from health
care suggests that
disseminating information
alone is insufficient. Many
interventions have been
designed to improve
practitioners adherence to
EBP guidelines and are
differentially effective. To
date, no intervention has
demonstrated powerful
effects (p. 77-78).
 Adoption & Implementation
Challenge
Can social agencies adopt EBP approach?
Can social workers become EB practitioners?
What are the barriers? Facilitators?
What resources are needed?
What training is required?
What systems need to be established?
How will EBP change client experience?
What outcomes will be achieved?
 Challenges in Teaching
Evidence-based Social Work
Fear of Loss of Human
Context
Disconnect between
classroom and field
Overwhelmed by new
skills and knowledge
needed

(Bilsker & Goldner, 2004)

 A Challenge to Critics

Knowledge and
information revolution
Valuable resource
Cannot be ignored
Must be harnessed
 A Measured Optimism
Real world constraints
-limitation of approach
-social and political realities
Great promise, but need for caution
-harnessing knowledge and information
-management of scarce resources
-unknowns abound
Hold EBP to its own evidentiary standards
-the jury is still out
Knowledge needs to be managed much more
effectively than it has been in the past

The challenge is to
rethink our view of what
knowledge is & how best
to facilitate its rapid
generation, sharing, and
application in a manner
that closes the policy-
research-practice gap