Evidence Based Social Work Practice (EBSWP) WorkshopAugust 22, 2011 Gallaudet University School of Social Work Edward J Mullen
Agenda • 9:00 – 10:30 Evidence Based Practice: Definitions, History, & Competencies • 10:30 – 10:40 Break • 10:40 – 12:00 Finding Evidence: Evidence-based Practices • 12:00 – 1:00 Lunch • 1:00 – 2:30 Resources &Curriculum Implications for Teaching & Learning • 2:30 – 2:40 Break • 2:40 – 4:00Break-out Group Discussion: Applications to Classroom & Field Curriculum
Evidence Based Practice (EBP): Definitions, History, & Competencies - Overview • Definitions • Conceptual Frameworks • Process Skills • Question Types • Evidence • History • Bridging Research & Practice in Social Work • Evidence-based Medicine (EBM) • Translating EBM into Social Work Contexts • Competencies
Issues for Break-out Group Discussion (handout 15) • How can EBP concepts, skills, & competencies be taught in the Gallaudet University School of Social Work Curriculum? • How can class and field teaching & learning be integrated around EBP? • How can EBP content be infused into current course syllabi? • How can EBP problem-based learning be fostered? • How can EBP critical thinking & EBP critical assessment skills be enhanced in the curriculum?
Evidence-based Social Work Practice Begins with Questions from All Practice Levels from Populations to Individuals • Evidence-based Policy Practice • Evidence-based Management Practice • Evidence-based Direct Practice
What is Evidence-based Policy Practice? Evidence-based policy is concerned with problems about how best to achieve group or population goals.
An Evidence-based Policy Question • For children with mental health problems is it best to: • provide remedial treatment services in residential treatment facilities • Or • in community-based programs that allow children to remain at home?
Another Evidence-based Policy Question • Is it best to provide adults with severe and persistent mental disorders: • sheltered work programs • Or • supportive services aimed at securing employment in the community?
What is Evidence-based Management? Evidence-based management deals with problems about how best to organize, finance &implement services to populations.
An Evidence-based Management Question: How best to create &sustain an organizational environment so as to move the organization toward policy-based outcomes?
Another Evidence-based Management Question: How best to create and sustain a learning-based organization?
What is Evidence-based Direct Practice? • Deals with problems of specific client units • Problems are those of identifiable clients in need of some type of: • Assessment • Intervention • Prevention • Evaluative service • Questions have to do with here-and-now practice choices that must be made for specific clients
EBP Defined by Institute of Medicine National Academy of Science(Adapted for Social Work) (see handout 1) • EBP is integration of • Best research evidence • Practitioner expertise • Client values • Research evidence • Practice relevant research from: • Basic sciences • Client-centered practice research about: • Accuracy & precision of assessment tests & interview procedures • Power of prognostic markers; • Efficacy & safety of therapeutic, rehabilitative, & preventive regimens. • Expertise • Ability to use skills & experience to rapidly identify each client’s: • Unique psychosocial state & problems or needs • Individual risks & benefits of potential interventions • Personal values & expectations. • Client values • Unique preferences, concerns, &expectations of client that must be integrated into intervention decisions to serve client
EBP in Social Work (EBSWP) • Placing client’s benefits FIRST • Practitioners adopt LIFELONG learning • CONTINUALLY ASKING specific questions • of direct practical importance to clients • SEARCHING objectively &efficiently • for current best evidence • Taking appropriate action GUIDED by evidence (Gibbs, et al., 2003).
Best available research evidence Decision-Making Client/population characteristics, state, needs, values, & preferences Resources including practitioner expertise Newest Trans-disciplinary View of EBP (handout 2) Evidence-based Behavioral Practice Council, EBBP.ORG
Evidence-Based Behavioral Practice Newest Trans-disciplinary View of EBP Evidence-based Behavioral Practice Council, EBBP.ORG
What is EBSWP Today? • Professional decision-making process in which social workers & their clients systematically make intervention choices using practitioner expertise to identify: • client conditions, needs, circumstances, preferences and values; • best evidence about intervention options including potential risk & benefit likelihoods; • contextual resources & constraints bearing on intervention options. • Intervention choices refer to action options about: • how to assess client conditions & circumstances; • how to provide services; • how to evaluate the process & outcomes of services. • Clients can be individuals, families, groups, communities or large populations. • Best evidence includes findings from scientific studies as well as from other reliable sources considered to be of highest quality, strength, & relevance. • Using this decision-making process social workers themselves provide the selected interventions or they link clients to others who can provide the interventions. • Together with their clients, practitioners monitor & evaluate the process & outcomes of services provided making changes in response to what is learned & sharing this information with others to benefit future clients.
5A’s: Process Steps of EBP (handout 3) • Ask well formed important questions about the care of individuals, communities, or populations. • Acquire the best available evidence regarding the question. • Appraise the evidence for validity & applicability to the problem at hand. • Apply the evidence by engaging in collaborative shared decision-making with the affected individual(s) and/or group(s). Appropriate decision-making integrates the context, values & preferences of client, as well as available resources, including professional expertise. • Analyze change & adjust practice accordingly. Assess outcome (process & intervention) & disseminate results.
Because the evidence-based process informs future questions & practice, it is useful to imagine it as a cycle: Five steps of evidence-based practice.
What Is Practitioner Expertise in EBP & What Additional Competencies Are Required?
Practitioner Expertise Includes Competency in Six Skill Areas (handout 4) • Assessment skills: • Competency appraising client & community characteristics, problems, values & expectations, & environmental context • Practitioner’s competency to assess own expertise level: • to implement interventions • outcomes of those techniques once implemented • Process skills: • Competency performing 5 EBP process steps: • ask well-formulated questions • acquire best available research evidence • appraise evidence for quality & relevance • apply evidence by engaging in shared decision-making with those who will be affected • analyze change & adjust practice accordingly • Communication & collaboration skills: • Competency to convey information clearly & appropriately • Competency to listen, observe, adjust, & negotiate as appropriate to achieve understanding & agreement on a course of action • Engagement & intervention skills: • Competency in motivating interest, constructive involvement, & positive change • Competency in provision of EBPs which vary in degree of training & experience required
In 5 A’s First Step Is ASK:What Are EBP Questions that Can Be Asked in EBP?
COPES Questions (POEM, PICO) • In Social Work (Gibbs– handout 5) • Client Oriented Practical Evidence Search (COPES) • In Medicine • Patient Oriented Evidence that Matters (POEM) • Patient (or Problem), Intervention, Comparison, Outcome (PICO)
Client Oriented Practical Evidence Search (COPES) Questions: • Client Oriented • Questions from daily practice, posed by practitioners, that really matter to client’s welfare • Practical • Concern problems that arise frequently • Concern agency mission • Knowing answer could impact decision • Search Oriented • Specific enough to guide electronic evidence search
Parts of COPES Effectiveness Questions • Client characteristics • Client problem • What practitioner is considering doing • Alternative course of action against which contemplated action is to be compared • What practitioner seeks to accomplish
Effectiveness Question: • If delinquent youth • Are exposed to A residential based program • Or A community based program • Will the former result in fewer delinquent behaviors?
Effectiveness Question • If families of latency aged boys with conduct disorder • Receive parent management training • Or • No formal training • Will the former exhibit lower externalizing behavior problems?
Effectiveness Question: • If disoriented aged persons residing in a nursing home • Are given • Reality orientation therapy • Or • Validation therapy • Which will result in better orientation to time, place, person?
Prevention Question: • If sexually active high school students at high risk for pregnancy • Are given • A problem exercise • (Baby-Think-It-Over) • Or • Didactic information • (material on use of birth control methods) • Will the former have fewer pregnancies during the year?
Prevention Question: • Among adolescents at risk for pregnancy • Will a sex education program that stresses abstinence • Or • One that provides birth control information • Result in the lowest pregnancy rates?
Prevention Question: • If adolescents at risk for violence • Receive school based violence prevention programs • Or • No formal violence prevention training • Will the former display lower rates of violence and aggression?
Assessment Question: • If aged residents of a nursing home who may be depressed or may have Alzheimer’s disease or dementia • Are administered • Depression Screening Tests • Or • A Short Mental Status Examination Tests • Which measure will be the briefest, most inexpensive, valid and reliable screening test to discriminate between depression and dementia?
Assessment Question: • If children &adolescents in my caseload • Are administered a computerized brief depression scale • Or • Are screened by a staff psychiatrist • Will the former detect childhood depression as frequently as the latter?
Descriptive Question: • If family members of children diagnosed with a learning disorder • Meet in a support group to receive information and support from staff and other families • What aspects of the support group will they find most helpful?
Descriptive Question • Among children who are cared for by a primary caregiver diagnosed as having a depressive disorder • Compared with • Children whose caregiver has no diagnosed mental disorder • Will the former children be more frequently diagnosed as having a behavioral or emotional disorder?
Risk Assessment Question: • If crisis line callers to a battered women shelter • Are administered • A risk assessment scale by telephone • Or • We rely on practical judgment unaided by a risk assessment scale • Will the scale have higher reliability and predictive validity regarding future violence?
Background & Foreground Questions • Background Questions Ask for General Knowledge about a Condition or Thing • What Causes AIDS? • How Does Neighborhood Violence Affect Probability of Delinquency? • Among children who are cared for by a primary caregiver diagnosed as having a depressive disorder compared with children whose caregiver has no diagnosed mental disorder will the former children be more frequently diagnosed as having a behavioral or emotional disorder?
Background & Foreground Questions • Foreground Questions Ask for Specific Knowledge to Inform Decisions or Actions • If children and adolescents in my caseload are administered a computerized brief depression scale or are screened by a staff psychiatrist will the former detect childhood depression as frequently as the latter? • If adolescents at risk for violence receive school based violence prevention programs or no formal violence prevention training will the former display lower rates of violence and aggression?
What are the arguments for EBSW? • Enhances quality of decisions about individual clients • Fosters skills to: • Gather and appraise client’s stories, symptoms, signs • Incorporating values and expectations in alliance • Fosters generic skills for finding, appraising, implementing scientific evidence • Provides educational and self-directed life-long learning framework • Identifies knowledge gaps leading to new research • Provides common interdisciplinary language
What are the arguments for EBSW? • EBP moves practitioners away from authoritarian practices & policies • EBP enhances opportunities to honor ethical obligations to clients & students • 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 client’s unique knowledge in terms of application concerns • EBP promotes transparency & honesty • EBP encourages systemic approach for integrating practical, ethical & evidentiary issues • EBP maximizes flow of knowledge & information about knowledge gaps Gambrill, 2003
Brief History of EBP • EBP originated in medicine in 1990’s • EBM has been transferred into other health disciplines over last 10-15 years • EBP is now widely accepted in health disciplines • A major factor stimulating EBP development is research showing that research findings flow into practice at an extremely slow pace: • Uptake of scientific discoveries into clinical practice: 14% after 17 years (Balas & Boren, 2000) • Only 15% of clinical practices based on evidence (IOM, 1985; Eddy 2005).
Brief History of EBP • EBM was first introduced into American social work in late 1990’s (Gambrill 1999) • Earlier models for integrating research &practice did exist (e.g., the empirical practice movement &scientific practitioner model) • Evidence-based social work practice is, however, qualitatively different from these earlier efforts &, like EBM, has been seen as a paradigm shift • The adoption of EBP has been facilitated by an increase in practice research as well as by mechanisms for evidence dissemination. • EBP is now required for accreditation of social work training programs • Use of research evidence for professional practice is required by the code of ethics for social work
In the past decade, all of the major health professions have endorsed EBP, as shown by these texts originating in medicine, followed by nursing, public health, social work, and finally psychology.
Acquiring Evidence & Evidence-based Practices (EBPs): Overview • Acquiring evidence as 3rd step of EBP process • What are evidence-based practices (EBPs)? • What qualifies as “evidence”? • How are EBPs& EBP related? • How can EBPs& “evidence” be found?
How can Evidence be Acquired? • Remember 5A’s which form process steps or skills of EBP (next slide) • Recall that 2nd step is ACQUIRING evidence needed to answer question ASKed in 1st step. • This step requires practitioners to conduct an evidence search to answer questions • Translate question into search terms • Search relevant evidence sources • Best done with assistance of reference librarian
Because the evidence-based process informs future questions & practice, it is useful to imagine it as a cycle: Five steps of evidence-based practice.
1st Rule for Planning Search: Efficiency Using 5S Framework • Busy practitioners typically do not have time or skills to: • Conduct searches for individual research studies which have examined their EBP question. • Synthesize the research evidence from these individual studies • Practitioners should first search for evidence summaries • Evidence summaries are rapidly becoming available in online systems & clearinghouses • These online systems/clearinghouses frequently do the work of: • Locating research studies • Systematically reviewing & summarizing study findings • Assessing quality, strength, & relevance of evidence • Publishing practice guidelines, model programs, best practices, or other forms of evidence-based recommendations • ONLY in absence of evidence systems, summaries, synopses, or syntheses & ONLY WHEN EBP QUESTION IS IMPORTANT should practitioners conduct searches for individual research studies
The “5S” levels of organization of evidence Reproduced from: Haynes, R Brian. 2006. Of studies, syntheses, synopses, summaries, and systems: the “5S” evolution of information services for evidence-based health care decisions. ACP Journal Club 145 (3):A-8 - A-9.EBBP.org Systems Summaries Synopses Syntheses Studies