Implementing Evidence-based Practice (EBP) in Social Work: A Pilot Study

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Implementing Evidence-based Practice (EBP) in
Social Work A Pilot Study

• Edward J Mullen
• Jennifer Bellamy
• Sarah Bledsoe
• Columbia University Musher Center
• Supported in part by National Institute of Health
  Doctoral Training Program in Mental Health
  Services Research 5 T32 MH14623-24/25
• the Willma Albert Musher Center at Columbia
  University

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Pilot Study

• Pilot study aim
• to design, test refine a strategy for
  implementing EBP in social work agencies
• Uses a social intervention research methodology
• Multi-site to permit comparison
• Conducted
• with support of the Columbia University Musher
  Center
• in collaboration with the National Institute of
  Mental Health/Columbia University School of
  Social Work Pre-doctoral Training Program in
  Mental Health Services Research (5 T32
  MH14623-24/25)

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Main Research Question

• We want to learn how social work organizations
  practitioners can be engaged helped to adopt
  implement evidence-based practice

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Social Intervention Research Design Phase 1

• Review literature pertaining what is known about
  dissemination implementation strategies
  targeting EBP in social work
• Talk to experienced researchers who have studied
  EBP and implementation of EBP to get their
  insights experiences
• Talk to agency administrators to explore interest
  in partnering
• Talk to practitioners to find out what would
  motivate them to do EBP, how they would like to
  learn EBP, perceived barriers to EBP

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Social Intervention Research Design Phase 2

• Select one or more agencies as partners in the
  pilot study
• Design the pilot study with the agency
  representatives so as to
• use the information gained in step 1
• shape the intervention to the context of the
  specific agency
• Secure funding for implementation of the pilot
  intervention
• Apply for Institutional Review Board Approval

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Social Intervention Research Design Phase 3

• Implement the intervention
• Monitor implementation
• Modify intervention during implementation as
  experience dictates
• Evaluate process outcomes

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Social Intervention Research Design Phase 4

• Use the information coming from the evaluation to
  redesign the implementation strategy the
  evaluation design
• Report experiences and findings
• Consider new pilot or larger field test if the
  strategy merits

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Immediate Question

• What strategy is most effective to achieve
  enduring, effective, efficient implementation
  of EBP in a social work agency?
• What are the options?
• The phase 1 literature review and interviews with
  EBP researchers were designed to help answer
  these questions

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Results of Literature Review Interviews
Reported

• Bellamy, J. L., Traube, D. E., Bledsoe, S. E.
  (2004). Strategies and barriers in sharing
  knowledge Caring for clients through methods of
  best practice. Unpublished manuscript, Quebec
  City, 4th International Conference on Social Work
  in Health and Mental Health
• Bellamy, J., Bledsoe, S. E., Traube, D. (in
  press). The current state of evidence based
  practice in social work a review of the
  literature and qualitative analysis of expert
  interviews. Journal of Evidence-Based Social Work

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Interviews

• To provide a comprehensive and unified approach
  to EBP social work should
• Network and share resources between agencies and
  practitioners
• Increase buy-in and ownership at all levels of
  stakeholders
• Provide more and higher quality continuing
  education
• Translate research into user-friendly,
  digestible, and specific approaches
• Provide tools such as toolkits, guidelines, and
  technical support to both support
• Attach evidence based practices to meaningful
  signposts
• Protect caseworker, team, or supervisor time for
  research, development, and training toward EBPs

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Literature Review

• Search of electronic databases
• Social Work Abstracts
• PsychLit
• MedLine
• Research Unit for Research Utilization (RURU)
• Major topics
• barriers to the process of using evidence/EBP
• frameworks strategies for dissemination
  implementation of research/EBP

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Barriers to Implementation

• Lack of Knowledge Skills for EBP
• Lack of Knowledge Fit to Agency Practice
• Suspicion of Researchers EBP
• Limited Resource for Doing EBP

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Lack of Knowledge Skills for EBP

• General lack of awareness of available evidence
  based practices and the difficulty in processing
  or understanding identified research
• How to best access, evaluate, and translate
  evidence (Anderson, Cosby, Swan, Moore,
  Broekhoven, 1999 Mullen Bacon, In press).
• Misunderstanding of what constitutes an evidence
  based practice such as (Gibbs Gambrill, 2002)
• Were already using evidence
• Its a matter of opinion
• There is no evidence

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Lack of Knowledge Fit to Needs of Agency Practice

• Evidence or research that is available or
  accessible is not often particularly helpful
• Cookbook/stilted approaches
• Overly broad
• Ignores contextual or cultural issues
• Not realistic in practice
• Mismatch with current policy and technology
• The culture of knowledge transmission within
  social work has been historically unsupportive of
  the use of research evidence in practice
• (Barratt, 2003 Anderson, Cosby, Swan, Moore,
  Broekhoven, 1999 Gibbs Gambrill, 2002 ).

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Suspicion of Researchers EBP

• Basic distrust for evidence, based on objections
  related to political, ethical, or control issues
• Politically motivated, guided by efficiency,
  researcher preferences, or simply a cost-cutting
  tool (something other than clients best
  interest)
• Devalues the practitioners professional judgment
  or clients preferences
• Trendy, more about research reputations, and
  malleable evidence
• (Gibbs Gambrill, 2002 Mullen Bacon, 2003)

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Limited Resource for Doing EBP

• Even for those practitioners and agencies that
  understand, appreciate, and want to use evidence
  in their work they may find themselves incapable
  due to a lack of resources including
• Lack of training, materials, time and staff
  dedicated to researching the evidence
• Poor technology resources (computers and internet
  access)
• Inconsistent funding routed everywhere else first
• (Anderson, Cosby, Swan, Moore, Broekhoven,
  1999 Barratt, 2003 Mullen Bacon, 2003)

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Current Strategies for EBP Implementation

• Bottom-up
• Teaching professionals to be evidence-based,
  lifetime learners (Sackett, 2000 Gibbs
  Gambrill, 2002 Gibbs, 2003 Gray, 2001)
• Top-down
• Tool kits/application kits/manuals/guidelines
  (Mueser, Torrey, Lynde, Singer and Drake, 2003)
• Top-down/bottom-up
• Combining evidence consensus (Cook, 2004)
• Combine focus on practitioner training
  organizational development
• Interactive staff training (McCracken Corrigan,
  2004)
• Outcomes objectives orientation (Rosen,
  Proctor, Morrow-Howell, Auslander, Staudt,
  1993)
• Targeting the Social Work Profession
• Objectives-Focused Multilevel Strategy (Proctor,
  2004)

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1. Bottom-upTeaching Professionals to be
Evidence-based, Lifetime Learners

• Oldest approach to disseminating implementing
  EBP
• Focus on teaching students practitioners
  evidence-based processes so they can be lifetime
  learners
• Clinical learning strategy developed at McMaster
  Medical School, Canada - 1980s, 1991 1992
• Adapted in healthcare (Gray, 2001) social work
  (Gibbs Gambrill, 2002)

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What is Taught?

• Motivation for EBP
• How to convert information need into a search
  question
• Evidence search tools
• Evidence appraisal skills
• Information integration skills (next slide)
• Self-evaluation
• Teaching EBP

Gibbs, 2003
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Integration Skills What Needs Integrating?
Haynes, Devereaux, and Guyatt, 2002
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Evidence-based Healthcare ProcessesAdapted from
J A Muir Gray (2001)
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Individuals OrganizationsAdapted from Gray,
p.xxii
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2. Top DownTool kits/application
kits/manuals/guidelines

• Identify evidence-based, empirically supported
  practices
• Develop tool/application kits/manuals/guidelines
• Engage in broad scale effort to disseminate
  facilitate local adoption by supporting training
  working with stakeholders
• Example
• Implementing Evidence-Based Practice Project
  (Mueser, Torrey, Lynde, Singer Drake, 2003)
• Goal to promote widespread adoption of 6 EBPs
  for mentally ill adults

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3. Top-down/Bottom-upCombining EBP with
Community Stakeholder Consensus

• Attempts to deal with
• gaps in empirically-based knowledge about
  effective interventions
• unevenness of knowledge about implementation
• need to involve community stakeholders in
  decision-making especially in the context of
  limited resources
• need to adapt knowledge to local conditions
• Example
• Texas Benefit Design Initiative (Cook, 2004)
• review evidence re effectiveness implementation
  needs
• present evidence to community stakeholder
  consensus groups at state level form
  recommendations
• present evidence and recommendations to local
  consensus groups for implementation planning

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Texas Benefit Design Initiative (Cook, 2004)

• Goal
• Combine best evidence with community consensus in
  designing psychosocial rehabilitation services
  using public mental health services
• Steps
• Experts reviewed evidence presented findings at
  consensus conference which included over 200
  citizens from around Texas
• Consensus panel formulated service package
  principles recommendations for service
  organization implementation
• Panels included stakeholder representatives from
  consumer family organizations, service
  providers, advocates, state level administrators,
  researchers, other interested parties
• Second level consensus meetings were held in each
  of the pilot sites to design specific benefit
  package for local application

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4.1 Combine Staff Training Organizational
DevelopmentInteractive Staff Training

• Interaction of educational organizational
  approaches
• Educational approach based on learning theory
• designed to help individual practitioners acquire
  EBP principles skills
• Organizational approaches teach individual staff
  members how to work as a team to develop EB
  treatment programs that are user-friendly meet
  consumer needs
• Guidelines for disseminating adopting
  evidence-based practice innovations
• Engage prepare organization
• Engage form working alliance with treatment
  team
• Develop a user friendly program based on
  identified program-development priorities the
  innovation
• Use established educational principles in
  training
• Stepwise implementation of program
• Plan for maintenance
• (McCracken Corrigan, 2004)

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4.2 Combine Staff Training Organizational
Development Outcomes Objectives Orientation

• Combines attention to
• practitioner training
• trained to use critical-thinking process
  (Systematic Planned Practice) specifying
• client problem to be addressed
• outcomes sought
• intermediate objectives needed to attain these
  outcomes
• self-evaluation skills
• practitioners prepared to critically
  selectively use evidence-based practices
  guidelines made available to them by organization
• organizational support
• organizational barriers to EBP identified
• organizational supports needed are identified
• barriers supports addressed in implementation
  strategy
• Rosen, Proctor, Morrow-Howell, Auslander,
  Staudt, 1993

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5. Professional Infrastructure as Agent
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Interventions Required for these Four
Intermediate Objectives

• Interventions specific to practice
  infrastructure
• research
• training
• organizational culture
• Based on theories research about
• diffusion of innovations
• knowledge utilization
• quality improvement
• Prochaska Di Clementes stages of change model

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Gira, Kessler and Poertner (2004)

• The literature from health care suggests that
  disseminating information alone is insufficient.
  Many interventions have been designed to improve
  practitioners adherence to EBP guidelines and
  are differentially effective. To date, no
  intervention has demonstrated powerful effects.
  (p. 77-78)
• They speculate that multiple strategies are
  needed rather than relying on any single
  intervention.

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Selection of a Strategy for Use in Our Study

• Review key findings from the literature regarding
  barriers to and strategies for implementation of
  EBP with agency teams
• Together with the agency partners select a
  best-fit strategy or a modified strategy that
  emerges from the discussions

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Selection of Partner Agencies

• Three New York City agencies have elected to join
  the project are collaborating with university
  researchers on the initial stages of the pilot
  design.
• Two have programs delivered in a wide range of
  geographical and problem areas. They are among
  the largest voluntary social agencies in the
  City. The third agency is neighborhood based,
  small informal. It too has a reputation of
  excellence, professionalism, and innovation.
• All are known for excellence the highest level
  of professionalism.
• Two have considerable resources the third has
  modest resources.

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Initial Meetings with Agencies

• Agency-university relationship
• -focus on partnership
• -respect for agency perspectives and
  practitioner wisdom
• -mixed reaction to unconventional research
• Evidence based practice in the agencies
• -unfamiliar term
• -teams

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Initial Meetings with Agencies

• Problem formulation
• -large agencies with diverse programs
• -continual narrowing of focus
• -process vs. outcome interest
• Team building
• -creative, innovative, or change oriented staff
• -midlevel administrator interest

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Initial Meetings with Agencies

• Resources
• -computers
• -time and scheduling
• Agencies want trainings in EBP, but not to be
  told how to practice
• Suspicion
• Varying levels of expertise and education

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Next Steps

• Refining focus of questions/issue areas
• Meeting with direct service staff
• Building teams
• Focus groups/trainings
• Search for funding
• Implementation
• Evaluate/revise
• Share findings

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Concluding Note

• We have learned a great deal during this past
  year from the literature review, the interviews
  with EBP experts, and, from our agency partners.
  Evidence-based practice is a new innovation for
  social work. There are many challenges and
  unknowns, especially pertaining to implementation
  in complex social work programs serving
  populations that have many needs and problems. We
  look forward to exploring these challenges with
  our agency partners and those they serve in the
  year ahead.

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References