Overview

The field of social work has called for the use of evidence-based practice; however, the concept of evidence based practice is not necessarily embraced by all in social work. Proponents of evidence based practice in social work maintain that by using empirically tested interventions is fundamental to building a core knowledge base in social work. Critics of evidence-based practice in social work have questioned what constitutes "best practices" and who identifies "best evidence." The questions continue today, fueling controversy and debate. Evidence-based practice is an ongoing and emendatory process. It is corrective and improving constantly, allowing for evolution in response to changing needs of clients and the environment. Regardless of the challenges, social workers will benefit from an understanding of how to conduct evidence-based research and incorporate the results into effective practice.

Education Category: Management
Release Date: 10/01/2014
Expiration Date: 09/30/2017

Audience

This course is designed for social workers in all settings with an interest in evidence-based practice.

Accreditations & Approvals

NetCE, #1092, is approved as a provider for social work continuing education by the Association of Social Work Boards (ASWB) www.aswb.org through the Approved Continuing Education (ACE) Program. NetCE maintains responsibility for the program. ASWB Approval Period: 03/13/2016 to 03/13/2019. Social workers should contact their regulatory board to determine course approval for continuing education credits. NetCE is accredited by the International Association for Continuing Education and Training (IACET). NetCE complies with the ANSI/IACET Standard, which is recognized internationally as a standard of excellence in instructional practices. As a result of this accreditation, NetCE is authorized to issue the IACET CEU. This course is approved by the Association of Social Work Boards - ASWB NJ CE Course Approval Program Provider #14 Course #296. NetCE SW CPE is recognized by the New York State Education Department's State Board for Social Work as an approved provider of continuing education for licensed social workers #0033. This course is considered self-study, as defined by the New York State Board for Social Work. Materials that are included in this course may include interventions and modalities that are beyond the authorized practice of licensed master social work and licensed clinical social work in New York. As a licensed professional, you are responsible for reviewing the scope of practice, including activities that are defined in law as beyond the boundaries of practice for an LMSW and LCSW. A licensee who practices beyond the authorized scope of practice could be charged with unprofessional conduct under the Education Law and Regents Rules. Social workers will receive the following type and number of credit(s): General Social Work Practice 3 for the approval period starting 04/23/2015 and ending 04/23/2017.

Designations of Credit

Social workers participating in this intermediate to advanced course will receive 3 Clinical continuing education clock hours, in accordance with the Association of Social Work Boards. NetCE is authorized by IACET to offer 0.3 CEU(s) for this program.

Individual State Behavioral Health Approvals

In addition to states that accept ASWB, NetCE is approved as a provider of continuing education by the following state boards: Alabama State Board of Social Work Examiners, Provider #0515; Florida Board of Clinical Social Work, Marriage and Family Therapy and Mental Health Counseling, CE Broker Provider #50-2405; Illinois Division of Professional Regulation for Social Workers, License #159.001094; Illinois Division of Professional Regulation for Licensed Professional and Clinical Counselors, License #197.000185; Illinois Division of Professional Regulation for Marriage and Family Therapists, License #168.000190; Texas State Board of Social Worker Examiners, Approval #3011; Texas State Board of Examiners of Professional Counselors, Approval #1121; Texas State Board of Examiners of Marriage and Family Therapists, Approval #425.

Course Objective

The purpose of this course is to increase the knowledge base of social workers and other allied mental health professionals who can work to incorporate the tenets of evidence-based practice into their own work with clients.

Learning Objectives

Upon completion of this course, you should be able to:

  1. Define evidence-based practice.
  2. Describe the historical trends of evidence-based practice.
  3. Discuss what constitutes "best evidence" for evidence-based practice.
  4. Identify the arguments for and against the inclusion of evidence-based practice in social work.
  5. Describe the barriers to and predictive factors for implementing evidence-based practice in social work.
  6. Discuss how evidence-based practice is used ethically in social work with racially and ethnically diverse populations and communities.
  7. Describe practical tips to implement evidence-based practice into day-to-day work.

Faculty

Alice Yick Flanagan, PhD, MSW, received her Master’s in Social Work from Columbia University, School of Social Work. She has clinical experience in mental health in correctional settings, psychiatric hospitals, and community health centers. In 1997, she received her PhD from UCLA, School of Public Policy and Social Research. Dr. Yick Flanagan completed a year-long post-doctoral fellowship at Hunter College, School of Social Work in 1999. In that year she taught the course Research Methods and Violence Against Women to Masters degree students, as well as conducting qualitative research studies on death and dying in Chinese American families.

Previously acting as a faculty member at Capella University and Northcentral University, Dr. Yick Flanagan is currently a contributing faculty member at Walden University, School of Social Work, and a dissertation chair at Grand Canyon University, College of Doctoral Studies, working with Industrial Organizational Psychology doctoral students. She also serves as a consultant/subject matter expert for the New York City Board of Education and publishing companies for online curriculum development, developing practice MCAT questions in the area of psychology and sociology. Her research focus is on the area of culture and mental health in ethnic minority communities.

Faculty Disclosure

Contributing faculty, Alice Yick Flanagan, PhD, MSW, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Table of Contents

Technical Requirements

Supported browsers for Windows include Microsoft Internet Explorer 9.0 and up, Mozilla Firefox 3.0 and up, Opera 9.0 and up, and Google Chrome. Supported browsers for Macintosh include Safari, Mozilla Firefox 3.0 and up, Opera 9.0 and up, and Google Chrome. Other operating systems and browsers that include complete implementations of ECMAScript edition 3 and CSS 2.0 may work, but are not supported.

#71480: Evidence-Based Practice in Social Work

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INTRODUCTION

"Evidence-based practice" is not necessarily a new or recent concept. In essence, evidence-based practice involves using the most current scientific evidence to support the decisions made for interventions and client care [1]. It has its roots in evidence-based medicine, and it can be traced back to World War II [2]. Many assert that evidence-based practice is particularly relevant in an economic climate with decreased funding for agencies in which the question of whether the program, service, and/or intervention is effective is at the heart of approved reimbursement. Furthermore, there is greater discussion of transparency and accountability today, not only in social work but in all fields. Regardless of whether social work practitioners view the collection of empirical data as a vital part of the occupation, social workers should be proficient in evaluating empirical literature in order to select the types of services and interventions most effective for their clients [3].

The social work profession has long advocated for evidence-based practice [4]. In an analysis of publications between 2006 and 2010 in PsychINFO, a major library database, twice as many citations used the key terms "social work" and "evidence-based practice" than the terms "psychotherapy" and "evidence-based practice." However, not everyone in the field of social work has embraced the concept. Proponents of evidence-based practice in social work maintain that empirically tested interventions are fundamental to building a core knowledge base in social work [1]. However, critics have questioned what constitutes "best evidence" and who gets to identify what encompasses "best evidence." The goal of this course is to provide an overview of the key definitions, historical evolution, and controversies of evidence-based social work practice, allowing professionals to be informed about the ongoing dialogue.

DEFINITIONS OF EVIDENCE-BASED PRACTICE

Evidence-based practice is defined as the "conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" [5]. Various terms have been used to describe evidence-based practice, including evidence-based treatment, evidence-based intervention, and evidence-informed intervention. These terms are generally used interchangeably [6]. However, for the purpose of this course, the term "evidence-based practice" will be used.

Some have argued that certain fields, such as social work, counseling, clinical psychology, and therapy, are an art. When making day-to-day decisions and intervening with clients, practitioners tend to employ a combination of common practice wisdom, experiences, sense of self, the therapeutic relationship, and awareness of issues of transference and countertransference. However, evidence-based practice involves using the most up-to-date scientific knowledge, expert knowledge, and/or best research evidence to guide clinical practice, answer direct practice questions, and make the most appropriate clinical decisions [7,8,9]. Consequently, some practitioners maintain that evidence-based practice is in conflict with the values instilled in these professions. Consider that evidence-based practice assists in answering two important questions: How do social workers know the services they offer are ethical and competent? How do they know that they are providing the best available treatment or intervention, or that services are offered in a way that benefits clients [10]? All practitioners should be able to answer these questions.

STEPS IN EVIDENCE-BASED PRACTICE

There are five steps to practicing evidence-based social work [11]. First, a question must be posed around the practice area or need, and the question must be answerable. For example, "What can be done to solve homelessness?" is not an easily answerable question. Next, the best available evidence should be searched in order to find an answer to the question that has been posed. The evidence should be critically evaluated regarding its scientific validity and usefulness. The evidence is then evaluated based on the practitioner's experiences, observations, and client values and situation before being applied to the practice decision. Finally, it is vital to evaluate the outcomes of the decision, if possible using single case designs.

Ideally, these steps are done with all clients—integrating evidence to make an informed intervention plan. For client problems that are not necessarily unique or that occur frequently (e.g., abuse), some experts recommend that evidence can be generally collected and analyzed without being applied to a specific client [12]. For problems that are more unusual, practitioners should always search for available current evidence formulated by others [12].

AN HISTORICAL OVERVIEW OF EVIDENCE-BASED PRACTICE

As noted, the concept of evidence-based practice is not necessarily a new one. Even dating back to medieval times, there are some indications of attempts to make decisions regarding medical interventions based on prior testing. In the 1850s, Florence Nightingale's efforts to sanitize hospital conditions were based on evidence-based practice steps—Nightingale identified the problem and critically evaluated and appraised the evidence [20].

Evidence-based practice as it is known today can be traced back to World War II [2]. However, it was not until 1972, when Dr. Cochrane, then director of the Medical Research Council Epidemiology Research Unit in Cardiff and involved in an evaluation research project to assess a governmental agency, that the concept of evidence-based practice began to gain notice [2]. He also published a book titled Effectiveness and Efficiency: Random Reflections on Health Services. These steps laid the foundation for evidence-based practice in a variety of disciplines today.

Also in the 1970s, Dr. David Sackett and his colleagues wrote manuscripts (published in the Canadian Medical Association Journal) about how to critically appraise clinical research, and from these manuscripts, the term "critical appraisal" began to be widely applied to evidence-based medicine. In 1992, the Evidence-Based Medicine Working Group wrote an article about the role of teaching evidence-based medicine in the Journal of the American Medical Association [20].

With the proliferation of digital access to clinical information, journals, and abstracts beginning in the 1990s, evidence-based practice became more practical, with practitioners more easily able to access literature in a variety of settings [20]. Today, the Cochrane Collaboration in the United Kingdom and the Rand Corporation in the United States promote evidence-based medicine, advocating for using experimental studies, meta-analysis, and systematic reviews to determine effectiveness of interventions [21]. In the United States, there is ongoing debate about evidence-based practice and the efforts of researchers and scholars are often fragmented or suboptimally organized [22]. However, much work has been done in the field of evidence-based mental health practice. There are organizations, such as the Human Services Research Institute, that promote studies on mental health issues and interventions and offer practitioners toolkits to help measure outcomes. The Center for Quality Assessment and Improvement in Mental Health has developed a searchable database to help practitioners locate the validated instruments and measures needed to conduct assessments in mental health. In addition, the Agency for Healthcare Research and Quality has developed principles for evaluating the effectiveness of interventions and publishes reviews of related evidence [22].

EVIDENCE-BASED PRACTICE IN SOCIAL WORK

Social work can trace the roots of evidence-based practice to Mary Richmond, who advocated for systematically collecting evidence before concluding a diagnosis in her seminal 1917 work Social Diagnosis [23]. In the early 20th century, Jane Addams, a famous social worker known for her role in the settlement house movement and her work with immigrants and the poor, also advocated for obtaining systematic data and evidence for community work [24].

In 1915, Abraham Flexner questioned whether social work was a legitimate profession. He argued that one of the criteria of a profession is that it draws upon scientific knowledge, which he stated social work did not [25]. In the 1970s, these questions regarding the legitimacy of social work as a profession were revisited, as some viewed social work as more of an art than a science. This led to the question of whether social workers should become familiar with and conduct empirically based practice [26].

In 1988, the National Institute of Mental Health created a task force to examine social work research and social work faculty's level of involvement in social work research [24]. This Task Force on Social Work Research published a report recommending that seven Social Work Research Development Centers be housed in social work programs, with each center testing intervention models and approaches for different population groups [24].

In the 1990s, the term "evidence-based practice" was applied in the social work literature by Eileen Gambrill [27,28]. Since then, social workers have grappled with implementing evidence-based practice. In 2006, the Austin Initiative was developed with the goal of having continual symposium meetings in order to advance the teaching of evidence-based practice in social work curricula [26].

THE DEBATE ABOUT EVIDENCE-BASED SOCIAL WORK PRACTICE

Debates about evidence-based practice in social work abound. First, there is a question of the context in which it should be employed. For example, should evidence-based practice be used in a micro (with individuals) or macro (with organizations) context [1]? The terms used are also a source of controversy; semantics in employing the term "interventions" versus "treatment," or "client" versus "client systems" have emerged. The term "evidence" alone has raised questions regarding ownership of data and expertise. In evidence-based practice, evidence is defined as research findings of various quality (levels of evidence) according to the study structure and statistical weight of the resultant data [13]. Some experts differentiate between hard and soft data. Hard data refers to quantifiable evidence that is supported by research studies that follow the empirical process, while soft data refers to qualitative studies and anecdotes from clients' experiences; observations from interviews with clients, service providers, and other stakeholders; and formal and informal observations [14]. It is also unclear how practitioners should act if evidence does not exist or if there is conflicting evidence regarding a particular intervention [13].

Some have argued that the term "evidence-informed practice" is more suitable than "evidence-based practice," as it focuses on the practitioner's actions being informed rather than being based solely on the evidence [15]. However, the process of evidence-informed practice is similar to evidence-based practice, making the distinction primarily semantic [15].

The term "empirically supported intervention" is also used in the social work literature. However, empirically supported interventions utilize even more rigid criteria than evidence-based practice. For example, an evidence-based practitioner can use literature on systematic reviews to understand the effectiveness of an intervention or treatment, but in order for an intervention to be considered empirically supported, it must be based on evaluation of randomized clinical trial study data by at least two independent investigators [16]. The empirically supported interventions paradigm has been advocated by the National Association of Social Workers, the National Association of Public Child Welfare Administrators, the National Institutes of Health, the Joint Commission, and the Council on Accreditation [16].

As of 2014, the profession of social work has not reached a consensus on evidence-based practice. In a national study involving 973 social work faculty members, there was a lack of agreement regarding the definition and necessary components of evidence-based practice. Even though a large majority (90%) believed that experimental studies with random assignments and control groups were necessary for evidence-based practice, 40% also indicated that studies that were not experiments and did not involve a control group could be sufficient for evidence-based practice [17].

Regardless of the terms used, when social workers rely on knowledge based on scientific evidence, common practice wisdom may be defied. Gilgun asserts that [18]:

When social workers are steeped in relevant research, we then have to hold this knowledge lightly and be willing to modify our knowledge in response to clients. If we do this, then we will base practice on evidence from two directions—from what clients communicate to us in subtle and forthright ways and from what we know from multiple other sources.

This is in support of social work practitioners' role as lifelong learners [19].

As noted, a variety of pro and con arguments have been made regarding the incorporation of evidence-based principles into social work practice. It is likely that these controversies will continue, and it is good to have a firm grasp of both sides of the argument when one is considering its impact on the social work profession.

ARGUMENTS AGAINST THE INCORPORATION OF EVIDENCE-BASED PRACTICE

Differences Between Social Work and Medicine

As evidence-based practice was originally derived from medicine, some argue that differences between the two professional fields mean that the practice cannot be applied to social work [26]. Often, medical interventions can be broken into distinct steps to be followed for all or most patients. However, social work takes into account all social, biological, psychological, cultural, and institutional factors, making developing a set of universal steps for interventions much more difficult [26]. Medicine is also highly positivistic (i.e., focusing on measurability), while social work is interpretivistic/constructivistic, relying on reflexivity and the social context [29]. This leads to unpredictability and difficulty in quantification of social work experiences.

Limitations of Empirical Literature

Opponents argue that the empirical knowledge base in social work is narrow and limited—meaning empirical information is not available for every clinical issue and every client population. It is important to note that if practitioners are unable to locate literature that meets evidence-based criteria, this does not necessarily mean that an intervention is "bad" [26]. The reality is that research topics are influenced by a host of factors, including funding sources and priorities, perception of what is "important," and other hidden social values [26].

Assigning of Value or Privilege

Some assert that evidence-based practice privileges certain knowledge––specifically, knowledge that is quantifiable and measurable [30]. Studies that use experimental designs that feature randomization and control and experimental groups are valued in evidence-based practice. However, other types of quantitative and qualitative methods have value as well and can provide insight into clients' realities [26,30]. Social work as a field deals with diverse social problems, and change in clients' lives frequently occurs gradually and in small ways that cannot always be captured using the experimental designs favored by evidence-based practice [30].

Negation of Clinical Experiences

The importance of practitioners' clinical experiences and intuition in shaping practice decisions should not be ignored [20]. Opponents of evidence-based social work practice posit that the essence of the art of clinical work with clients (e.g., use of self, intuition, rapport building with clients, past experiences) is not captured in evidence-based practice.

Threat to Client Autonomy

Some experts maintain that a focus on evidence-based outcomes could potentially risk the client autonomy that social work values [30]. For example, evidence-based literature may demonstrate that a certain medication is effective, but a client may rather avoid pharmacologic interventions and employ alternative treatment. In this case, should the practitioner push for what the literature supports despite the client's wishes?

Practical Constraints

Opponents of evidence-based social work practice maintain that agencies often have limited resources (e.g., money, time, expertise) with which to promote evidence-based practice. Furthermore, given how long the scientific process can take when it comes to data collection, evaluation, and publication of findings in peer-reviewed journals, the literature may be outdated even before public scrutiny and critiques of the findings are possible [31].

ARGUMENTS FOR THE INCLUSION OF EVIDENCE-BASED PRACTICE

Ethics and Values

Proponents of evidence-based social work argue that professionals are expected to practice good social work, which entails providing clients the best treatment possible [14]. In order to do so, social workers should amass and evaluate the available evidence before making informed decisions and formulating a client's intervention plan. The National Association of Social Workers Code of Ethics states [32]:

Social workers practice within their areas of competence and develop and enhance their professional expertise. Social workers continually strive to increase their professional knowledge and skills and to apply them in practice. Social workers should aspire to contribute to the knowledge base of the profession.

Although there may be challenges to implementing evidence-based practice, ethical codes demand that practitioners address these challenges rather than avoid them [19].

Client-Centered Care

As noted, one of the criticisms of evidence-based social work is that it is too mechanistic and procedural. In response to this, proponents claim that the steps in evidence-based practice are focused on each individual client. If followed correctly, the decisions that result from the process are deliberate and client-centered [19].

In addition, evidence-based practice does not violate client self-determination. All collected evidence is synthesized taking into account the client's background, characteristics, environment, support system resources, and preferences [19].

Valuing Clinical Expertise

Some experts object to the argument that evidence-based practice ignores the practitioner's vast clinical experience and background. One of the steps in evidence-based practice is the evaluation of evidence-based on experience and the specific situation, which highlights the role of the practitioner's clinical background and intuition [19].

Objective Evaluations

Taking a more broad definition of evidence-based practice and using a range of "hard" and "soft" data as best evidence, evidence-based clinical practice is advantageous because it moves away from client insight as being a sign of progress. Instead, it focuses on observable behavioral change [28]. This behavioral change can trigger clients' understanding of their emotional life [28].

Improving Social Work Core Knowledge

Proponents of evidence-based practice in social work maintain that using empirically tested interventions is fundamental to building a core knowledge base in social work [1]. By expanding this core knowledge base, social work as a discipline can be more legitimate and "professional," ultimately increasing its credibility.

Educated Clients

In an increasingly technology-oriented society, consumers have greater access to information and are becoming more educated about the services they receive. Because of this, they expect service providers and professionals to be updated on the latest developments in their field. For example, 72% of adult Internet users (18 years of age and older) have searched online for information on a health topic in the past year [33]. Among individuals with diagnosed psychiatric disorders who use the Internet, 64.7% have proactively employed the Internet to find more health-related information [34]. Because social work clients are active consumers, they can be encouraged to use the Internet to research and can offer feedback in terms of what they discover [9]. This becomes a vehicle for empowerment, improving communication and reducing the power disparities between practitioners and clients.

Valuing All Research Methods

It is true that randomized experimental designs are preferred in evidence-based practice [19]. However, other research methods have value as well. Some "less rigorous" methods are more suitable to answering certain questions.

MEETING IN THE MIDDLE

Using the definition that evidence-based practice is the "integration of the best research evidence with clinical expertise and client values in making practice decisions," some experts advocate for an evidence-based practice model that bridges the viewpoints of proponents and opponents [1]. Best research evidence may refer to employing both applied (e.g., intervention and outcome research) and basic research studies [1]. Clients' values are based on their culture, upbringing, expectations, and environment, and these values are not discarded when using evidence-based practice. Instead, they should be at the forefront, shaping decisions made by both the client and social worker [1]. The practitioner's clinical expertise is also part of this equation. Similarly, Gilgun suggests that [18]:

There are four cornerstones of evidence-based practice in social work: (1) what we know from research and theory; (2) what we and other professionals have learned from our clients, or practice wisdom, which also includes professional values; (3) what we, as social workers, have learned from personal experience; and (4) what clients bring to practice situations. All four come into play and mutually affect each other as we go about our daily work with clients. In sum, evidence-based practice promotes a high degree of practitioner reflection and mindfulness.

IMPLEMENTING EVIDENCE-BASED PRACTICE

BARRIERS

There are logistical barriers for social workers and practitioners to fully implement evidence-based practice. Some social service organizations do not have the technology, hardware, datasets, and informational technology specialists to assist practitioners to access information needed for evidence-based practice [35]. Implementing evidence-based practice well requires social workers to spend time learning how to use resources, search for literature, and develop research skills, but social workers and other practitioners often have heavy caseloads and are extremely busy seeing clients [26]. Social workers often do not have sufficient research skills to conduct outcome studies and evaluate interventions, and locating and appraising evidence-based literature requires additional training [35]. In addition, many social workers view research and the empirical literature as irrelevant and impractical. The research produced from clinical studies is often university-based and viewed as not reflecting the problems of the real world [29]. Consequently, some social workers tend not to employ research literature and do not view mutual collaboration between practitioners and researchers favorably [29].

Social workers' fears may also influence the willingness to employ evidence-base models. Many anxieties involve the perception that evidence-based practice is a top-down, mechanistic, one-size-fits-all approach that devalues client autonomy and clinical experience and wisdom [29]. However, if used correctly, evidence-based practice supports client and practitioner expertise.

FACTORS THAT PREDICT ADOPTION

Although there are many barriers, there are also factors that support implementation of evidence-based social work practice. These organizational or individual factors are key in a social worker's decision to adopt an evidence-based practice.

Not surprisingly, social workers who are willing to alter their interventions in light of new evidence are more open to implementing evidence-based practice [35]. Social workers' desire and readiness for change should be supported by colleagues, employers, and the profession as a whole. When staff perceive that an organization is committed to fostering change and when practitioners are encouraged to take on challenging tasks that will help them grow, use of evidence-based practice increases [35]. Practitioners who are given external positive incentives (e.g., monetary bonuses, extra vacation time) for learning new skills and interventions are more likely to adopt evidence-based practice [35]. Because time and energy are often constrained due to heavy caseloads, social workers may feel more motivated if the time they put into implementing a new intervention is rewarded in the incentive structures of an agency [35]. Organizations may also provide education on the principles of evidence-based practice. Practitioners who participate in education and training that focuses on specific skills, such as research, library database searches, and critically appraising intervention studies, are more likely to incorporate evidence-based models into their practice [35].

PROMOTION OF EVIDENCE-BASED PRACTICE IN SOCIAL WORK

There are several steps social service organizations and social workers can take to support the incorporation of evidence-based research into practice [29]. Agencies and universities should make coordinated efforts to join resources. Pooling empirical articles (e.g., systematic reviews, meta-analyses, randomized, controlled trials) that document the effectiveness of various interventions in different populations is beneficial for researchers and practitioners alike. Empirical findings should be translated into practical social work applications, keeping in mind that social workers tend to have busy schedules and intense caseloads.

Increased access to digital and web-based learning technologies is crucial to allow social workers to conduct point-of-care literature searches. In order to effectively conduct literature searches, training is needed in how to effectively use databases, the Internet, and other resources to locate articles and instruments. Social work education should prepare students to overcome the logistical barriers of implementing evidence-based practice. In addition, more research is needed to understand social workers' decision-making processes when applying findings from evidence-based research to their work with clients

ETHICAL ISSUES

It is important that social work practitioners and researchers explore the ethical implications of conducting evidence-based practice [36]. Specifically, this type of practice can involve the ethical principles of beneficence, self-determination, conflict of interest, and confidentiality [37]:

  • Beneficence: Beneficence refers to the duty to do good, and practitioners should consider the benefits of conducting evidence-based research. What specific benefits will the group being studied obtain? What are the risks and does it have any negative outcomes for vulnerable populations? What additional safeguards can be implemented to promote the welfare of the client(s) and mitigate risks?

  • Self-determination: Self-determination refers to the duty to maximize an individual's rights to make his/her own decisions. Clients' self-determination and autonomy should be protected. For example, when implementing an intervention, do the clients feel they have no choice but to comply or risk having services somehow negatively affected?

  • Conflict of interest: Potential dual-role issues and conflicts of interest can arise when a social worker is both the practitioner working with the client and the researcher collecting evidence about his/her own practice and interventions. What will the social worker report to the agency if the findings about the intervention are negative?

  • Confidentiality or anonymity: All social workers should implement adequate safeguards to promote clients' privacy, anonymity, and/or confidentiality.

  • Study design: The study design and data collection procedures should serve to answer the research question. If not, this raises the issue of inconveniencing the clients, which is not ethical. Do the study design and procedures ultimately serve to empower the clients?

EVIDENCE-BASED PRACTICE IN A MULTICULTURAL CONTEXT: WORKING WITH DIVERSE CLIENTS

Social workers and practitioners wrestle with the challenge of providing culturally competent services. The goal of cultural competence is to reduce the differences between the norms and belief systems of clients from diverse cultural groups and the institutional cultural norms of service delivery agents. Ultimately, this will mitigate the disparities that exist in the current mental health and healthcare systems [38].

Historically, there are four ways that intervention studies have dealt with the issue of diversity [39]. These four categories may be viewed as existing along a continuum, with one end of the continuum consisting of full involvement of the cultural group (the most culturally sensitive) and the other end not recognizing the importance of including racial and ethnic minorities in the sample (the least culturally sensitive). The categories are:

  • Full partnership: With this approach, researchers collaborate with the community and consider the diverse interests of the group when formulating a culturally sensitive and competent intervention, identifying the research question(s), collecting data, analyzing and interpreting data, and disseminating research findings.

  • Ad hoc involvement: In this category, the population of interest and the community are asked to provide input after the intervention has been implemented or after the research question has been posed. The targeted group may be viewed as an ad-hoc advisory group.

  • No involvement in the process: In some cases, researchers include racial and ethnic minorities in the sample, but they do not attempt to target the intervention to the specific group, nor do they attempt to gain insight into the group's perspective about the intervention.

  • No diversity represented in the sample: Some researchers do not actively recruit diverse racial and ethnic minorities in the study sample. If there is some diversity in the sample, there are no sufficient numbers to be able to conduct statistically valid analyses.

Another way to explore the issue of cultural competency is through the debate about emic and etic perspectives. The etic perspective maintains that, along important dimensions, all humans are basically similar. On the other hand, the emic perspective argues that it is vital for professionals to begin from the paradigm that unique cultural characteristics exist in various cultural groups. This emic orientation acknowledges individual differences within culturally different populations while simultaneously viewing clients/patients within the context of their primary cultural group [40]. It is believed that etic interventions can be used for all groups and if modification is necessary, it would be minimal. In contrast, emic interventions focus on formulating interventions that reflect the group's characteristics and value systems, with the belief that these interventions will be more effective for the target group [41]. Either approach may be taken when conducting evidence-based practice. However, the emic perspective is considered culturally sensitive and ethically sound, and these interventions may have a greater likelihood of success.

When implementing evidence-based social work practice, it is important to consider how evidence-based practice translates when working with culturally and racially diverse clients and the potential controversies. A research study's ecological validity may be in question if the intervention is only tested and shown effective with white, middle-class clients [42]. In other words, practitioners should determine if there is a gap between the client's ethnocultural experience and background and the attributes of the research population [42]. The litmus test may be if there is some evidence that demonstrates the intervention's effectiveness with a specific racial or ethnic minority group and the community has come to own or accept the intervention to a certain degree [39].

The issue of culture and how it is measured is also at the heart of the debate. In the discussion of evidence-based practice, it is acknowledged that culture is dynamic, involving a group's shared values, beliefs, sociopolitical histories, and rituals [41]. It also interacts with a group's or client's sociocultural and institutional context, including socioeconomic status, health disparities, racism, and access to health and mental health services [41]. These points will all affect the effectiveness of a given intervention.

Research methods and how evidence is gathered with diverse populations will also influence evidence-based practice discussions. Some scholars have advocated for an expansion of acceptable evidence-based research methods to include qualitative research methods. When working with some ethnic populations (e.g., Native American groups), using the art of storytelling is a culturally congruent strategy of acquiring data. Evidence collection via digital storytelling (i.e., filming and audio recording) places the ownership in the hands of the community and its leaders, who often wish to perpetuate their history and traditions to the next generation [43]. The transcripts of these stories and the analyses of the resultant qualitative data could produce rich evidence.

The inclusion of certain qualitative research strategies would help to mitigate the concern many racial and ethnic minority communities have that researchers will enter into the community to impose their research agenda. Participatory action research, for example, promotes collaboration and assists in reducing the unequal and hierarchical structure of the researcher (expert) and the participant (research subject) [44]. This is extremely important when dealing with marginalized populations who have experienced a history of oppression and racism. Of course, there are limitations to using qualitative data (e.g., the risk of bias), but triangulating the data (i.e., obtaining multiple sources for verification) can minimize these risks. Overall, such methods are congruent with culturally sensitive practice and research [43].

PRACTICAL TIPS FOR PRACTITIONERS

Formulating Research Questions

The first step in conducting evidence-based practice is to formulate a question that will drive the research. The question will dictate the evidence used to answer and should be succinct, clear, and as specific as possible. One way to develop the question is to use the PICO formula: population, intervention, comparison, and outcome [45]. Using this approach, the first step is to pinpoint the client population. The more detailed one can be regarding the attributes or characteristics of the client population, the more helpful the question will be and the more applicable the research findings will be. If possible, the practitioners should identify gender, socioeconomic status, racial/ethnic minority status, health conditions, religion, and other factors. Examples of strong population component include:

  • Male clients diagnosed with generalized anxiety disorder

  • Chinese immigrants who came to the United States in the last five years

  • Hispanic adolescents residing in single-parent households

Next, pinpoint the program, therapy, or treatment being considered. Again, it is vital to be as specific as possible when describing the intervention, including details such as the setting, frequency, type of modality, and provider [45]. For example:

  • 8-week psychoeducational group

  • 15-minute diabetes prescreening

  • A set of three weekly social work home visits

Determining a comparison component is optional, but it can be useful when further evaluating the findings. The comparison group may be a control, a group of patients on a waiting list, or placebo.

Finally, define the intended outcome of the intervention. This will be the criteria by which success or effectiveness is measured [45]. Examples include:

  • Increased knowledge about triggers of anger

  • Decreased levels of depression as measured by the CES-D

Search Techniques

A good way to begin searching databases is to identify key words. Key words may be gleaned from the PICO formula used to develop the question [45]. Alternatively, the entire question may be inputted, but this will likely result in more confused findings. Take, for example, the following question: How effective is an 8-week psychoeducational group about healthy eating in improving food choice decision for young mothers (younger than 30 years of age) with young children (younger than 12 years of age) compared to the food choice decisions of mothers on a waiting list? Using this question, a social worker might employ search terms such as "food choice," "young adults," and "psychoeducation" or "psychoeducation and healthy eating." From there, synonyms may be generated for the terms identified. When an article is retrieved, the practitioner can glean other common terminologies, which can provide new ideas on how to search for additional literature. Depending on how many results return for a given search, filters may then be used, perhaps further limiting the search by methodology (e.g., clinical trial) or outcome (e.g., weight loss) [8].

Databases

Several databases are available for social workers to use in their search for articles and reports to use when adopting evidence-based practice. Some are free, while others require a paid subscription. Please note that this is far from a comprehensive list, and practitioners are encouraged to explore other options provided by their agency or organization.

ACP Journal Club
http://acpjc.acponline.org
Agency for Healthcare Quality and Research
http://www.ahrq.gov/clinic/epcix.htm
American Psychological Association
http://www.apa.org/pubs/databases
BioMed Central
http://www.biomedcentral.com
California Evidence-Based Clearinghouse for Child Welfare
http://www.cebc4cw.org
The Campbell Collaboration
http://www.campbellcollaboration.org
The Cochrane Library
http://www.thecochranelibrary.com
German Institute of Medical Documentation and Information Database of Abstracts of Reviews of Effects (DARE)
http://www.dimdi.de/static/en/db/index.htm
Essential Evidence Plus
http://www.essentialevidenceplus.com
Evidence-Based Behavioral Practice
http://www.ebbp.org/aboutus.html
Evidence-Based Mental Health
http://ebmh.bmj.com
Evidence Updates From BMJ
http://plus.mcmaster.ca/EvidenceUpdates
Health Services/Technology Assessment Texts (HSTAT)
http://www.ncbi.nlm.nih.gov/books/NBK16710
Human Services Research Institute
http://www.hsri.org
Medline/PubMed PICO Search
http://pubmedhh.nlm.nih.gov/nlmd/pico/piconew.php
National Association of State Mental Health Program Directors Research Institute
http://www.nri-inc.org
National Guideline Clearinghouse
http://www.guideline.gov
The National Working Group on Evidence-Based Healthcare
http://www.evidencebasedhealthcare.org
Public Library of Science (PLoS)
http://www.plos.org
Research in Practice
http://www.rip.org.uk
Substance Abuse and Mental Health Services Administration National Registry of Evidence-Based Programs and Practices
http://www.nrepp.samhsa.gov
Turning Research Into Practice (TRIP)
http://www.tripdatabase.com

The key to searching and learning how to best use the different databases is to practice. As an additional resource, the article "Evidence Searching for Evidence-Based Psychology Practice" provides an excellent summary of the different types of databases and their strength and weaknesses [45]. The article may be accessed online at http://www.ncbi.nlm.nih.gov/pmc/PMC3077562.

CONCLUSION

Evidence-based practice in social work is premised on and supports the ethical principles and values of social work [10]. Knowing if interventions and programs are effective is important for funders, agencies, and practitioners. However, while the benefits of using evidence-based practice in the field of social work may be embraced in theory, there are challenges to real-life implementation that should be acknowledged. Fiscal constraints, time and resource constraints, and lack of training on the implementation of evidence-based practice are a few of the barriers that impede adoption. Just as important as being able to produce and expand the social work knowledge base is the necessity to translate the findings into practical applications for social workers. The findings from evidence-based searches should be made accessible to practitioners via online clearinghouses and databases that are easily available to users [46]. Furthermore, definitions of "best evidence" may need to be broadened to include qualitative research in addition to systematic reviews, clinical trials, and meta-analyses. Regardless of the challenges, social workers will benefit from an understanding of how to conduct evidence-based research and incorporate the results into effective practice.

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