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Evidence Based Practice in Social Care

Introduction

This chapter aims to introduce students to the concept of evidence-based practice

and how it might be used in social care practice. However, it is important to

bear in mind that as future professional practitioners you need to be mindful of

adopting a critical and inquisitorial approach to research or more importantly

evidence. This chapter aims to encourage you to develop a „research-mindedness‟

approach to your future practice.

How did you do that and why did you do it that way? If you have asked those

question or been asked those questions then you have engaged in research. We

often think of research and those who undertake it as a ponderous activity

carried out by serious-minded people removed from the hustle and bustle of „real-

life‟. Research can be seen as a remote activity, particularly by those at the

„coal-face‟ of practice. Yet many practitioners are engaged in the research

process even if they don‟t realise it. Every time you read a study, a report, a

journal article, a review document you are consuming research. If there were no

readers there would be no research, thus you are an invaluable link in the

research process chain. However, as well as being consumers of research;

practitioners can and indeed should be producers of research.

What is Evidence Based Practice?

There is nothing new about the idea that policy and practice should be informed

by the best available evidence. Evidence based practice was first introduced in

medicine and allied health professions. More recently it (EBP) has been advocated

in social work as an alternative to "authority based practice," or practice that

was based solely on the expertise and experience of practitioners (Edmond et al.

2006). Gibbs & Gambrill (2002 p. 452) define evidence-based practice as „the

conscientious, explicit, and judicious use of current best evidence in making

decisions about the care of clients‟.

Evidence-based practice has become a byword for better, more appropriate and

efficient practice. In essence an evidence-based approach asks that practitioners

use the best available evidence to guide and inform their practice. However, we

need to ask ourselves what constitutes best evidence and how do we choose between

one source of evidence over another (Sheppard 2004)? In addition, we also need to

unpack the term Evidence Based Practice particularly as it relates to the area of

social care.

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Appleby et al‟s (1995) definition of evidence base practice belies its medical

origins noting that it represents a shift in healthcare decision making. Evidence

based practice represents a move away from opinion, past practice and precedent

towards a decision making framework that relies on greater use of research and

evidence. The basic principles underlying the „evidence-based‟ practice movement

are that there is a hierarchy of evidence and that modern informatics can make

the evidence available to practitioners at the point of care.

Why an Evidence Based Approach to Social Care?

The Department of Health & Children‟s (2004) policy document: „Working for

Children and Families: Exploring Good Practice‟ outlines seven management

principles that should underpin child and family services. From an EBP

perspective, principle number three stresses the need for practitioners and

managers to „ensure that their practice and its supervision are grounded in the

most up-to-date knowledge‟ (DOHC 2004 p. 15). In addition to relevant empirical

research, evidence should be drawn from local statistical data; national

policies, evaluations and audits and the lessons learned from case reviews (DOHC

2004).

Williams (2000) argues that the benefits of an evidence based approach for

social care work are:

1. More Effective Social Care Interventions

2. Improved Resource Efficiency

3. Improved Analytical Practice

4. Raising the Status of Social Care Professionals

5. Improved Public Confidence in Social Care

Marsh & Fisher (2005:3-4) make some very strong arguments for the adoption of a

research evidence based approach and these are summarised in table 1.

Table 1

Reason Argument

Impact on the immediate life

chances of service users In extreme cases e.g. child

protection decisions may influence

life or death situations,

practitioners should be as informed

as possible

Impact on the long-term life

chances of service users

Decisions made may well effect long

term life chances such as

educational outcomes, mental health;

practitioners should be as informed

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as possible

Challenge to fundamental

assumptions about

social care

Evidence may produce a shift in the

way practitioners, service users,

the public and other allied

professions see social care work

Providing safeguards to service

users

There are substantial areas of social

care where

professionals have strong powers, or

where the courts may make decisions

regarding

major aspects of people‟s lives… best

available evidence is an important

component of processes of control of

this power

Encourage and facilitate a more

informed public

An informed public can engage better

with relevant debates about services

…it is right that citizens have

access to the best evidence

Informed service user and carer

communities, and individuals

Direct involvement in services and

engagement with the development of

services requires access to the best

evidence

Few if any would argue that social care interventions should not be as effective

as possible. The argument goes that the use and application of new and/or

existing interventions should be informed by evidence.

Issues in adopting an Evidence Based approach to social care practice

Whilst the arguments for the adoption of an evidence based approach may be

convincing it should be noted that locating and utilising research, particularly

relevant quality research is not always easy.

Stevens et al‟s. (2007) review of the research priorities of practitioners

working with children in social care highlighted a number of important issues

with regard to the expansion of the use of evidence based practice. The study

found that social care workers make limited use of research findings in practice.

The barriers to using research included: a lack of time, lack of research skills

and research resources, and an underdeveloped culture of research use within many

organisations. Another problem highlighted was the range of target groups within

social care; practitioners work with a wide range of clients, family support,

elderly, children and people with disabilities and so on thus making it more

difficult to adopt a unified approach to research.

Rosen (2003 p. 199) identifies five categories of the factors that impede

implementation of evidence-based practice. These are:

1. Characteristics of the knowledge to be used

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2. Characteristics of the practice situation and setting

3. Attributes of the medium through which the knowledge is communicated

4. Characteristics of the practitioner

5. The social-cultural context in which utilisation takes place

Activity

When you have finished reading this chapter return to Rosen‟s (2003) five

characteristics above and consider the extent to which practitioners are

constrained from engaging in an evidence-based approach to practice.

What constitutes Evidence/Knowledge?

Utilising research in social care requires the integration of different types of

knowledge. Pawson et al.’s (2003) review of the types and quality of knowledge in

social care provides a useful system for the classification of the sources social

care knowledge.

Table 2

Type Source

Organisational

knowledge

knowledge gained from organising social care,

through governance and regulation activities

Practitioner

knowledge

knowledge gained from doing social care,

which tends to be tacit, personal and

context-specific

User knowledge Knowledge gained from experience of and

reflection on using social care services,

which again is often tacit.

Research knowledge knowledge gathered systematically within a

planned strategy, which is mostly explicit

and provided in reports, evaluations and so

forth

Policy community

knowledge

knowledge gained from the wider policy

context and residing in the civil service,

ministries, think tanks and agencies

Pawson et al. (2003:22)

This is system of classification should not be taken to imply that all sources of

knowledge are equally regarded; research or empirical knowledge generally appears

to be held in higher esteem than other sources of knowledge. Furthermore, not all

research is regarded equally; health care, for example, has a well established

„hierarchy of evidence‟. At the top of this hierarchy are randomised experiments

and systematic reviews; conversely studies employing observation are regarded as

having less rigour and credibility (Davies and Nutley, 1999).

This dichotomy in sources of evidence is frequently characterised by the

conceptual shorthand of the terms quantitative and qualitative approaches to

research.

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The label qualitative is a generic term incorporating a range of different

methodologies (Flick et al. 2004). Whilst these methodologies differ somewhat in

their object of investigation and methodological focus they all share a number of

defining characteristics. Bryman (2004 pp. 19/20) states that the qualitative

approach is a „research strategy that usually emphasizes words rather than

quantification in the collection and analysis of data‟. From this perspective the

social world is not the same as the natural world, human beings react differently

in different situations therefore scientific positivist methods are not

appropriate. This approach rejects the practices and understandings of the

natural scientific model that is positivism, rather it emphasises the ways in

which individuals interpret and construct reality (Bryman 2004). Research methods

(or tools) associated with this approach often include: observations, diaries and

interviews.

Quantitative research, as its name suggests „is a research strategy that

emphasizes quantification and analysis of data‟ (Bryman 2004 p. 19). As with

qualitative research, this approach also incorporates a number of methodologies

that share a number of commonalities. This approach incorporates the practices

and norms of the scientific or positivist model with its understanding that

social reality is an external, objective and measurable reality (Sarantakos

2005). This type of research is characterized by the tight control of the

variables under investigation, protocols for measurement and intervention and the

use of statistical testing to establish levels of confidence in the results

(Houser 2008). Research methodologies associated with this approach often include

quasi and natural experiments and surveys.

From the perspective of becoming an evidence based practitioner it must be

acknowledged that the two research approaches are not necessarily regarded as

being of equal value, consequently different sources of research evidence may be

regarded to a greater or lesser extent. With its presumed adherence to superior

procedural rigour and validity it is argued that quantitative studies „produce

some of the strongest evidence for the benefits of an intervention‟ (Houser 2008

p. 38). Conversely, qualitative research is sometimes accused of being too

impressionistic and subjective and very difficult to generalize the findings

(Bryman 2004). However, this „either or‟ dichotomy should be treated with some

degree of caution and scepticism. Layder (1993) argues that this debate is no

longer useful, going as far as to suggest that it is a false distinction with no

real merit. Punch (1998) argues that being at loggerheads about which approach is

better misses the point; the argument should simply be: what is the most

appropriate method to answer the research question posed? and not some rigid

adherence to one approach over another. Plath (2006 p. 64) argues that

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„effectiveness research becomes more complex than deciding between qualitative

and quantitative approaches‟. Nonetheless, regardless of the research approach

used, the knowledge produced by empirical studies is frequently regarded as

superior to the knowledge produced by users and practitioners.

How do I critique Evidence?

There is sometimes a tendency to overestimate the quality of a piece of research,

particularly if the reader is less than familiar with the topic in question

and/or inexperienced in evaluating research. Simply because a study has been

published does not necessarily mean it is good quality research. Becoming an

evidenced based practitioner requires the adoption of a critical stance to

research. However, it should be borne in mind that being critical does not mean

criticising by simply pointing out the limitations of the study (Burns and Grove

1997). Critiquing a piece of research is about undertaking the methodical

appraisal of the strengths and weaknesses of the study in order to determine its

credibility (Coughlan et al. 2007). The key word in this instance is methodical;

we need to adopt a step-by-step process or framework that will enable us to make

an informed judgement about the quality of the evidence offered. The informed

practitioner does not just know what the research says about the topic, they are

also able to judge the quality and the relevance of the research (Sheppard 2004).

Table 3 offers a framework that employs a set of questions that adopts a

journalistic approach to understanding the details behind a story; these are:

who, what, why, when and where? As noted in the evidence section there is two

broad types of research: qualitative and quantitative each with their own

theoretical and methodological approaches and considerations. Nonetheless there

are a number of common questions that can be applied to either type of research;

where there is a notable difference I have adapted the question/s to take account

of these differences.

Table 3

Critiquing Research: An Introductory Framework

Who

Who are the authors, are they practitioners and/or

academics? What qualifications and experience do they

have? Are they noted in their field of expertise?

Who commissioned the study? There may be an issue of

funding bias; quite simply he who pays the piper may

call the tune.

Who was the target population of the study? Are they

so dissimilar to the group that you work with that

lessons may be difficult to apply?

Who is the study aimed at? Is it meant for general

readership, academic, policy makers and/or

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practitioners?

Where

Where is the study published? A Peer-reviewed

journal? A government report? Peer-reviewed journals

generally adopt a more rigorous approach and

consequently the study‟s integrity and reliability

Where was the study conducted? If the location is

very different can the findings be applied? For

example the study in question focussed on

interventions in a residential setting and you work

in a community setting.

Why Why was the study undertaken? Is it part of a post-

graduate programme? Was it undertaken to evaluate an

intervention or initiative?

Why did the author adopt one research method in

preference to another, is this justified and

consistent with the overall research approach either

qualitative or quantitative? Do the methods chosen

add to the general credibility and reliability of the

study and were they carried out in an appropriate

manner?

When

When was the study carried out? How recent is the

publication? Has the context changed much over time?

What What operational definitions were employed? For

example if the study is about investigating poverty

what definition of poverty is being employed?

What ethical safeguards were put in place? Were

participants fully informed about their rights such

as confidentiality and anonymity; being able to

withdraw at any time?

What was time-frame? Was it a longitudinal or a

cross-sectional study? A cross-sectional study simply

provides a once-off „snap-shot‟ of a phenomena or

event which can be useful but it is understandably

limited to a degree.

What is the research question? Is this question

clearly stated? Qualitative type studies are

interested in understanding not testing thus they

will simply have a question while quantitative type

studies employ testable hypotheses to either proves

or disproves.

What size was the sample and how was the sample

selected? In quantitative studies sample sizes are

required to be at least 30 in order to be considered

statistically significant. In addition probability or

randomly selected samples are considered to be more

appropriate. Qualitative studies are less concerned

with probability and minimum sizes, rather they are

concerned with providing a greater depth and rich

understanding of the topic.

What is the strength of the link between the evidence

and the conclusions and recommendations? Has the

author made a logical and believable argument?

This framework is not intended to be wholly comprehensive; in fact few frameworks

can make such a claim. What is does offer is a useful toolbox through which you

can begin the process of critiquing articles, reports and studies.

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Activity

Pick a published research article and try to work your way through the set of

questions. Don‟t worry if you cannot answer all the questions; where necessary

try different strategies to answer a question.

For example, when trying to determine the standing of the author; articles will

often give the name of the author‟s employer such as a research centre or

university. However, in all likelihood it will not give any indication of the

number of previous publications they have authored. In this case simply try an

Internet search to ascertain such things as academic positions, professional

bodies, advisory groups, books, studies, reports and so on that they may have

been or are currently involved in.

Remember you will get better with practice

Utilising the Internet as a source of Research

The vast majority of searches are now undertaken using electronic sources which

in reality means using the internet. However, it is important to realise and

understand the range of search facilities open to the practitioner and

researcher. Students or practitioners who have access to an online library

facility can remotely retrieve a vast range of journals through databases such as

EBSCO, Ingenta, ERIC, Cinahl and MEDLINE.

For the hard pressed practitioner (or student), the availability of the internet

has provided a very powerful research tool providing as it does remote access to

a wealth of material. Search engines have become an increasingly important part

of the online experience for the majority of internet users. Well known providers

such as Google and Yahoo dominate the market providing a quick and easy to use

search tool. A recent addition to the Google site is the „scholar‟ option which

allows users to access a wide range of academic papers; however, this is still

quite limited as it will often only provide a link to a title and an abstract

rather than full text. Nonetheless it provides a relatively quick way to search a

wide range of academic sources and provide a starting point in the search for

evidence.

Another recent phenomenon that has provided a source of reference for countless

students throughout the world is the world's leading online encyclopaedia -

Wikipedia. However, as with all sources of evidence it is important to exercise

caution and judgement. The problem with judging the trustworthiness of

information „on the World Wide Web is becoming increasingly acute as new tools

such as wikis and blogs simplify and democratize publications‟ (Dondio et al.

2006 p. 362). On Wikipedia, the various topics are edited by the users, allowing

any user to contribute information on a topic, but the sites also rely on other

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users to correct errors found on the site. Whilst there have been a number of

stories that highlighted the vulnerability of Wikipedia to hoaxes (Parfitt 2006);

there have also been studies that argue that Wikipedia is generally reliable. As

a source of information to help clarify or introduce a topic Wikipedia is useful,

as a source of definitive evidence upon which to base practice; the best advice

is the Latin phrase: „caveat emptor‟ or „buyers beware‟.

Whichever source is used it is vital that clear search terms are used. Gossett &

Weinman (2007 p. 147) provide a useful step-by-step guide to using electronic

sources for locating evidence:

STEP ONE – Converting Client Needs into Answerable Questions. Questions that lend

themselves to searching for the best evidence must be specific enough to generate

an answer in an electronic search.

STEP TWO – Locating the Best External Evidence to Answer the Question. This step

requires access to bibliographic databases such as the Cochrane Database and

Campbell Collaboration. In addition to database access, the skills to effectively

navigate the various sources are important.

STEP THREE – Critically Evaluating the Evidence. The framework in table three can

be employed as a useful starting tool. When critically evaluating the evidence,

Gibbs (2003) recommended using a rating form, such as the Quality of Study Rating

Form, which can be located in his book: Evidence-Based Practice for the Helping

Professions1. Whichever framework or analysis tool is employed the important

feature is that it is a systematic approach.

Where can I find critiqued research?

No one framework can be considered to be exhaustive and this framework is no

different, nonetheless it provides the novice researcher a useful guide with

which to begin the process of evaluating empirical evidence. As a practitioner

becomes more adept at evaluating research, they may wish to enhance their range

of research sources. However, sifting through a series of research documents can

be time consuming particularly so for practitioners.

What the hard-pressed practitioner needs is some form of clearing house for

research. Luckily there is such an organisation; the Campbell Collaboration.

Based on the protocols developed by its older sister organisation: the Cochrane

Collaboration; the Campbell Collaboration (C2) maintains a large group of

members, reviewers and contributors who undertake systematic reviews in the areas

1 In addition to the book there is also a companion website available at:

http://www.evidence.brookscole.com/index.html

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of crime & justice, social welfare and education. With its emphasis on the

systematic review of randomised control trials in the biomedical arena, the

Cochrane Collaboration may be of less use to social care practitioners;

nonetheless it can provide some useful material with regard to certain topics

such as mental health and health promotion.

Systematic reviews are an extensive and rigorous literature review that focuses

on a single question with the aim of identifying, appraising and summarizing

research studies in order to derive guidelines that can inform practice (Houser

2008). From the practitioners‟ perspective, a systematic review can take a lot of

the drudgery and guesswork out of finding and evaluating a wide range of studies.

The following scenario provides an example of how using a systematic review can

aid evidence based practice.

Scenario: You are a social care worker in a children‟s residential unit. One of

the children (a 13 year old girl) has a history of being sexually abused. In

preparation for her next case review meeting the unit manager has asked that you

investigate possible interventions to be included as part of the forthcoming

discussions.

In addition to your own and co-workers knowledge and experience and some locally

sourced research you are keen to explore the range of available interventions.

Thus you undertake the following search:

1. Access the Campbell Collaboration (C2) website:

http://www.campbellcollaboration.org/index.asp

2. You now have two options (a) access the social welfare tab and click on

side menu for protocols, reviews and related papers and scroll down the

webpage looking for possible suitable reviews or (b)click on the link

for the C2-RIPE‟s Report Generator. This method has the advantage of

doing the search for you providing you give specify the criteria.

3. Through the search a promising review is identified: Cognitive-

behavioural interventions for children who have been sexually abused

(Macdonald et al. 2006). In investigating the efficacy of cognitive

behavioural approaches (CBT) this review synthesises ten studies

involving 847 children into one accessible and comprehensible document.

4. The reviewers note that CBT offers some positive possible outcomes but

that the evidence offered only enable a tentative conclusion to be

drawn.

In reality you would need to undertake a more comprehensive search; nonetheless

this one brief example demonstrates how you as a practitioner can access a wide

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range of well reviewed research material that in turn can be used to inform your

practice.

However, it is very important to note that despite the huge advantages that the

internet presents to the researcher/practitioners, other mediums are and continue

to be of great importance. Books, theses, print journals, conference proceedings

amongst others should also be used as sources of evidence that can inform

practice. Moreover, a systematic and critical approach should be employed

regardless of the source of evidence (Tremblay & Downey 2004).

Practitioners as Researchers

Social care is essentially a practice – based discipline; consequently there

remains the potential difficulty in reconciling the relationship between

empirical scientific knowledge and the knowledge derived from experience and

practice. As previously noted it has been the empirical scientific forms of

knowledge that have taken precedence over experiential practice-based knowledge

(Brechin & Siddell 2000), a model referred to as „technical rationality‟ by

Donald Schon (1983). The philosopher Gilbert Ryle (1963) suggests that it is the

prepositional or „knowing that‟ knowledge that “precedes and informs „knowing

how‟ that we must first learn the theory before applying it to practice” (Rolfe,

et al. 2001: 6). If this is the case then it can be appreciated how the

scientific theories or the „knowing that‟ knowledge came to be seen as having

pre-eminence over experiential „knowing how‟.

The former Director of Research at the Joseph Rowntree Foundation, Janet Lewis

writing in 2001 offers a more balanced view of the knowledge base for social

care:

Knowledge = evidence + practice wisdom + service user and carer experiences and

wishes.

As you can see from this formula there is no hierarchy; knowledge is the equal

combination of all three components: evidence (empirical research), the practice

wisdom or practitioner knowledge and the users and carers experiences and wishes.

Thus, this formula argues that the producers of knowledge and hence evidence are

practitioners as well as researchers. Taking this perspective it is can be argued

that as well as using knowledge to become evidence based practitioners; these

same practitioners can produce knowledge and thus inform others in their

practice.

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Engaging in research is widely accepted as being one of the defining

characteristics of a profession. Tripodi (1974) argued that many of the processes

and skills used in professional practice transfer easily and support the tasks

required to undertake research. For example, in social work, practitioners are

required to make an initial assessment whilst the researcher is required to

formulate a question; the social worker is then required to design an

implementation plan whilst the researcher is required to design a strategy that

will enable the collection of the data and so on. In essence, research and

practice are about applying a methodical approach to solving a problem.

In fact, some of you may have begun the process of becoming research-minded

already, without being necessarily aware of the fact. When starting a research

project where do you begin? Table 4 provides some suggested three entry points

for beginning research (adapted from the Research Mindedness Virtual Learning

Resource 2005):

Table 4

A problem in practice

- an idea to test

A number of social care workers have

reported the effectiveness of Therapeutic

Crisis Intervention (TCI) with children in

residential care longer than two years

appears to markedly drop, why might this be

so?

A gap in the

available data

The child protection team has produced local

guidelines to help indicate whether an

injury to a child might be non-accidental.

However, there appears to be no such

guidelines to draw upon for the elder care

team. Surely such guidelines must exist:

could these be sourced and presented to the

team?

Service Evaluation Your family support unit has introduced

summer camps as a pilot project. Anecdotal

evidence seems to indicate success but you

need to evaluate the effectiveness if you

are to seek continued funding.

Research can involve a large team with plenty of resources and

focussing a large number of people. However, it can focus on one or

two people and be carried out by a lone researcher. Simply because

the focus of a piece of research may be small and may have little

widespread applicability does not mean that undertaking that study is

not worthwhile.

The relationship between research, policy and practice

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Although the need to translate research messages into policy and

practice has been recognised and improved, this tripartite

relationship continues to be complex. Policy makers often want

research messages that are unequivocal and relevant to current and

impending issues.

In Gaffney and Harmon‟s (2007) overview of the proceedings of the

National Economic and Social Forum (NESF) conference on evidence-

based policy making they note that whilst it is not the role of the

research community to design policy; it does have a role to “assist

in the design of policy, evaluation of its effectiveness, and,

perhaps challenging the policymaker … based on the available

evidence” (2007:8). At the same conference, the then Taoiseach Mr.

Bertie Ahern TD noted the importance of an evidenced-based approach

noting that “the better quality information we have, the better

founded our beliefs and working models will be” (Ahern, 2007:13).

A Cautionary Note

Whilst there are apparent benefits to the adoption of an evidence

based practice, it should be noted that there have been a number of

concerns raised. These can be summarised as:

Critics that question the appropriateness and validity of the

scientific or positivist approach to the generation of

evidence

Critics that question the genuineness of the motives behind

the adoption of an evidence based approach, notably if the

move is really about improving services or simply a

managerialist push for efficiencies

Plath (2006 p. 57) argues:

the association of evidence-based practice with a scientific

or positivist paradigm can produce tension for social workers

who recognise the importance of reflective, interpretive and

humanist responses to the personal and social conditions

encountered in practice

This tension can result in the marginalisation of the esoteric and

aesthetic elements of care work such as intuition and reflection as

they cannot easily be reduced to quantifiable measurable constructs

and hence they do not lend themselves easily to positivistic

reductionism.

As previously noted by Williams (2000) one of the arguments for

introducing an EBP approach is that it should bring improved

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resource efficiencies. However, the pursuit of greater efficiencies

can only be carried to a finite limit, agencies need adequate

resources. Adoption of an EPB approach to practice requires an

honest appraisal of a number of issues, not least an agency‟s

ability to implement new regimes or ways of operating. Fundamental

issues such as staff workload, physical resources and staff

qualifications also need to be considered. However attractive it may

be to adopt a more evidenced based approach to practice the mundane

issues also need to be attended to: „EBP will not overcome

structural issues like caseload size‟ (Blome & Steib 2004 p. 612).

Conclusion

A formalised evidence based approach to social care practice remains

largely underdeveloped. Nonetheless it should be acknowledged that

many practitioners are engaged in practice that is informed and

reflective. There is a lot of research available that focuses on the

topics of interest to social care practitioners: childhood,

addiction, intellectual disability and so on. The amount of this

research that constitutes „quality evidence‟ remains debatable.

Social services are by their very nature fluid and dynamic, as such

practitioners need to be mindful of adopting a dogmatic approach.

Sheppard (2004 p. 23) argues that practitioners should be „looking at

information that can help provide guidance, and better-informed

judgements, but not certainty‟ (italics in original). Perhaps the

term research-informed practice might be a more applicable term than

research-based.

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