Evidence-based practices in health care: social work possibilities.

Evidence-based practices in health care: social work possibilities. Within the health care community, discusions abound that includephrases like evidence-based practice, evidence-based research, andevidence-based interventions. Are they buzzwords of the new millenniumor the key to promoting effective outcomes for client-oriented, ethical,and culturally responsive delivery of services? There are varyingfactors undergirding this discourse; explorations of the types ofresearch designs that should result in the "best" evidence;initiatives to highlight and disseminate demonstrated effectiveprograms; and policies that seek to identify evidence-based practicesand promote their use. To what extent are social workers contributing tothis discourse, and to what extent is there sufficient user-friendlyevidence to guide social work practitioners? WHAT IS EVIDENCE-BASED PRACTICE? In reviewing definitions of evidence-based practice, a frequentlycited one is the definition offered by Sackett, identified as the fatherof the evidence-based medicine evidence-based medicineDecision-making 'The use of scientific data to confirm that proposed diagnostic or therapeutic procedures are appropriate in light of their high probability of producing the best and most favorable outcome'.See Meta-analysis. movement in England. He stated thatevidence-based practice is "the conscientious, explicit andjudicious use of current best evidence in making decisions about thecare of the individual patient. It means integrating individual clinicalexpertise with the best available external clinical evidence fromsystematic research" (Sackett, Rosenberg, Muir Gray, Haynes, &Richardson, 1996). The Institute of Medicine (2001) definesevidence-based medicine as the "integration of best researchedevidence and clinical expertise with patient values" (p. 147). Thisevidence-based medicine movement has morphed into a more generic focuson evidence-based practice, and the discussions can now be found in thebroad health and behavioral health arena, as well as in the context ofeducation, criminal justice, and child welfare services. In the social work profession, evidence-based practice (EBP EBP Evidence Based PracticeEBP Enterprise Buyer ProfessionalEBP Education Business PartnershipEBP European Business ProgrammeEBP Efficiency Bandwidth ProductEBP Electronic Billing and PaymentEBP Extended Base PointerEBP Error Back Propagation ) isreceiving increasing attention. Rosen (2003) addressed several basicpremises that support a social work focus on EBP, including commitmentto clients' best interest, values-guided practice, goal-directedpractice, accountability, and commitment to scientific standards ofevidence. Gibbs (2003) suggested that "placing the client'sbenefits first, evidence-based practitioners adopt a process of lifelonglearning that involves continually posing specific questions of directpractical importance to clients, searching objectively and efficientlyfor the current best evidence relative to each question and takingappropriate action guided by evidence" (p. 6). Standard 4.6 of the Educational Policy and Accreditation Standards(Council on Social Work Education The Council on Social Work Education (CSWE) is the national association for social work education in the United States of America.The CSWE sets and maintains standards of courses and accreditation of bachelor's degree's and Master's degree programs in social work. [CSWE CSWE Council on Social Work EducationCSWE Certificate in Spoken and Written EnglishCSWE Center for Student Work Experience ], 2002) states that"[research] content prepares students to develop, use, andeffectively communicate empirically based knowledge, includingevidence-based interventions." In response to this call to useevidence-based interventions, concerns arise that evidence-basedinterventions might be too prescriptive because services will bedeveloped according to guidelines without attention to individual clientneeds. A comprehensive definition of EBP is intended, however, to takeinto account the values, ethics, and individual situation of the client. DEVELOPING EVIDENCE With increased focus on EBP, questions arise about what constitutesevidence. Randomized controlled trials (RCT RCT Randomized Controlled TrialRCT Regimental Combat Team (infantry regiment with their own artillery, engineers, medical and tanks)RCT Rollercoaster TycoonRCT Randomized Clinical TrialRCT Rhondda Cynon Taff ) are seen as the goldstandard of evidence. However, in many areas of social work practice,there may be limited or no randomized controlled trials ofinterventions. Random assignment of individuals to an experimental orcontrol group may not be feasible or ethical. In fact, the evidence baseshould go beyond randomized experiments to include quasi-experimentaldesigns and nonexperimental, clinical, and descriptive studies. McCalland Green (2004) suggested the need to use other research methods tocomplement experimental designs because RCTs may have strong internalvalidity but limited generalizability to real-world situations. In May2004, the National Institutes of Health, the Centers for Disease Controland Prevention Centers for Disease Control and Prevention(CDC), agency of the U.S. Public Health Service since 1973, with headquarters in Atlanta; it was established in 1946 as the Communicable Disease Center. (CDC See Control Data, century date change and Back Orifice. CDC - Control Data Corporation ), and the Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality,n.pr formerly known as the Agency for Health Care Policy and Research, this agency researches the quality of medical care and health services. convened "Research Designs for Complex, Multi-Level Health andProgram Interventions" to look at research strategies beyond randomassignment in RCTs--including those that use random assignment at thegroup or community level, community-based participatory research Community-based participatory research (CBPR) is research that is conducted as an equal partnership between traditionally trained "experts" and members of a community. In CBPR projects, the community participates fully in all aspects of the research process. strategies, and systematic research reviews. The international Campbell Collaboration(www.campbellcollaboration.org) is modeled after the CochraneCollaboration (www.cochrane.org) to develop methodologically rigoroussystematic reviews in education, social welfare, and criminal justice.Social welfare is defined broadly to incorporate substance abuse, mentalhealth, behavioral health, public health, aging and adult protection,income maintenance, employment, housing, child care, and transportation;the development of reviews involves active social work leadership. Thebottom line is the need for more efforts that focus on high-qualityevaluations of programs and intervention studies intervention studies,n.pl the epidemiologic investigations designed to test a hypothesized cause and effect relation by modifying the supposed causal factor(s) in the study population. , using sophisticateddesigns that are replicable in multiple sites and with multiplepopulations. TRANSLATING RESEARCH INTO PRACTICE The President's New Freedom Commission on Mental Health (2003)asserted that "New, relevant research findings must besystematically conveyed to front-line providers so that they can beapplied to practice quickly" (p. 5). Federal agencies are focusedon dissemination, aided by the Internet, to accelerate the translationof research into practice. For example, SAMHSA SAMHSA Substance Abuse and Mental Health Services Administration supports the NationalRegistry of Effective Programs (http://www.modelprograms.samhsa.gov);the CDC has Community Guides (http://www.thecommunityguide.org/) thatdescribe research-based evidence in broad areas of health, includinghome-visiting violence prevention programs and therapeutic foster care;and the National Cancer Institute has launched Cancer Control PLANET(plan, link, act, network with evidence-based tools)(http://cancercontrolplanet.cancer.gov). In the policy arena, the Positive Aging Act of 2004 (S. 2572/H.R.4694), which focused on the mental health needs of older people,proposed "Grants to states for the development and testing of modelmental health delivery systems utilizing evidence-based protocols forthe identification and treatment of mental illness in the elderly"and demonstration projects to "support the integration ofevidence-based mental health services health servicesManaged care The benefits covered under a health contract by geriatric mental healthspecialists in primary care settings" (CSWE, 2004, p. 1). Clearly,this legislative initiative supports the use of evidence-based practice. POSSIBILITIES FOR SOCIAL WORK For the health care social worker, what actions are needed? First,there is a need to recognize that the term evidence-based is omnipresentfor the foreseeable future and second, to ensure that the social workvoice and social work perspective are visible in the development ofevidence, the dissemination of evidence, and the adoption and adaptationof what works. Social work practitioners and clients must be involved indeveloping and testing interventions and supporting high-quality programevaluation focused on both process and outcomes. Social workers alsoneed to be active in organizing the evidence through systematic reviewsand meta-analyses, in developing participatory research efforts, and inarticulating what types of evidence fit best for which types ofproblems. Professional associations, social work education andcontinuing education continuing education:see adult education. continuing educationor adult educationAny form of learning provided for adults. In the U.S. the University of Wisconsin was the first academic institution to offer such programs (1904). programs, and publishers have roles asintermediaries in disseminating what works to practitioners.Dissemination is a somewhat passive process of the transmittal ofinformation. Therefore, more active strategies are needed to get whatworks adopted and adapted in different settings. These strategies canoccur through grant and program incentives, mentoring, cross-settingcollaborations and research--practitioner partnerships, networks, andsponsoring effective program implementation and replication strategies. The articles in this issue examine critical topics related to thedelivery of health and social work services. The research in some ofthese articles describes the collection and analysis of data that movesus closer to achieving evidence-based practice. For instance, byexamining the impact of social work services through the use of controland intervention groups, Ross and colleagues' data suggest thatsocial work intervention with high-risk groups may be effective inreducing inappropriate emergency department utilization and increasingscheduled primary care visits. The results of this study have importantimplications for social work practice. Li, Morrow-Howell, and Proctor examined the effects of post-acuteinformal and formal services on hospital readmission. Although theresearchers found no evidence of service impact, their data indicatedthat hospital readmission was associated with a longer congestive heartfailure congestive heart failure,inability of the heart to expel sufficient blood to keep pace with the metabolic demands of the body. In the healthy individual the heart can tolerate large increases of workload for a considerable length of time. history and noncompliance with medication regimes. Thesefindings confirm the critical nature of medication compliance tohospital readmissions. Using a national survey, Egan and Kadushinexamined job satisfaction and related variables of home health caresocial workers working under the guidelines of the Medicare interimpayment system. The researchers found that in this cost-containmentenvironment, social workers' job satisfaction was affected whenthey were placed in situations in which their professional ethics professional ethics,n the rules governing the conduct, transactions, and relationships within a profession and among its publics.professional ethics liability,n 1. werecompromised. Newhill and Korr examined social worker's attitudestoward working with people with severe mental illness. The findingsindicated that the majority of social workers who participated in theirsurvey provide professional services to individuals with severe mentalillness and find their practice rewarding. Using a qualitative approach,Bent-Goodley examined African American African AmericanMulticulture A person having origins in any of the black racial groups of Africa.See Race. women's perceptions aboutdomestic violence. Her research provides us with a better understandingof domestic violence from the client's perspective, includingbarriers to care. A qualitative study conducted by Sands and colleaguesprovides insight into the custodial status, legal relationships tocaregivers, and living arrangements of children of women with severemental illness. Davey's Practice Forum column descriptively reports on acreative multiple family group intervention for homeless families.Davis's Practice Forum column provides evidence-basedrecommendations on the provision of psychosocial care to women withbreast cancer. To round out this issue, the National Health Line column,by Gorin and Moniz, provides a provocative discussion on universalhealth care coverage. We hope that the articles in this issue stimulatean interest in the topics covered and that readers obtain a heightenedunderstanding of evidence-based practice and the importance of it to theprofession of social work. REFERENCES Council on Social Work Education. (2002). Educational policy andaccreditation standards. Alexandria, VA: Author. Council on Social Work Education. (2004). Positive Aging Act of2004 (S. 2572/H.R. 4694), Summary. Retrieved July 30, 2004, fromwww.cswe.org Gibbs, L. (2003). Evidence-based practice for the helpingprofessions: A practical guide. Pacific Grove, CA: Brooks/Cole. Institute of Medicine. (2001). Crossing the quality chasm: A newhealth system for the 21st century. Washington, DC: National AcademiesPress. McCall, R. B., & Green, B. L. (2004). Beyond the methodologicalgold standards of behavioral research: Considerations for practice andpolicy. Social Policy Report, 18(2). Retrieved July 30, 2004, fromhttps://www.srcd.org/sprrecent.html President's New Freedom Commission on Mental Health. (2003).Achieving the promise: Transforming mental health care in America, Finalreport [DHHS DHHS Department of Health & Human Services (US government)DHHS Dana Hills High School (Dana Point, California)DHHS Deaf and Hard of Hearing ServicesDHHS Deaf and Hard of Hearing Services Publication No. SMA-03-3832]. Rockville, MD: Author. Rosen, A. (2003). Evidence-based social work practice: Challengesand promise. Social Work Research, 27, 197-208. Sackett, D. L., Rosenberg, W.M.C., Muir Gray, J. A., Haynes, R. B.,& Richardson, W. S. (1996). Evidence-based medicine--What it is andwhat it isn't. Retrieved July 30, 2004, fromhttp://www.cebm.net/ebm_is_isnt.asp ABOUT THE EDITORS Joan Levy Zlotnik, PhD, ACSW ACSW Academy of Certified Social WorkersACSW Australasian Computer Science WeekACSW Advisory Council on the Status of WomenACSW Alberta College of Social WorkersACSW Advanced Crew-Served Weapon (US DoD)ACSW Actuaries�� Club of the Southwest , is executive director, Institute forthe Advancement of Social Work Research, NASW NASW National Association of Science WritersNASW National Association of Social Workers (Washington, DC)NASW National Association of Social WorkersNASW National Association for Social Work (UK), 750 First Street, NE,Suite 700, Washington, DC 20002; e-mail: jzlotnik@naswdc.org. ColleenGalambos, PhD, is director, School of Social Work, University ofMissouri-Columbia, 730 Clark Hall, Columbia, MO 65211; e-mail:galambosc@missouri.edu.