oancea

7/31/2019 oancea

1/15

Revista de asisten]\ social\ nr. 1_2010158

The Evidence of Evidence-BasedSocial Work

Mariana Oancea*

Direcia General de Asisten Social i Protecia Copilului, Sector 1, Bucureti

Abstract: The article will define terms and critical issues in evidence-based medicine,

introducing professionals to the language and importance of evidence-based practiceand critical thinking. It will explain how to search for and evaluate evidence, how toask the right questions, how to develop standards, and how to make use of the bestresearch. It will also illustrate some practical applications in social work: obstaclesand solutions. Such information can be used by students and professionals within theprocess and practice of evidence-based social work, teaching them to be criticalthinkers and judicious decision-makers. It helps practitioners to better serve theirclients, making this an excellent foundation for the study and practice of evidence-basedsocial work. Its final aim is to ask ourselves some questions: Are we helping? Whoare we helping and how? Are we harming? Who are we harming and how? How can

we find out? Are practice and policy decisions well reasoned and informed by availableresearch? Are clients involved as informed participants?

Keywords: social work, evidence-based social work, social-work practice, researchpractice

Introduction

In everyday life people have to make decisions about their life and it is not always an easy

thing to do. In order to make a good decision, someone must know himself/herself verywell, must know his/her possibilities and limits. The most difficult task, however, is todecide for someone else. The responsibilities are bigger and there are other factors, whichmight come in between and change the course of the intervention and, consequently, itseffects. It is a saying that the road to hell is paved with good intentions, i.e. very oftenpeoples intentions are good but they see the person from theirpoint of view and they aredoing whatthey consider being good for that person and dont take into consideration thevery desires of that person. What is good for someone isnt necessarily good for everybody.A good way of taking decisions would be searching for some evidence that what we aredoing is actually good. Professionals grow to be aware of the implications of their actions

upon clients live hence, attending to evidentiary, ethical and application issues becomeimportant for them as well as becoming skilled in critical appraising the practice and policy

Mariana Oancea

7/31/2019 oancea

2/15

Mariana Oancea 159

related literature. During daily practice, they came across gaps between obligations describedin their professional codes of ethics and different issues that occurred in their work and, asa consequence, professionals discovered limitations in traditional methods of knowledgedissemination and traditional professional education system. In the same time, professionalsfeel the need to know what has been done in the field up to this moment and to what effect.With the purpose of finding the best solutions to clients problems, a new component has tointervene in decision-making process, that of client values, as they are involved as informedparticipants. Being aware of these problems, all along their work, practitioners shouldgenerate knowledge that should help policy makers in developing an integrated system ofsocial services designed on clients unique circumstances and characteristics and not anauthority-based one.

The problem thus becomes: where and how are we to look for the evidence? Consequently,we must discover what is now available, when it was first mentioned and in what context,how accurately it is described in the professional and academic literature, what critical tests

were performed if any and with what results and which aspects of research findings wereimplemented so far. All these searches were made possible due to web revolution, thecreation of a technology designed to decrease gaps among evidentiary, ethical and applicationissues and the promotion of client involvement and informed choice.

Evidence-based medicine tried to answer to these questions and has established someprinciples, which can guide the evidence-based practice that, according to Reynolds (2000,17), is a more suited concept for the interdisciplinary application of evidence-based medicine.

Short History

In recent years the scientific body of knowledge concerning social work practice has grown,as well as its accessibility for practitioners due to the availability of electronic bibliographicdatabases and increased acceptance of systematic reviews and evidence-based practiceguidelines. This knowledge conducted to new forms of practice, social work becoming notonly a profession but also a science. The rise of the evidence-based practice movementprovides the field with a wonderful opportunityto dramatically increase the extent to whichprofessional activitiesin the realms of policy and practice can be more solidly groundedinscientific research (Thyer, 2008).

Earl Muir Gray (2001) suggests that the evidence-based medicine and mostly its

philosophy emerged as a consequence of too many variations in service delivery andclinical practice, too many gaps showing that professionals were not acting systematicallyor promptly on research findings, of the failure to start services that did more good thanharm at reasonable cost, failure to stop services shown to be little value and economicspressure. There was a knowledge revolution as well, consisting in increased recognitionof harmful side-effects of medicine and health care, flaws in traditional modes ofdissemination such as books, editorials and articles, the evolution of the systematic reviewand web-based updates (Gambrill, 2003). In the same time, medicine care needed a changein a sense that clinicians had to break down the gap between research and practice, to usetheir judgement and scientific training to interpret and integrate guidelines and to incorporateclient values. These problems became surmountable by clinicians due to new strategies to

efficiently tracking down and appraise evidence. A big step was the creation of aninformation system consisting in systematic reviews of health care effects, put together by

i i i i

7/31/2019 oancea

3/15

The Evidence of Evidence-Based Social Work160

If in medicine things are more advanced, in social work we have limited knowledgeabout the prevalence of a problem, the variability of problem-related behaviours, the causesof social crisis and methods that are most effective in attaining given outcomes. I believe

that the danger of failing in our profession if not using evidence-based practice principlesresides in making a problem too simple, in not seeing the whole picture. As a consequence,professionals tend to see different entities as more similar that they actually are, treatdynamic phenomena as static, assume that a general principle accounts for all phenomena,treat multidimensional phenomena as unidimensional and treat highly interconnected conceptsas separable (Feltovich et al., 1993).

Evidence-based practice is an interactive process also characterized by the fact that theclient has the possibility to inform himself about his problem and about the possiblesolutions. According to evidence, he can choose to proceed or not with an intervention. Thelimitations of the traditional forms of knowledge lead to a necessity of using evidence-based

practice in our work.

Definitions

What is evidence-based medicine? Some authors state that evidence based-medicine has itsorigins in 19th century medical practice and, according to Greenhalgh (2001, 1), is theenhancement of a clinicians traditional skills in diagnosis, treatment, prevention andrelated areas through the systematic framing of relevant and answerable questions and theuse of mathematical estimates of probability and risk. In other words, evidence-based

medicine means the sum of all information one can find when searching for a particularanswer of a well-built question. Therefore, it is a process of research based on differentmethods of finding the information you need, analysing it and taking the good decision forthe problems you are dealing with. A definition of evidence-based practice that is used inmedicine and health care is given by Sackett et al. (1996, 71), as follows Evidence-basedmedicine is the conscientious, explicit, and judicious use of current best evidence in makingdecisions about the care of individual patients. The practice of evidence-based medicinemeans integrating individual clinical expertise with the best available external clinicalevidence from systematic research.

Another definition is given also by Sackett et al. (2000): Evidence-based medicine is

the integration of the best research evidence with clinical expertise and patient values.Talking about clinical expertise and client values, Haynes et al. (2000, 6) indicate thatindividual helpers should use their relationship skills and experience to rapidly identify eachclient unique circumstances, characteristics and their individual risks and benefits ofpotential interventions and their personal values and expectations.

The essence of evidence-based practice is described by Gibbs (2003, 5) as follows:Placing the clients benefit first, evidence-based practitioners adopt a process of lifelonglearning that involves continually posing specific questions of direct practical importance toclients, searching objectively and efficiently for the current best evidence relative to eachquestion, and taking appropriate action guided by evidence.

We can see that one of the characteristics of evidence-based practice and policy is tocreate and use technologies to pursue desired goals, characteristic that make the difference

7/31/2019 oancea

4/15

Mariana Oancea 161

Using evidence-based practice principles and technologies, practitioners are betterendowed to fight practice-related obstacles. Oxman and Flottorp (1998) consider obstaclesrelated to:

standards of practice: fears about practicing differently from others in the communitymay inhibit adoption of new effective forms of service or promote the continued use ofservices that may not be effective or maybe harmful;

opinion leaders: local opinion leaders may encourage use of services found to beineffective or which are untested or may discourage the use of effective services;

professional training: ineffective or harmful practices may be used because of theinfluence of what helpers learned in educational programs;

advocacy: made by institutions who actively promote and disseminate programs ofunknown effectiveness or those found to be ineffective or harmful.In order to overcome these obstacles, we need to know what evidence-based practice is.

Philosophy

One of the professionals that took interest and made a contribution to the evidence-based-practice movement is Eileen Gambrill, Hutto Patterson Professor of Child and FamilyStudies at the School of Social Welfare, University of California at Berkeley. She is keenon showing students and social work professionals how to ask the right questions, search forreliable answers, and rigorously evaluate the results. All through her work, Eileen Gambrilltried to equip students with practical abilities and knowledge as to better understand the

larger picture in which social workers practice, a picture that considers solving the clientproblems by utilizing his/her own resources and taking into account the economic, political,social, and ethical aspects. Learning from Gambrills work, future social work practitionerswill become better advocates for their clients and better informed decision makers. Gambrill(2001) points out that evidence-based decision-making arose in medicine and health care asan alternative to authority-based practice in which decisions are based on criteria such asconsensus, anecdotal experience or tradition.

According to Gambrill (2003), there are interrelated hallmarks and contributions ofevidence-based decision-making such as:1. Moving away from authority-based practices and policies, evidence-based decision-

-making process describes gaps among evidentiary, ethical and practical concerns,describes limitations of research, proposes well-argued alternative views and evidenceagainst favored views and avoids questionable criteria for making decisions such asstatus, popularity, and tradition.

2. Evidence-based decision-making philosophy includes some ethical obligations focusingon client concerns and desired outcomes, attending to individual differences in clientcircumstances and characteristics including client values and preferences, involvingclients as informed participants, minimizing harm in the name of helping and providingclear descriptions of services.

3. Evidence-based decision-making process also stresses out the services transparencydescribing the outcomes variations, encouraging rigorous testing and revealing the gapsbetween research regarding the causes of social problems.

4. Another important aspect that is included in evidence-based decision-making philosophy

7/31/2019 oancea

5/15


are established as to respond to clients when resources are scarce, professionals areeducated as lifelong learners.

5. Evidence-based decision-making process is based on accumulating knowledge. Sources

of available knowledge are multiplied, knowledge is seen as a resource to be shared,criticism is welcomed, high quality critical appraisals of practice and related researchrelated to practice are disseminated (e.g. Cochrane and Campbell Collaboration). Clientsand professionals learn how to rapidly and critically appraise practice-related research.Educational programs are created and implemented to create lifelong learners andmethods to identify errors and their causes are developed. Professionals use thisinformation to minimize avoidable errors that may harm clients.

In her article Evidence-based practice: Sea change or the emperors new clothes?Eileen Gambrill (2003, 4) states that EBP and social care involve a philosophy of ethics

of professional practice and related enterprises such as research and scholarly writing, aphilosophy of science (epistemology views about what knowledge is and how it can begained), and a particular philosophy of technology. The author explains that: Ethics involves decisions regarding how and when to act; it involves standards of

conduct. Epistemology includes views about knowledge and how to get it or if we can. The philosophy of technology involves questions such as: Should we develop technology?

What values should we draw on to decide what to develop? Should we examine the consequences of a given technology?

Concerning the technology related to the philosophy of evidence-based practice, thesteps that a professional has to make in order to solve a problem are the following:1. To convert information related to practice into answerable questions.2. To discover with maximum efficiency the best evidence with which to answer them.3. To critically appraise the evidence for its validity, impact and applicability.4. To apply the results of this appraisal to practice, considering also the client involvement

and values.5. To evaluate the effectiveness and efficiency in carrying out these steps and to seek ways

to improve them in the future (Sackett et al., 2000, 3-4).

From Theory to Practice

I will now take each step and discuss its implications for practice. The first step, that ofconverting the information one needs into answerable questions, is very important. Butbefore even formulating the research question a social worker must be sure of the problemsetiology. In other words he must label the social problem, give a diagnostic. According toFrances J. Turner (2002)1 the conceptual diagnosis being understood as that process of aconsciously formed series of judgments made during the life of a case, judgments uponwhich a practitioner grounds his or her interventions, and for which each is prepared to takeresponsibility does have application across all aspects of social work practice. In his bookDiagnosis in Social Work New Imperatives,Francis J. Turner draws attention upon the

7/31/2019 oancea

6/15

Mariana Oancea 163

this shift in terminology was indeed more than word substitution and that the termdiagnosis has his important place within the social work practice.

Setting a correct diagnosis is the social workers responsibility. The whole structure of

the intervention process is based upon detecting the true nature of the problem. This impliesthat the social worker must collect data about the clients personality, social situation andhistory and then to analyze the data in order to arrive at an objective definition of theclients situation.

How hard is it to give a diagnostic in social work? Like in medicine, where differentillnesses could have the same symptoms, within social problems we may find the samereactions caused by different social malfunctions. Nevertheless, a social worker must makea judgment in order, to set a diagnostic upon the cases he has. As in the cases above, ofharm and interventions, when dealing with a complex situation a good practitioner mustsearch for the best studies that could support his/her diagnosis and questions.

Different questions require distinct research methods to critically appraise proposedassumptions (Greenhalgh, 2000; Guyatt & Rennie, 2002, Sackett et al., 2000). When wefirst see a social services beneficiary, we need some information about his/her problems, weneed to set a diagnosis. Sometimes, we can easily find out the roots and the growth of theproblem but, often, the information is not obvious and we need some external evidence tosupport our theories. The efforts that professionals put in transforming the information theyneed into questions and finding the best answers are immense, especially when they are timelimited and assaulted by many cases. Specialists give us some tips about how to askquestions, considering that they believe that is the hardest step in finding answers.

A professional can ask background questions searching for general knowledge about

the clients problems (who, what, where, when, how, why) and foreground questionsabout intervention, comparative interventions and desired outcomes. Both kinds of questionshave to take into account aspects such as client physiology and psychological implications.Specialists have to analyze clients on three levels: individual, communitarian and societal,and they have to find answers related to all of them. As professional social workers, we allneed background and foreground facts in proportions that fluctuate over time dependingon our accumulating experience with a specific problem. It is very important to ask goodquestions for several reasons: it helps us to rapidly focus on the evidence related to ourproblem, saving precious time for us; it energises the communication with our colleagueswhen sharing information and it maintains us up to date with news on the field.

Once we conceive a good question, another problem arises where to look for theanswer. Books are the first solution they should be frequently revised and heavilyreferenced in order to find the right answer. The statements they make have to be inaccordance with the evidence-based principles. Even if the quotations and web-linkedtextbooks are encouraged, professionals are advised to critically appraise the information.The internet databases, numerous for medicine (Cochrane Database of Systematic Reviews,Best Evidence, Evidence-Based Mental Health and Evidence-Based Nursing, Cancerlit,Healthstar, Aidsline, Bioethicsline and MEDLINE) but scarce for social problems (CampbelCollaboration) are also a very helpful tool. The difficulties in accessing these large databasesconsist in efficiently finding the information we need. Thats why a good solution would bethat institutions make subscriptions to online specialised journals, in order to receive thenewest information. These journals summarise the best evidence and make their selectionsaccording to explicit criteria for merit, providing structured abstracts of the best studies,

7/31/2019 oancea

7/15


journals of relevance to our interests. If a social worker has tried to search for evidence onclients problems, he/she should compare what he/she did and what he/she found with themethods proposed by evidence. Specialists in evidence-based medicine propose a general

search strategy that can easily be functional for social work as well. Consequently, thesocial worker has to:1. clearly define the problem;2. define important searchable question;3. select the resource;4. design a search strategy;5. summarize the evidence;6. apply the evidence;7. If he/she has got poor results then, he/she should go for the second best resource and

follow the steps again.

The third step in better solving problems for our client refers to critically appraise theevidence we found. The critical appraisal is the process of assessing and interpretingevidence by systematically considering its validity, results and relevance to an individualswork (Parks et al., 2001). We agreed that not all research is qualitative and many studiesare biased, with uncertain results.

Knowing which study didnt draw false conclusions, whether a research is reliable ornot, which study to choose from those with different solutions for the same problem, is theresult of using critical appraisal skills. According to Belsey (2009), in order to take the bestdecisions the professional should know if the studies have been made in a way their results

are reliable, should make sense of the results and know what the results mean in the contextof the decision. Studies conducted so that they lead to a particular conclusion are biased.Amanda Burls, MBBS, BA MSc FFPH, Director of the Critical Appraisal Skills,Programme, Director of Postgraduate Programmes in Evidence-Based Health care,University of Oxford in a What is? series published on internet said that: Bias can bedefined as the systematic deviation of the results of a study from the truth because of theway it has been conducted, analyzed or reported.2 The same author points out that whenone critically appraises a study, he should first look for biases in the study; that is, whetherthe findings of the study might be due to the way the study was designed and carried out,rather than reflecting the truth. Burls mentions that it is also important to remember that no

study is perfect and free from bias; it is therefore necessary to systematically check that theresearchers have done everything to minimize the bias, and that any remaining biases do notseriously alter the results observed. A study which is sufficiently free from bias is said tohave internal validity.As I said before, different kinds of questions require different kindsof study designs.

The questions could address: Effectiveness: i.e. Do vocational training programs help clients get and maintain jobs?

Are there harmful effects of such programs? Prevention: i.e. Do domestic violence prevention programs addressing family doctors

reduce the number of domestic violence acts?

Screening, risk prognosis: i.e. Do ANPF (National Agency for Family Protection)reported data on domestic violence really reflects the actual number of these cases in the

7/31/2019 oancea

8/15

Mariana Oancea 165

Thus the best design for effective studies are randomised controlled trials (RCT). Whenusing research to help with a question, look for high quality studies, but do not be tooquick to dismiss everything as irrelevant. Try to take what does apply from the research and

use it to resolve the problem at hand. (Koufogiannakis and Crumley, 2004). There is ahierarchy of evidence but professionals should develop their skills to make sense of scientificevidence and to find the best answer to their questions. When analysing any research be itRCT, systematic reviews, meta-analyses or other it is relevant to consider validity, relevanceand results. There are a lot of difficulties for a researcher when he/she wants to assess theeffectiveness of complex interventions and when he/she needs information to answerquestions related to prevention, diagnosis, therapy, potential harm, or causation. However,it is very easy for a researcher to find studies in support his/her ideas. However, if he/shesearches for more, he/she may also find some contradictory evidence.

Under these circumstances of controversial discussions about research in social work

field, a good practitioner should know what research method provides the best evidence forthe particular research question at-hand. It is very important to know that there is no suchthing as the best research method. A wise practitioner knows that the research methodshould be tailored to the needs of the research question. As Sackett et al. (1996, 71) said,the question being asked determines the appropriate research architecture, strategy andtactics to be used not tradition, authority, experts, paradigms, or school of thought.

A tool widely used by the practitioners when searching for studies to sustain adecision-making process is the hierarchies of evidence, developed by the Canadian TaskForce on The Periodic Health Examination.

Paul Glasziou et al. (2004) draw attention to the danger of using hierarchies of evidence

that rank research studies according to their quality. Glasziou (2004, 39) says that thesimplification involved in creating and applying hierarchies have led to misconceptions andabuses. In their view, five aspects must be considered when appraising the quality ofresearch:1. First of all, they agree with Sackett by saying thatdifferent types of questions require

different types of evidence. Glasziou et al. (2004) point out that practitioners shouldunderstand the indications and contraindications for different types of researchevidence. Randomized controlled trials can give good estimates of treatment effects,but poor estimates of overall prognosis, comprehensive non-randomized inception cohortstudies with prolonged follow-up however, might provide the reverse (Glasziou et al.,

2004, 39).2. Systematic reviews of research are always preferred. A study gives better evidence

when it is interpreted in relation to what other studies and case studies may indicate aspotential rare harms or benefits of an effective treatment.

3. Level alone should not be used to grade evidence. Examining the first substantialhierarchy made by Canadian Task Force on the Preventive Health Examination, theauthors indicate three disadvantages: The definitions of the levels that vary withinhierarchy, novel, or hybrid designs are not accommodated in these hierarchies and suchhierarchies can lead to anomalous rankings.

4. Clinicians need efficient search strategies for identifying reliable clinical research.

Hierarchies could be used however, to find other sources of evidence when systematicreviews are not available.

7/31/2019 oancea

9/15


Glasziou (2004) indicates non-randomized cohort studies or case-controlled studies forfinding the best harm-related evidence.Given these problems of hierarchies, Glaszious advice for practitioners has two

directions: (1) To standardize and to improve the current hierarchies and (2) To abolish thenotion of evidence hierarchies and to teach practitioners the general principles of researchand the possible utilizations of these principles to appraise the quality and relevance ofparticular studies.

Burl concludes that it is always necessary to consider the following questions: Has theresearch been conducted in such a way as to minimize bias?If so, what does the study show?What do the results mean for the particular patient or in the context of a particular decision?

The next step is to apply the evidence to practice. Applicability may be determined by thefollowing variables listed by Koufogiannakis and Crumley (Booth & Brice, 2004, Ch.10):

User Group

Is the user group similar to mine? Did the research measure outcomes important to my situation and users? What is the impact of the age of the user group? Will the users benefit from it? Does the service/product fit with values, needs and preferences of my user group?

Timeliness Has the situation changed since the evidence was gathered? Is there a potentially newer technical solution that should be explored?

Cost

Are the benefits worth the cost in my situation? How big an impact will be achieved and is it worth the cost? Are there any side effects for users that may be costly in the long run? Are there other less costly things that can be done instead or prior to implementation to

control costs?

Politics Is there support within the institution and who do I need to partner/target to become my

champion? What will be the positive and negative effects of this initiative in my environment?

Will my employer/users embrace the different way of doing things?Severity

What is the level of severity of the issue? Will implementation make a difference? If so, how much, and is it worth the effort? Are there other remedies for this situation? Are the potential consequences so severe that any solutions will only work in the short term?

Decision-Making Using the Evidence

The tools/strategies to help weigh up the best evidence found when considering localconditions include the SWOT analysis.

The last step for professionals is that of evaluating the intervention impact The

7/31/2019 oancea

10/15

Mariana Oancea 167

the intervention has made a difference. To facilitate this course of action we have to identifywhat we want to measure, which data we need to measure it and to determine the suitablemeasurement. We must compare the desirable outcomes stated in the original plan with the

acquired changes. We must also answer two questions: Have the changes resulted in customer service improvement? Have any further questions arisen?

Evidence-Based Medicine and Evidence-Based

Social Work Practice

But as I said, not all thats appropriate for an area is also appropriate for other areas;therefore, we might ask whether the principles from evidence-based medicine can be

applied to social work.We can see from these definitions, which are the main principles of E.B.P. The question

is how do they match with social work practice? I will take each principle of theevidence-based medicine and I will try to see how it can be applied to social work:

Search for the Best Research Evidence

Where can we find such evidence in medicine? We can find it in various specialisedjournals and at the same time, on the Internet as an important source of evidence. A verygood source to start searching is the Cochrane Library, which provides systematic reviews,

meta-analyses and randomised control trials results of the effects of health care. There arealso other sources, which can provide evidence of different ways to solve medical problems.So, we can find out, in most medicine cases, sufficient evidence to help us with ourproblems. Both clinicians and patients can have access to the information and can contributeto the decision-making process. According to Gambrill (2002), EBP is designed to createprofessionals who are lifelong learners who draw on practice-related research findings andinvolve clients as informed participants in decisions made (452). What it is the situation insocial work? Where can we find evidence for social work problems? Considering thecomplexity of social work field which deals with a lot of diverse cases from one individualto another and from one country to another, it is much more difficult to find valid and

high-quality evidence which can be applied to a specific situation. We can also findsituations or places where the social problem has different definitions or even it is notconsider a social problem (e.g. domestic violence in Romania). The research tradition insocial work is also based on randomised-controlled trials, meta-analyses and single-casedesigns, trying to identify the relative effectiveness of different interventions. But withinthis kind of research, in social work there is no sufficient and valid evidence. Whilemedicine has a well-built scientific body of knowledge common for almost all countries, itis highly improbable for social work to achieve such a body of knowledge because almostall social cases are unique and we can hardly find general applicable methods of interventions.For example, if in medicine, a colon cancer can have the same pattern regarding patients

from all over the world and can be healed by applying the same treatment, clients who havethe same social problem (e.g. homelessness) require different methods of interventions

7/31/2019 oancea

11/15


it is very difficult to find out why some interventions worked well or failed. Also, wecannot know what the contribution of individuals involved in experiment was or how theprofessionals who worked with them did influence them.

The principle itself of searching for the right evidence is good and apparent. All theprofessionals should do this in their practice. What happens when we generalise the outcomesto the natural environment of the client? The problem is that in social work there is not somuch evidence and the practitioners must rely on their practice experience in the field inorder to make good decisions. Another problem, particularly in less developed countries,regards the social work clients who come from very poor circumstances: how can theyaccess evidence and how to gain good enough appraisal skills in order to decide the bestsolution for their situation? This aspect can lead us towards a second principle in evidence-basedmedicine:

Good Clinical Expertise

It is desirable that a professional clinician and a professional social worker should make adecision. If in medicine all the clinicians are doctors and they have a medical knowledgebackground, in social work it is possible that a social worker doesnt have special socialwork knowledge.3 So, how can these people make a decision in really difficult cases? Also,if in medicine we have standardized treatments based mostly on pharmacological andphysical interventions, in a social work intervention, the social worker should consider theclients network of relationships, his relations with his family, with his friends and with thesociety in general. This aspect complicates the decision-making process. Another aspect

concerns patient and clients involvement in the decision-making process. In the medicalcontext, the patient has a more passive attitude and he often lets the doctor make thedecision for him. The influence of the external factors is much more reduced than in socialwork field and it is relatively easier to predict the possible effects of an intervention. Thesocial work clients usually come from very disturbed environments, they come with theirown perception of their situation and its causality. Thats why it is difficult to combine theprofessional expertise with the clients preferences, which are more affected by the external,societal factors (e.g. poverty, emotional distress, mental disorders, and political context).The social work practitioners dont have a great amount of trial data available. There is arecent series ofWhat Works summaries produced by Barnados, which intend to focus on

RCT evidence in social areas.According to Liz Trinder (2000), there are a number of technical issues that makeRTCs4 more difficult to operationalise within social work and probation than in medicine(150). These difficulties are related to the ethical and practical process of randomisation, ofexternal variables, which can change the research parameters, and of the nature of outcomeindicators and thats why the aim of RCTs in social work field will remain limited totechnical reasons. The danger of contamination between the social work clients is bigger.We can often see that in order to receive more benefits, clients can influence each other onhow to act during an interview or what answers are the best or what specific service heshould ask for and, therefore, we cant be sure that what they are saying is, actually, what

they believe.According to Sackett et al. (2000), the first step in the practice of EBP5 is convertingthe need for information (about prevention, diagnosis, therapy, causation) into answerable

7/31/2019 oancea

12/15

Mariana Oancea 169

information, which could influence our decision. A good clinical expertise can also meanthat a professional who finds negative results or no evidence on a specific problem, shouldcomunicate it to the client. If we dont want to lose clients we must have good communication

skills and be able to reach a common agreement regarding the implementation of a newmethod for solving the problem. Therefore, social workers should ground their expertise onscience but at the same time they must be aware of its limitations. As soon as one expert hasfound enough evidence on a problem he should follow another principle:

Consider Clients Values

We live in an ever-changing world in many aspects and we may find different and evencontradictory values from one society to another. Within the same society, a large scale ofexternal factors influences individual values. Consequently, how can we integrate the

clients values if they are opposite to our findings? E.g. can we convince a woman not tomake a circumcision even if she is going to have many difficulties to find a husband withinthe societies who value this tradition? How can we apply our strategies among differentcultures without any negative effects? How can we know that we are actually doing wellrather than harm? Who is right: the science or the client? Of course, that evidence-basedpractice gives us some methods of evaluating the effectiveness of the intervention butconsidering the complexity of human nature can we be sure that applying some actions fromsimilar cases is the best solution for our clients? According to Reynolds (2000, 257)research validity refers to the extent to which the results of the research are likely to befree from bias. In the social work field, it is difficult to prevent the influence of biases and

not always the social worker can find out whether any bias has occurred during theintervention.A very important aspect is how evidence can be transferred into real situations. Each

country has different implementation services and not necessary very developed ones and ofcourse we must consider the limited resources we have. We must make the best decision forthe client using the limited resources we have but this cannot be done so easily in everysociety (usually, the societies which need most social work are the poor ones). It is veryimportant to consider clients own definition of their problems and the difficulties to whichthese lead. If there are differences between social workers and clients then, these must bediscussed and negotiated until a common objective is achieved.

Relying on evidence is good but is not enough for social work. The outcomes ofapplying the evidence-based principles in social work are desirable but there is a problemregarding the methods of searching and implementing the findings. It is not enough toanalyze only the studies, which have been made, but we should also integrate the studies ofthe consumers reactions. We must see the evidence we have as a guideline of the safest andmost effective interventions but not as an authority in the field. Every professional mustanalyze the evidence carefully and must take that decision which can minimise the potentialharm of the intervention and maximise the potential benefits.

Most of the interventions in social work are very complex both on individual and oncommunity level. It is usually hard to find good evidence for complex interventions,

especially in those cases when social phenomena occur for the first time. At this level, wecan search for evidence by different methods from gathering data from the people involvedto structured surveys or qualitative interviews, notes from a field work or focus groups etc.

7/31/2019 oancea

13/15


difficulty may be the actual analysing of the results and their impact upon all the participantsand other secondary effects.

Alderson and Groves (2004) cite Archie Cochrane, who asked three keyquestions about

a healthcare intervention: Can it work?,

Does it work in practice? and Is it worthit? The problem that these authors raised is: what are we doing when the answer of thesequestions is situated between no and not sure? The answer is the same with thatrelated to intervention, which might do more harm than good: searching for the bestevidence.

The challenge, then, is to raise awareness of the way in which policy so often fails toaddress the human individual when assessing need. The result of the present failure is thatso much policy provides for problems and not for people: hence the predicament ofproviding for people with multiple support needs (Ham, 1996).

Notes

1. http://www.haworthpressinc.com/store/SampleText/4539.pdf.2. http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/What_is_critical_appraisal.pdf.3. In some countries the social work is done by peoples who come from different areas than

social work, they are not real professionals (e.g. Romania).4. Randomized control trials.5. Evidence-based practice.

References

Alderson, P. and Groves, T. What doesnt work and how to show it. BMJ 2004; 328:473(February 28), doi: 10.1136/bmj.328.7438.473

Belsey, J. (2009) What is Evidence-based Medicine? London: Hayward Medical Communications.Bruce, A.T. (2008)Research on Social Work Practice, 18, 4, 339-345.Gambrill, E. (2003) Evidence-based practice: Sea change or emperors new clothes?Journal of

Social Work Education, 39, 3-23.Gibbs, L. & Gambrill, E. (2002) Evidence-based practice: Counterarguments to objections.

Research on Social Work Practice, 12, 452-476.Glasziou, P., Vandenbroucke J., Chalmers, I. Assessing the quality of research, BMJ 2004;

328:39-41 (January 3), 10.1136 bmj. 328.7430.39http://bmj.bmjjournals.com/cgi/content/full/328/7430/REF2

Greenhalgh, T. (2001)How to Read a Paper: The Basics of Evidence Based-Medicine. London:BMJ Publishing Group.

Guyatt, G.H., Haynes, R.B., Jaeschke, R.Z., Cook, D.J., Green, L., Naylor, C.D., et al. Usersguides to the medical literature: XXV. Evidence-based medicine: principles for applying theusers guides to patient care. JAMA 2000; 284: 1290.

Feltovich, P.J., Spiro, R.J. and Coulson, R. (1993)Learning, Teaching and Testing for ComplexContextual Understanding.

Ham, C. (1996) A primary care market? British Medical Journal,313, 127-128.

Koufogiannakis, C. (2004)Booth & Brice, Ch. 10, 126.Muir-Gray J.A. (2001)Evidence-based Healthcare: How to Make Health Policy and ManagementDecisions. London: Churchill Livingstone.

7/31/2019 oancea

14/15

Mariana Oancea 171

Oxman & Flottrop (1998) An overview of strategies to promote implications of evidence-basedhealth care. Silagy, C. & Haines, P. (eds.), Evidence-based Practice in Primary Care.London: BMJ Books.

Parkes, J., Hyde, C., Deeks, J., and Mline, R. (2001) Teaching critical appraisal skills in healthcare settings. Cocharne Database Systematic Reviews, 3, CD00120.

Reynolds, S. (2000) Evidence-based practice and psychotherapy research. Journal of MentalHealth, 9, 3, June, 257-266.

Sackett, D.L., Richardson, W.S., Rosemberg, W., Straus, and Haynes, R.B. (2000)Evidence-BasedMedicine: How to Practice and Teach EBM. New York: Churchill Livingstone.

Sackett, D.L., Rosemberg, W.M.C., Gray, J.A.M., Haynes, R.B., and Richardson, W.S. (1996)Evidence-based medicine: What it is and what it isnt. British Medical Journal, 312, 71-2.

Trinder, L. & Reynolds, S. (2000) Evidence-Based Practice: A Critical Appraisal. London:Blackwell Science.

7/31/2019 oancea

15/15

Copyright of Social Work Review / Revista de Asistenta Sociala is the property of University of Bucharest,

Faculty of Sociology & Social Work with Polirom Publishing House and its content may not be copied or

emailed to multiple sites or posted to a listserv without the copyright holder's express written permission.

However, users may print, download, or email articles for individual use.

oancea

Documents