||This page offers
a starting point for finding information on Evidence Based Practice [EBP].
There are many definitions of EBP with differing emphases. A survey of social work faculty even showed they have different ideas about just what makes up EBP (This can be a source of confusion for students and newcomers to this topic of study. Perhaps the best known is Sackett et al's (1996, 71-72) now dated definition from evidence based medicine: "Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice. Increased expertise is reflected in many ways, but especially in more effective and efficient diagnosis and in the more thoughtful identification and compassionate use of individual patients' predicaments, rights, and preferences in making clinical decisions about their care. By best available external clinical evidence we mean clinically relevant research, often from the basic sciences of medicine, but especially from patient centered clinical research into the accuracy and precision of diagnostic tests (including the clinical examination), the power of prognostic markers, and the efficacy and safety of therapeutic, rehabilitative, and preventive regimens."
This early definition, however, proved to have some important limitations in practice. Haynes et al (2002) - Sackett's colleagues in the McMaster Group of physicians in Canada - pointed out the definition did not pay enough attention to the traditional determinants of clinical decisions. That is, it purposefully emphasized research knowledge but did not equally emphasize the client's needs and situation, nor the client's stated wishes and goals, nor the clinicians' expertise in assessing and integrating all these elements into a plan of intervention.
The contemporary definition of EBP is simply "the integration of the best research evidence with clinical expertise and patient values" (Sackett, et al. 2000, p. x). This simpler, current, definition gives equal emphasis to 1) the patient's situation, 2) the patient's goals, values and wishes, 3) the best available research evidence, and 4) the clinical expertise of the practitioner. The difference is that a patient may refuse interventions with strong research support due to differences in beliefs and values. Similarly, the clinician may be aware of factors in the situation (co-occurring disorders, lack of resources, lack of funding, etc.) that indicate interventions with the best research support may not be practical to offer. The clinician may also notice that the best research was done on a population different from the current client, making its relevance questionable, even though its rigor is strong. Such differences may include age, medical conditions, gender, race or culture and many others.
This contemporary definition of EBP has been endorsed by many social workers. Gibbs and Gambrill (2002), Mullen and Shlonsky (2004, Rubin (2008), and Drisko and Grady (2012) all apply it in their publications. Social workers often add emphasis to client values and views as a key part of intervention planning. Many social workers also argue that clients should be active participants in intervention planning, not merely recipient's of a summary of "what works" from an "expert" (Drisko & Grady, 2012) Actively involving clients in intervention planning may also be a useful way to enhancing client motivation and to empower clients.
Some in social work view EBP as a mix of a) learning what treatments "work" based on the best available research (whether experiential or not), b) discussing client views about the treatment to consider cultural and other differences, and to honor client self determination and autonomy, c) considering the professionals "clinical wisdom" based on work with similar and dissimilar cases that may provide a context for understanding the research evidence, and d) considering what the professional can, and can not, provide fully and ethically (Gambrill, 2003; Gilgun, 2005). With much similarity but some differences, the American Psychological Association (2006, p. 273) defines EBP as "the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences." Gilgun (2005) notes that while research is widely discussed, the meanings of "clinical expertise" and "client values and preferences" have not been widely discussed and have no common definition.
Drisko & Grady (2012) argue that the EBP practice decision making process defined by Sackett and colleagues seems to fit poorly with the way health care payers enact EBP at a macro, policy, level. Clinical social workers point to list of approved treatments that will be funded for specific disorders - and note this application of EBP does not include specific client values and preferences and ignores situational clinical expertise. Drisko & Grady point out that there is a conflict between the EBP model and how it is implemented administratively to save costs in health care. While cost savings are very important, this use of "EBP" is not consistent with the Sackett model. Further, the criteria used to develop lists of approved treatments is generally not clear or transparent - or even stated. Payers very often appear to apply standards that are different from multidisciplinary sources of systematic reviews of research like the Cochrane Collaboration. Clinical expertise and client values too often drop out of the administrative applications of EBP.
Evidence based practice is one useful approach to improving the impact of practice in medicine, psychology, social work, nursing and allied fields. Of course, professions have directed considerable attention to "evidence" for many years (if not for as long as they have existed!). They have also honored many different kinds of evidence. EBP advocates put particular emphasis on the results of large-scale experimental comparisons to document the efficacy of treatments against untreated control groups, against other treatments, or both. (See, for example, the University of Oxford's Hierarchy of Evidence for EBM). They do this because well conceptualized and completed experiments (also called RCTs) are a great way to show a treatment caused a specific change. The ability to make cause and effect determinations is the great strength of experiments. Note that this frames "evidence" in a very specific and delimited manner. Scholars in social work and other professions have argued for "Many Ways of Knowing" (Hartman, 1990). They seek to honor the knowledge developed by many different kinds of research - and to remind clinicians, researchers and the public that the conceptualization underlying research may be too narrow and limited. Thus Drisko & Grady (2012) argue that EBP, as summarized by researchers, may devalue non-experimental research. Experiments are only as good as the exploratory research that discovers new concepts, and the descriptive research that helps in the development of tests and measures. Only emphasizing experiments ignores the very premises on which they rest. Finally, note that EBM/EBP hierarchies of research evidence include many non-experimental forms of research since experiments for some populations may be unethical or impractical - or simply don't address the kinds of knowledge needed in practice.
All the "underpinnings" of experimental research: the quality of conceptualizations, the quality of measures, the clarity and specificity of treatments used, the quality of samples studied and of the quality and completeness of collected data are assumed to be sound and fully adequate when used to determine "what works." There is also an assumption that the questions framing the research allow for critical perspectives and are fully ethical. Social workers would argue they should also include social diversity samples well - since diverse kinds of people show up at real world clinics. International standards affirm basic ethical principles supporting respect for persons, beneficence and social justice (see The Belmont Report.)
Is EBP only about Intervention or Treatment Planning?
No. This may be the most common application of EBP for clinical social workers, but the EBP process can also be applied to a) making choices about diagnostic tests and protocols to insure thorough and accurate diagnosis), b) selecting preventive or harm-reduction interventions or programs, c) determining the etiology of a disorder or illness, d) determining the course or progression of a disorder or illness, e) determining the prevalence of symptoms as part of establishing or refining diagnostic criteria, f) completing economic decision-making about medical and social service programs (University of Oxford Centre for Evidence-based Medicine, 2011), and even g) understanding how a client experiences a problem or disorder (Rubin, 2008).
EBP is also not the same as defining empirically supported treatments (ESTs), empirically supported interventions (ESIs), or 'best practices.' These are different ideas and are based on different models. These models don't include client values and preferences nor clinical expertise as EBP does.
EBP as a Social Movement
While EBP is most often described in terms of a practice decision-making process, it is also useful to think of it as a much larger social movement. Drisko and Grady (2012) argue that at a macro-level, EBP is actively used by policy makers to shape service delivery and funding. At a messo- level, EBP is impacting the kinds of interventions that agencies offer, and even shaping how supervision is done. Drisko and Grady (2012) also argue that EBP is establishing a hierarchy of research evidence that is privileging experimental research over other ways of knowing. Experimental evidence has many merits, but is not the only way of knowing of use and importance in social work practice. Finally, the impact of EBP may alter how both practice and research courses are taught in social work. There are other aspects of EBP beyond the core practice decision-making process that are re-shaping social work practice, social work education, and our clients' lives. As such, it may be viewed as a public idea or a social movement at a macro level.
Why Evidence Based Practice or EBP?
It is one step toward making sure each client gets the best service possible.
Some argue it helps keep your knowledge up to date, supplements clinical judgment, can save time and most important can improve care and even save lives. Its a way to balance your own views with large scale research evidence.
Some say it's unethical to use treatments that aren't known to work. (Of course, services may need to be so individualized in unique circumstances that so that knowing "what works" in general may not be the most salient factor in helping any particular client. Still, using the best available research knowledge is always beneficial.)
Several web sites serve as portals to bodies of research useful to EBP. The focus on these organizations varies, but the emphasis remains on (mainly) experimental demonstration of the efficacy of treatments.
How is EBP Implemented in Practice?
Profiling research that informs professionals and clients about what works is where evidence based practice starts. These summaries tells us what we know about treatment and program efficacy based on experimental work - as well as what we don't know or aren't really sure about.
Having access to information on what works allows professionals, in conjunction with clients, to select treatments that are most likely to be helpful (and least likely to be harmful) before intervention is begun. Practice evaluation is quite different in that takes place at the start of treatment, during treatment and after treatment. Practice evaluation also uses single case methods rather than large sample, experimental research designs. EBP and practice evaluation work together very well, but they have different purposes and use very different methods.
The creation of "User's Guides" is one way to make the results of research more available to practitioners. In medicine, the idea is to get research results to the practitioner in an easy to assimilate fashion, though this often has a price.
Funding is being offered to support EBP from governments and private/insurance sources.
However, to understand and critically appraise this material, a lot of methodological knowledge is needed. Sites offering introductions to the technology of EBP are growing.
How is EBP Taught?
There are some useful resources for Teaching and Learning about EBP. One fine example is offered by Middlesex University in the United Kingdom which includes good information on critical appraisal of information in EBP.
The Major Sources of Research for use in EBP:
The Cochrane Collaboration [ www.cochrane.org ] sets standards for reviews of medical, health and mental health treatments and offers "systematic reviews" of related research by disorder. The Cochrane Reviews offer a summary of international published and sometimes pre-publication research. Cochrane also offers Methodological Abstracts to orient researchers and research consumers alike.
The Campbell Collaboration [ www.campbellcollaboration.org ] offers review of the impact of social service programs. "The Campbell Collaboration (C2) is an organization that aims to help people make well-informed decisions about the effects of interventions in the social, behavioral and educational arenas. C2's objectives are to prepare, maintain and disseminate systematic reviews of studies of interventions. C2 acquires and promotes access to information about trials of interventions. C2 builds summaries and electronic brochures of reviews and reports of trials for policy makers, practitioners, researchers and the public."
The United States government also offers treatment guidelines based on EBP principles at the National Guideline Clearinghouse. [ http://www.guideline.gov/ ] This site includes very good information on medication as wll as very clear statements of concern about medications indicated in guidelines which later prove to have limitations.
The U.S. government provides information on ongoing,
government sponsored, clinical trials.
Other Online Resources for EBP and Treatment Guidelines Derived from EBP Criteria and Procedures:
The American Psychiatric Association offers Practices Guidelines. Please be aware that the numbers of practice guidelines are few. Existing guidelines may be up to 50 pages in length. If you are not allowed to enter via this hyperlink, paste the following URL into your browser: http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm
The Agency for Healthcare Research and Quality also offers outcome research information. AHRQ offers an alphabetical listing out outcome studies.
Note that there are a growing number of commercial [.com] sites that offer their consultation regarding EBP. It is not always easy to determine their organization structure and purposes, the basis of their recommendations and any potential conflicts of interest. In this regard, the sites of the government and of professional organizations are "better" resources as their purposes, missions and funding sources are generally more clear and publicly stated.
American Psychological Association. (2006). APA presidential task force on evidence based practice. Washington, DC: Author
Dobson, K., & Craig, K. (1998). Empirically supported therapies: Best practice in professional psychology. Thousand Oaks, CA: Sage.
Drisko, J. & Grady, M. (2012). Evidence-based practice in clinical social work. New York: Springer-Verlag.
Elwood, J.M. (2007). Critical appraisal of epidemiological studies and clinical trials (3rd ed.) New York: Oxford University Press.
Gambrill, E. (2003). Evidence-based practice: Implications for knowledge development and use in social work. In A. Rosen & E. Proctor (Eds.), Developing practice guidelines for social work intervention (pp. 37-58). New York: Columbia University Press.
Gibbs, L. (2003). Evidence-based practice for the helping professions. New York: Wadsworth.
Gilgun, J. (2005). The four cornerstones of qualitative research. Qualitative Health Research, 16(3), 436-443.
Howard, M., McMillen, C., & Pollio, D. (2003). Teaching evidence-based practice: Toward a new paradigm for social work education. Research on Social Work Practice, 13, 234-259.
Mace, C., Moorey, S., & Roberts, B. (Eds.). (2001). Evidence in the psychological therapies: A critical guide for practitioners. Philadelphia, PA: Taylor & Francis.
Mantzoukas, S. (2008). A review of evidence-based practice, nursing research and reflection: Levelling the hierarchy. Journal of Clinical Nursing, 17(2), 214-223.
Roberts, A., & Yeager, K. (Eds.). (2004). Evidence-based practice manual: Research and outcome measures in health and human services. New York: Oxford University Press.
Sackett, D., Rosenberg, W., Muir Gray, J., Haynes, R. Richardson, W. (1996). Evidencebased medicine: what it is and what it isn't. British Medical Journal, 312, 71-72. http://cebm.jr2.ox.ac.uk/ebmisisnt.html
Sackett, D., Richardson, W., Rosenberg, W., & Haynes, R. (1997). Evidence-based medicine: How to practice and teach EBM. New York: Churchill Livingstone.
Simpson, G., Segall, A., & Williams, J. (2007). Social work education and clinical learning: Reply to Goldstein and Thyer. Clinical Social Work Journal, (35), 33-36.
Smith, S., Daunic, A., & taylor, G. (2007). Treatment fidelity in applied educational research: Expanding the adoption and application of measures to ensure evidence-based practice. Education & Treatment of Children, 30(4), pp. 121-134.
Stout, C., & Hayes, R. (Eds.). (2005). The evidence-based practice: Methods, models, and tools for mental health professionals. Hoboken, NJ: Wiley.
Stuart, R., & Lilienfeld, S. (2007). The evidence missing from evidence-based practice. American Psychologist, 62(6), pp. 615-616.
Trinder, L., & Reynolds, S. (2000). Evidence-based practice: A critical appraisal. New York: Blackwell.
Wampold, B. (2007). Psychotherapy: The humanistic (and effective) treatment. American Psychologist, 62(8), pp. 857-873.
text copyright by J. Drisko - page begun 3/11/04; updated 9/24/12