Evidence-Based Practices in Health Care: Social Work Possibilities
Zlotnik, Joan Levy, Galambos, Colleen, Health and Social Work
Within the health care community, discusions abound that include phrases like evidence-based practice, evidence-based research, and evidence-based interventions. Are they buzzwords of the new millennium or the key to promoting effective outcomes for client-oriented, ethical, and culturally responsive delivery of services? There are varying factors undergirding this discourse; explorations of the types of research designs that should result in the "best" evidence; initiatives to highlight and disseminate demonstrated effective programs; and policies that seek to identify evidence-based practices and promote their use. To what extent are social workers contributing to this discourse, and to what extent is there sufficient user-friendly evidence to guide social work practitioners?
WHAT IS EVIDENCE-BASED PRACTICE?
In reviewing definitions of evidence-based practice, a frequently cited one is the definition offered by Sackett, identified as the father of the evidence-based medicine movement in England. He stated that evidence-based practice is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research" (Sackett, Rosenberg, Muir Gray, Haynes, & Richardson, 1996). The Institute of Medicine (2001) defines evidence-based medicine as the "integration of best researched evidence and clinical expertise with patient values" (p. 147). This evidence-based medicine movement has morphed into a more generic focus on evidence-based practice, and the discussions can now be found in the broad health and behavioral health arena, as well as in the context of education, criminal justice, and child welfare services.
In the social work profession, evidence-based practice (EBP) is receiving increasing attention. Rosen (2003) addressed several basic premises that support a social work focus on EBP, including commitment to clients' best interest, values-guided practice, goal-directed practice, accountability, and commitment to scientific standards of evidence. Gibbs (2003) suggested that "placing the client's benefits first, evidence-based practitioners adopt a process of lifelong learning that involves continually posing specific questions of direct practical importance to clients, searching objectively and efficiently for the current best evidence relative to each question and taking appropriate action guided by evidence" (p. 6).
Standard 4.6 of the Educational Policy and Accreditation Standards (Council on Social Work Education [CSWE], 2002) states that "[research] content prepares students to develop, use, and effectively communicate empirically based knowledge, including evidence-based interventions." In response to this call to use evidence-based interventions, concerns arise that evidence-based interventions might be too prescriptive because services will be developed according to guidelines without attention to individual client needs. A comprehensive definition of EBP is intended, however, to take into account the values, ethics, and individual situation of the client.
With increased focus on EBP, questions arise about what constitutes evidence. Randomized controlled trials (RCT) are seen as the gold standard of evidence. However, in many areas of social work practice, there may be limited or no randomized controlled trials of interventions. Random assignment of individuals to an experimental or control group may not be feasible or ethical. In fact, the evidence base should go beyond randomized experiments to include quasi-experimental designs and nonexperimental, clinical, and descriptive studies. McCall and Green (2004) suggested the need to use other research methods to complement experimental designs because RCTs may have strong internal validity but limited generalizability to real-world situations. …