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Revista de asisten]\ social\ nr. 1_2010

Mariana Oancea

The Evidence of Evidence-Based Social Work

Mariana Oancea* Direcia General de Asisten Social i Protecia Copilului, Sector 1, Bucureti
Abstract: The article will define terms and critical issues in evidence-based medicine, introducing professionals to the language and importance of evidence-based practice and critical thinking. It will explain how to search for and evaluate evidence, how to ask the right questions, how to develop standards, and how to make use of the best research. It will also illustrate some practical applications in social work: obstacles and solutions. Such information can be used by students and professionals within the process and practice of evidence-based social work, teaching them to be critical thinkers and judicious decision-makers. It helps practitioners to better serve their clients, making this an excellent foundation for the study and practice of evidence-based social work. Its final aim is to ask ourselves some questions: Are we helping? Who are we helping and how? Are we harming? Who are we harming and how? How can we find out? Are practice and policy decisions well reasoned and informed by available research? Are clients involved as informed participants? Keywords: social work, evidence-based social work, social-work practice, research practice

Introduction
In everyday life people have to make decisions about their life and it is not always an easy thing to do. In order to make a good decision, someone must know himself/herself very well, must know his/her possibilities and limits. The most difficult task, however, is to decide for someone else. The responsibilities are bigger and there are other factors, which might come in between and change the course of the intervention and, consequently, its effects. It is a saying that the road to hell is paved with good intentions, i.e. very often peoples intentions are good but they see the person from their point of view and they are doing what they consider being good for that person and dont take into consideration the very desires of that person. What is good for someone isnt necessarily good for everybody. A good way of taking decisions would be searching for some evidence that what we are doing is actually good. Professionals grow to be aware of the implications of their actions upon clients live hence, attending to evidentiary, ethical and application issues become important for them as well as becoming skilled in critical appraising the practice and policy
* ef Birou Prevenire Violena n Familie, Direcia General de Asisten Social i Protecia Copilului, sector 1, Bucureti, e-mail: bobocmariana@yahoo.co.uk.

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related literature. During daily practice, they came across gaps between obligations described in their professional codes of ethics and different issues that occurred in their work and, as a consequence, professionals discovered limitations in traditional methods of knowledge dissemination and traditional professional education system. In the same time, professionals feel the need to know what has been done in the field up to this moment and to what effect. With the purpose of finding the best solutions to clients problems, a new component has to intervene in decision-making process, that of client values, as they are involved as informed participants. Being aware of these problems, all along their work, practitioners should generate knowledge that should help policy makers in developing an integrated system of social services designed on clients unique circumstances and characteristics and not an authority-based one. The problem thus becomes: where and how are we to look for the evidence? Consequently, we must discover what is now available, when it was first mentioned and in what context, how accurately it is described in the professional and academic literature, what critical tests were performed if any and with what results and which aspects of research findings were implemented so far. All these searches were made possible due to web revolution, the creation of a technology designed to decrease gaps among evidentiary, ethical and application issues and the promotion of client involvement and informed choice. Evidence-based medicine tried to answer to these questions and has established some principles, which can guide the evidence-based practice that, according to Reynolds (2000, 17), is a more suited concept for the interdisciplinary application of evidence-based medicine.

Short History
In recent years the scientific body of knowledge concerning social work practice has grown, as well as its accessibility for practitioners due to the availability of electronic bibliographic databases and increased acceptance of systematic reviews and evidence-based practice guidelines. This knowledge conducted to new forms of practice, social work becoming not only a profession but also a science. The rise of the evidence-based practice movement provides the field with a wonderful opportunity to dramatically increase the extent to which professional activities in the realms of policy and practice can be more solidly grounded in scientific research (Thyer, 2008). Earl Muir Gray (2001) suggests that the evidence-based medicine and mostly its philosophy emerged as a consequence of too many variations in service delivery and clinical practice, too many gaps showing that professionals were not acting systematically or promptly on research findings, of the failure to start services that did more good than harm at reasonable cost, failure to stop services shown to be little value and economics pressure. There was a knowledge revolution as well, consisting in increased recognition of harmful side-effects of medicine and health care, flaws in traditional modes of dissemination such as books, editorials and articles, the evolution of the systematic review and web-based updates (Gambrill, 2003). In the same time, medicine care needed a change in a sense that clinicians had to break down the gap between research and practice, to use their judgement and scientific training to interpret and integrate guidelines and to incorporate client values. These problems became surmountable by clinicians due to new strategies to efficiently tracking down and appraise evidence. A big step was the creation of an information system consisting in systematic reviews of health care effects, put together by Cochrane Collaboration, system that easily brings to us the best evidence. The emergence of evidence-based medicine journals was also very important, and it determined professionals to improve their strategies to lifelong learning.

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If in medicine things are more advanced, in social work we have limited knowledge about the prevalence of a problem, the variability of problem-related behaviours, the causes of social crisis and methods that are most effective in attaining given outcomes. I believe that the danger of failing in our profession if not using evidence-based practice principles resides in making a problem too simple, in not seeing the whole picture. As a consequence, professionals tend to see different entities as more similar that they actually are, treat dynamic phenomena as static, assume that a general principle accounts for all phenomena, treat multidimensional phenomena as unidimensional and treat highly interconnected concepts as separable (Feltovich et al., 1993). Evidence-based practice is an interactive process also characterized by the fact that the client has the possibility to inform himself about his problem and about the possible solutions. According to evidence, he can choose to proceed or not with an intervention. The limitations of the traditional forms of knowledge lead to a necessity of using evidence-based practice in our work.

Definitions
What is evidence-based medicine? Some authors state that evidence based-medicine has its origins in 19th century medical practice and, according to Greenhalgh (2001, 1), is the enhancement of a clinicians traditional skills in diagnosis, treatment, prevention and related areas through the systematic framing of relevant and answerable questions and the use of mathematical estimates of probability and risk. In other words, evidence-based medicine means the sum of all information one can find when searching for a particular answer of a well-built question. Therefore, it is a process of research based on different methods of finding the information you need, analysing it and taking the good decision for the problems you are dealing with. A definition of evidence-based practice that is used in medicine and health care is given by Sackett et al. (1996, 71), as follows 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. Another definition is given also by Sackett et al. (2000): Evidence-based medicine is the integration of the best research evidence with clinical expertise and patient values. Talking about clinical expertise and client values, Haynes et al. (2000, 6) indicate that individual helpers should use their relationship skills and experience to rapidly identify each client unique circumstances, characteristics and their individual risks and benefits of potential interventions and their personal values and expectations. The essence of evidence-based practice is described by Gibbs (2003, 5) as follows: Placing the clients benefit 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. We can see that one of the characteristics of evidence-based practice and policy is to create and use technologies to pursue desired goals, characteristic that make the difference from empirical social work. Empirical social work practice fails to attend technological problems in a systemic manner; technological problems were ignored and minimized in an unrealistic manner (Gambrill, 2003).

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Using evidence-based practice principles and technologies, practitioners are better endowed to fight practice-related obstacles. Oxman and Flottorp (1998) consider obstacles related to: standards of practice: fears about practicing differently from others in the community may inhibit adoption of new effective forms of service or promote the continued use of services that may not be effective or maybe harmful; opinion leaders: local opinion leaders may encourage use of services found to be ineffective or which are untested or may discourage the use of effective services; professional training: ineffective or harmful practices may be used because of the influence of what helpers learned in educational programs; advocacy: made by institutions who actively promote and disseminate programs of unknown effectiveness or those found to be ineffective or harmful. In order to overcome these obstacles, we need to know what evidence-based practice is.

Philosophy
One of the professionals that took interest and made a contribution to the evidence-basedpractice movement is Eileen Gambrill, Hutto Patterson Professor of Child and Family Studies at the School of Social Welfare, University of California at Berkeley. She is keen on showing students and social work professionals how to ask the right questions, search for reliable answers, and rigorously evaluate the results. All through her work, Eileen Gambrill tried to equip students with practical abilities and knowledge as to better understand the larger picture in which social workers practice, a picture that considers solving the client problems by utilizing his/her own resources and taking into account the economic, political, social, and ethical aspects. Learning from Gambrills work, future social work practitioners will become better advocates for their clients and better informed decision makers. Gambrill (2001) points out that evidence-based decision-making arose in medicine and health care as an alternative to authority-based practice in which decisions are based on criteria such as consensus, anecdotal experience or tradition. According to Gambrill (2003), there are interrelated hallmarks and contributions of evidence-based decision-making such as: 1. Moving away from authority-based practices and policies, evidence-based decision-making process describes gaps among evidentiary, ethical and practical concerns, describes limitations of research, proposes well-argued alternative views and evidence against favored views and avoids questionable criteria for making decisions such as status, popularity, and tradition. 2. Evidence-based decision-making philosophy includes some ethical obligations focusing on client concerns and desired outcomes, attending to individual differences in client circumstances and characteristics including client values and preferences, involving clients as informed participants, minimizing harm in the name of helping and providing clear descriptions of services. 3. Evidence-based decision-making process also stresses out the services transparency describing the outcomes variations, encouraging rigorous testing and revealing the gaps between research regarding the causes of social problems. 4. Another important aspect that is included in evidence-based decision-making philosophy is related to a systemic approach for integrating ethical, evidentiary and application issues. The practice has limits and challenges that have to be decreased, clients are involved as informed participants in decision-making, criteria used to purchase services

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are established as to respond to clients when resources are scarce, professionals are educated as lifelong learners. 5. Evidence-based decision-making process is based on accumulating knowledge. Sources of available knowledge are multiplied, knowledge is seen as a resource to be shared, criticism is welcomed, high quality critical appraisals of practice and related research related to practice are disseminated (e.g. Cochrane and Campbell Collaboration). Clients and professionals learn how to rapidly and critically appraise practice-related research. Educational programs are created and implemented to create lifelong learners and methods to identify errors and their causes are developed. Professionals use this information to minimize avoidable errors that may harm clients. In her article Evidence-based practice: Sea change or the emperors new clothes? Eileen Gambrill (2003, 4) states that EBP and social care involve a philosophy of ethics of professional practice and related enterprises such as research and scholarly writing, a philosophy of science (epistemology views about what knowledge is and how it can be gained), and a particular philosophy of technology. The author explains that: Ethics involves decisions regarding how and when to act; it involves standards of conduct. Epistemology includes views about knowledge and how to get it or if we can. The philosophy of technology involves questions such as: Should we develop technology? What values should we draw on to decide what to develop? Should we examine the consequences of a given technology? Concerning the technology related to the philosophy of evidence-based practice, the steps that a professional has to make in order to solve a problem are the following: 1. To convert information related to practice into answerable questions. 2. To discover with maximum efficiency the best evidence with which to answer them. 3. To critically appraise the evidence for its validity, impact and applicability. 4. To apply the results of this appraisal to practice, considering also the client involvement and values. 5. To evaluate the effectiveness and efficiency in carrying out these steps and to seek ways to improve them in the future (Sackett et al., 2000, 3-4).

From Theory to Practice

I will now take each step and discuss its implications for practice. The first step, that of converting the information one needs into answerable questions, is very important. But before even formulating the research question a social worker must be sure of the problems etiology. In other words he must label the social problem, give a diagnostic. According to Frances J. Turner (2002)1 the conceptual diagnosis being understood as that process of a consciously formed series of judgments made during the life of a case, judgments upon which a practitioner grounds his or her interventions, and for which each is prepared to take responsibility does have application across all aspects of social work practice. In his book Diagnosis in Social Work New Imperatives, Francis J. Turner draws attention upon the implication of the term diagnosis that could have a more pathological significance. He firstly accepts the replacement of the term diagnosis with that of assessment is a more holistically and politically correct term but, after years of practice, the author realize that

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this shift in terminology was indeed more than word substitution and that the term diagnosis has his important place within the social work practice. Setting a correct diagnosis is the social workers responsibility. The whole structure of the intervention process is based upon detecting the true nature of the problem. This implies that the social worker must collect data about the clients personality, social situation and history and then to analyze the data in order to arrive at an objective definition of the clients situation. How hard is it to give a diagnostic in social work? Like in medicine, where different illnesses could have the same symptoms, within social problems we may find the same reactions caused by different social malfunctions. Nevertheless, a social worker must make a judgment in order, to set a diagnostic upon the cases he has. As in the cases above, of harm and interventions, when dealing with a complex situation a good practitioner must search for the best studies that could support his/her diagnosis and questions. Different questions require distinct research methods to critically appraise proposed assumptions (Greenhalgh, 2000; Guyatt & Rennie, 2002, Sackett et al., 2000). When we first see a social services beneficiary, we need some information about his/her problems, we need to set a diagnosis. Sometimes, we can easily find out the roots and the growth of the problem but, often, the information is not obvious and we need some external evidence to support our theories. The efforts that professionals put in transforming the information they need into questions and finding the best answers are immense, especially when they are time limited and assaulted by many cases. Specialists give us some tips about how to ask questions, considering that they believe that is the hardest step in finding answers. A professional can ask background questions searching for general knowledge about the clients problems (who, what, where, when, how, why) and foreground questions about intervention, comparative interventions and desired outcomes. Both kinds of questions have to take into account aspects such as client physiology and psychological implications. Specialists have to analyze clients on three levels: individual, communitarian and societal, and they have to find answers related to all of them. As professional social workers, we all need background and foreground facts in proportions that fluctuate over time depending on our accumulating experience with a specific problem. It is very important to ask good questions for several reasons: it helps us to rapidly focus on the evidence related to our problem, saving precious time for us; it energises the communication with our colleagues when sharing information and it maintains us up to date with news on the field. Once we conceive a good question, another problem arises where to look for the answer. Books are the first solution they should be frequently revised and heavily referenced in order to find the right answer. The statements they make have to be in accordance with the evidence-based principles. Even if the quotations and web-linked textbooks are encouraged, professionals are advised to critically appraise the information. The internet databases, numerous for medicine (Cochrane Database of Systematic Reviews, Best Evidence, Evidence-Based Mental Health and Evidence-Based Nursing, Cancerlit, Healthstar, Aidsline, Bioethicsline and MEDLINE) but scarce for social problems (Campbel Collaboration) are also a very helpful tool. The difficulties in accessing these large databases consist in efficiently finding the information we need. Thats why a good solution would be that institutions make subscriptions to online specialised journals, in order to receive the newest information. These journals summarise the best evidence and make their selections according to explicit criteria for merit, providing structured abstracts of the best studies, and expert commentaries to provide the context of the studies and the applicability of findings. Thus, these summary journals allow us to solve the problem in a relatively short time and even summarize the best evidence from high-quality studies selected from all the

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journals of relevance to our interests. If a social worker has tried to search for evidence on clients problems, he/she should compare what he/she did and what he/she found with the methods proposed by evidence. Specialists in evidence-based medicine propose a general search strategy that can easily be functional for social work as well. Consequently, the social worker has to: 1. clearly define the problem; 2. define important searchable question; 3. select the resource; 4. design a search strategy; 5. summarize the evidence; 6. apply the evidence; 7. If he/she has got poor results then, he/she should go for the second best resource and follow the steps again. The third step in better solving problems for our client refers to critically appraise the evidence we found. The critical appraisal is the process of assessing and interpreting evidence by systematically considering its validity, results and relevance to an individuals work (Parks et al., 2001). We agreed that not all research is qualitative and many studies are biased, with uncertain results. Knowing which study didnt draw false conclusions, whether a research is reliable or not, which study to choose from those with different solutions for the same problem, is the result of using critical appraisal skills. According to Belsey (2009), in order to take the best decisions the professional should know if the studies have been made in a way their results are reliable, should make sense of the results and know what the results mean in the context of the decision. Studies conducted so that they lead to a particular conclusion are biased. Amanda Burls, MBBS, BA MSc FFPH, Director of the Critical Appraisal Skills, Programme, Director of Postgraduate Programmes in Evidence-Based Health care, University of Oxford in a What is? series published on internet said that: Bias can be defined as the systematic deviation of the results of a study from the truth because of the way it has been conducted, analyzed or reported.2 The same author points out that when one critically appraises a study, he should first look for biases in the study; that is, whether the findings of the study might be due to the way the study was designed and carried out, rather than reflecting the truth. Burls mentions that it is also important to remember that no study is perfect and free from bias; it is therefore necessary to systematically check that the researchers have done everything to minimize the bias, and that any remaining biases do not seriously alter the results observed. A study which is sufficiently free from bias is said to have internal validity. As I said before, different kinds of questions require different kinds of study designs. The questions could address: Effectiveness: i.e. Do vocational training programs help clients get and maintain jobs? Are there harmful effects of such programs? Prevention: i.e. Do domestic violence prevention programs addressing family doctors reduce the number of domestic violence acts? Screening, risk prognosis: i.e. Do ANPF (National Agency for Family Protection) reported data on domestic violence really reflects the actual number of these cases in the country? Description/Assessment: i.e. Do ANPF reported data on domestic violence really reflects all the causes of the phenomenon?

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Thus the best design for effective studies are randomised controlled trials (RCT). When using research to help with a question, look for high quality studies, but do not be too quick to dismiss everything as irrelevant. Try to take what does apply from the research and use it to resolve the problem at hand. (Koufogiannakis and Crumley, 2004). There is a hierarchy of evidence but professionals should develop their skills to make sense of scientific evidence and to find the best answer to their questions. When analysing any research be it RCT, systematic reviews, meta-analyses or other it is relevant to consider validity, relevance and results. There are a lot of difficulties for a researcher when he/she wants to assess the effectiveness of complex interventions and when he/she needs information to answer questions related to prevention, diagnosis, therapy, potential harm, or causation. However, it is very easy for a researcher to find studies in support his/her ideas. However, if he/she searches for more, he/she may also find some contradictory evidence. Under these circumstances of controversial discussions about research in social work field, a good practitioner should know what research method provides the best evidence for the particular research question at-hand. It is very important to know that there is no such thing as the best research method. A wise practitioner knows that the research method should be tailored to the needs of the research question. As Sackett et al. (1996, 71) said, the question being asked determines the appropriate research architecture, strategy and tactics to be used not tradition, authority, experts, paradigms, or school of thought. A tool widely used by the practitioners when searching for studies to sustain a decision-making process is the hierarchies of evidence, developed by the Canadian Task Force on The Periodic Health Examination. Paul Glasziou et al. (2004) draw attention to the danger of using hierarchies of evidence that rank research studies according to their quality. Glasziou (2004, 39) says that the simplification involved in creating and applying hierarchies have led to misconceptions and abuses. In their view, five aspects must be considered when appraising the quality of research: 1. First of all, they agree with Sackett by saying that different types of questions require different types of evidence. Glasziou et al. (2004) point out that practitioners should understand the indications and contraindications for different types of research evidence. Randomized controlled trials can give good estimates of treatment effects, but poor estimates of overall prognosis, comprehensive non-randomized inception cohort studies with prolonged follow-up however, might provide the reverse (Glasziou et al., 2004, 39). 2. Systematic reviews of research are always preferred. A study gives better evidence when it is interpreted in relation to what other studies and case studies may indicate as potential rare harms or benefits of an effective treatment. 3. Level alone should not be used to grade evidence. Examining the first substantial hierarchy made by Canadian Task Force on the Preventive Health Examination, the authors indicate three disadvantages: The definitions of the levels that vary within hierarchy, novel, or hybrid designs are not accommodated in these hierarchies and such hierarchies can lead to anomalous rankings. 4. Clinicians need efficient search strategies for identifying reliable clinical research. Hierarchies could be used however, to find other sources of evidence when systematic reviews are not available. 5. Balanced assessments should draw on a variety of types of research. Although a certain type of research can offer information about the effectiveness of a treatment, for finding some possible side effects, we should rely on other research approaches, as well.

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Glasziou (2004) indicates non-randomized cohort studies or case-controlled studies for finding the best harm-related evidence. Given these problems of hierarchies, Glaszious advice for practitioners has two directions: (1) To standardize and to improve the current hierarchies and (2) To abolish the notion of evidence hierarchies and to teach practitioners the general principles of research and the possible utilizations of these principles to appraise the quality and relevance of particular studies. Burl concludes that it is always necessary to consider the following questions: Has the research been conducted in such a way as to minimize bias? If so, what does the study show? What do the results mean for the particular patient or in the context of a particular decision? The next step is to apply the evidence to practice. Applicabilitymay bedetermined by the following variables listed by Koufogiannakis and Crumley (Booth & Brice, 2004, Ch.10): User Group Is the user group similar to mine? Did the research measure outcomes important to my situation and users? What is the impact of the age of the user group? Will the users benefit from it? Does the service/product fit with values, needs and preferences of my user group?

Timeliness Has the situation changed since the evidence was gathered? Is there a potentially newer technical solution that should be explored? Cost Are the benefits worth the cost in my situation? How big an impact will be achieved and is it worth the cost? Are there any side effects for users that may be costly in the long run? Are there other less costly things that can be done instead or prior to implementation to control costs?

Politics Is there support within the institution and who do I need to partner/target to become my champion? What will be the positive and negative effects of this initiative in my environment? Will my employer/users embrace the different way of doing things? Severity What is the level of severity of the issue? Will implementation make a difference? If so, how much, and is it worth the effort? Are there other remedies for this situation? Are the potential consequences so severe that any solutions will only work in the short term?

Decision-Making Using the Evidence

The tools/strategies to help weigh up the best evidence found whenconsidering local conditions include the SWOT analysis. The last step for professionals is that of evaluating the intervention impact. The evaluation procedure should be established when the research question is raised. It is important for professionals, and for the system they activate within and clients to know if

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the intervention has made a difference. To facilitate this course of action we have to identify what we want to measure, which data we need to measure it and to determine the suitable measurement. We must compare the desirable outcomes stated in the original plan with the acquired changes. We must also answer two questions: Have the changes resulted in customer service improvement? Have any further questions arisen?

Evidence-Based Medicine and Evidence-Based Social Work Practice

But as I said, not all thats appropriate for an area is also appropriate for other areas; therefore, we might ask whether the principles from evidence-based medicine can be applied to social work. We can see from these definitions, which are the main principles of E.B.P. The question is how do they match with social work practice? I will take each principle of the evidence-based medicine and I will try to see how it can be applied to social work:

Search for the Best Research Evidence

Where can we find such evidence in medicine? We can find it in various specialised journals and at the same time, on the Internet as an important source of evidence. A very good source to start searching is the Cochrane Library, which provides systematic reviews, meta-analyses and randomised control trials results of the effects of health care. There are also other sources, which can provide evidence of different ways to solve medical problems. So, we can find out, in most medicine cases, sufficient evidence to help us with our problems. Both clinicians and patients can have access to the information and can contribute to the decision-making process. According to Gambrill (2002), EBP is designed to create professionals who are lifelong learners who draw on practice-related research findings and involve clients as informed participants in decisions made (452). What it is the situation in social work? Where can we find evidence for social work problems? Considering the complexity of social work field which deals with a lot of diverse cases from one individual to another and from one country to another, it is much more difficult to find valid and high-quality evidence which can be applied to a specific situation. We can also find situations or places where the social problem has different definitions or even it is not consider a social problem (e.g. domestic violence in Romania). The research tradition in social work is also based on randomised-controlled trials, meta-analyses and single-case designs, trying to identify the relative effectiveness of different interventions. But within this kind of research, in social work there is no sufficient and valid evidence. While medicine has a well-built scientific body of knowledge common for almost all countries, it is highly improbable for social work to achieve such a body of knowledge because almost all social cases are unique and we can hardly find general applicable methods of interventions. For example, if in medicine, a colon cancer can have the same pattern regarding patients from all over the world and can be healed by applying the same treatment, clients who have the same social problem (e.g. homelessness) require different methods of interventions according to their particular situation. How relevant can the evidence we can find be for other countries considering the fact that most of the cases come from the United States? Even when we analyze such studies,

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it is very difficult to find out why some interventions worked well or failed. Also, we cannot know what the contribution of individuals involved in experiment was or how the professionals who worked with them did influence them. The principle itself of searching for the right evidence is good and apparent. All the professionals should do this in their practice. What happens when we generalise the outcomes to the natural environment of the client? The problem is that in social work there is not so much evidence and the practitioners must rely on their practice experience in the field in order to make good decisions. Another problem, particularly in less developed countries, regards the social work clients who come from very poor circumstances: how can they access evidence and how to gain good enough appraisal skills in order to decide the best solution for their situation? This aspect can lead us towards a second principle in evidence-based medicine:

Good Clinical Expertise

It is desirable that a professional clinician and a professional social worker should make a decision. If in medicine all the clinicians are doctors and they have a medical knowledge background, in social work it is possible that a social worker doesnt have special social work knowledge.3 So, how can these people make a decision in really difficult cases? Also, if in medicine we have standardized treatments based mostly on pharmacological and physical interventions, in a social work intervention, the social worker should consider the clients network of relationships, his relations with his family, with his friends and with the society in general. This aspect complicates the decision-making process. Another aspect concerns patient and clients involvement in the decision-making process. In the medical context, the patient has a more passive attitude and he often lets the doctor make the decision for him. The influence of the external factors is much more reduced than in social work field and it is relatively easier to predict the possible effects of an intervention. The social work clients usually come from very disturbed environments, they come with their own perception of their situation and its causality. Thats why it is difficult to combine the professional expertise with the clients preferences, which are more affected by the external, societal factors (e.g. poverty, emotional distress, mental disorders, and political context). The social work practitioners dont have a great amount of trial data available. There is a recent series of What Works summaries produced by Barnados, which intend to focus on RCT evidence in social areas. According to Liz Trinder (2000), there are a number of technical issues that make RTCs4 more difficult to operationalise within social work and probation than in medicine (150). These difficulties are related to the ethical and practical process of randomisation, of external variables, which can change the research parameters, and of the nature of outcome indicators and thats why the aim of RCTs in social work field will remain limited to technical reasons. The danger of contamination between the social work clients is bigger. We can often see that in order to receive more benefits, clients can influence each other on how to act during an interview or what answers are the best or what specific service he should ask for and, therefore, we cant be sure that what they are saying is, actually, what they believe. According to Sackett et al. (2000), the first step in the practice of EBP5 is converting the need for information (about prevention, diagnosis, therapy, causation) into answerable question. In social work, where we are dealing with very complex situations, it is very hard to synthesise all the information you need into a standardised type of question and it is much difficult to find the best answer. There is the danger of losing some very important

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information, which could influence our decision. A good clinical expertise can also mean that a professional who finds negative results or no evidence on a specific problem, should comunicate it to the client. If we dont want to lose clients we must have good communication skills and be able to reach a common agreement regarding the implementation of a new method for solving the problem. Therefore, social workers should ground their expertise on science but at the same time they must be aware of its limitations. As soon as one expert has found enough evidence on a problem he should follow another principle:

Consider Clients Values

We live in an ever-changing world in many aspects and we may find different and even contradictory values from one society to another. Within the same society, a large scale of external factors influences individual values. Consequently, how can we integrate the clients values if they are opposite to our findings? E.g. can we convince a woman not to make a circumcision even if she is going to have many difficulties to find a husband within the societies who value this tradition? How can we apply our strategies among different cultures without any negative effects? How can we know that we are actually doing well rather than harm? Who is right: the science or the client? Of course, that evidence-based practice gives us some methods of evaluating the effectiveness of the intervention but considering the complexity of human nature can we be sure that applying some actions from similar cases is the best solution for our clients? According to Reynolds (2000, 257) research validity refers to the extent to which the results of the research are likely to be free from bias. In the social work field, it is difficult to prevent the influence of biases and not always the social worker can find out whether any bias has occurred during the intervention. A very important aspect is how evidence can be transferred into real situations. Each country has different implementation services and not necessary very developed ones and of course we must consider the limited resources we have. We must make the best decision for the client using the limited resources we have but this cannot be done so easily in every society (usually, the societies which need most social work are the poor ones). It is very important to consider clients own definition of their problems and the difficulties to which these lead. If there are differences between social workers and clients then, these must be discussed and negotiated until a common objective is achieved. Relying on evidence is good but is not enough for social work. The outcomes of applying the evidence-based principles in social work are desirable but there is a problem regarding the methods of searching and implementing the findings. It is not enough to analyze only the studies, which have been made, but we should also integrate the studies of the consumers reactions. We must see the evidence we have as a guideline of the safest and most effective interventions but not as an authority in the field. Every professional must analyze the evidence carefully and must take that decision which can minimise the potential harm of the intervention and maximise the potential benefits. Most of the interventions in social work are very complex both on individual and on community level. It is usually hard to find good evidence for complex interventions, especially in those cases when social phenomena occur for the first time. At this level, we can search for evidence by different methods from gathering data from the people involved to structured surveys or qualitative interviews, notes from a field work or focus groups etc. There are a lot of difficulties for a researcher when he wants to assess the effectiveness of such complex interventions. The first difficulty consists in defining the intervention, its delivery methods, its components and how are they are related with each other. Another

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difficulty may be the actual analysing of the results and their impact upon all the participants and other secondary effects. Alderson and Groves (2004) cite Archie Cochrane, who asked three key questions about a healthcare intervention: Can it work?, Does it work in practice? and Is it worth it? The problem that these authors raised is: what are we doing when the answer of these questions is situated between no and not sure? The answer is the same with that related to intervention, which might do more harm than good: searching for the best evidence. The challenge, then, is to raise awareness of the way in which policy so often fails to address the human individual when assessing need. The result of the present failure is that so much policy provides for problems and not for people: hence the predicament of providing for people with multiple support needs (Ham, 1996).

Notes
1. http://www.haworthpressinc.com/store/SampleText/4539.pdf. 2. http://www.medicine.ox.ac.uk/bandolier/painres/download/whatis/What_is_critical_appraisal.pdf. 3. In some countries the social work is done by peoples who come from different areas than social work, they are not real professionals (e.g. Romania). 4. Randomized control trials. 5. Evidence-based practice.

References
Alderson, P. and Groves, T. What doesnt work and how to show it. BMJ 2004; 328:473 (February 28), doi: 10.1136/bmj.328.7438.473 Belsey, J. (2009) What is Evidence-based Medicine? London: Hayward Medical Communications. Bruce, A.T. (2008) Research on Social Work Practice, 18, 4, 339-345. Gambrill, E. (2003) Evidence-based practice: Sea change or emperors new clothes? Journal of Social Work Education, 39, 3-23. Gibbs, L. & Gambrill, E. (2002) Evidence-based practice: Counterarguments to objections. Research on Social Work Practice, 12, 452-476. Glasziou, P., Vandenbroucke J., Chalmers, I. Assessing the quality of research, BMJ 2004; 328:39-41 (January 3), 10.1136 bmj. 328.7430.39 http://bmj.bmjjournals.com/cgi/content/ full/328/7430/REF2 Greenhalgh, T. (2001) How to Read a Paper: The Basics of Evidence Based-Medicine. London: BMJ Publishing Group. Guyatt, G.H., Haynes, R.B., Jaeschke, R.Z., Cook, D.J., Green, L., Naylor, C.D., et al. Users guides to the medical literature: XXV. Evidence-based medicine: principles for applying the users guides to patient care. JAMA 2000; 284: 1290. Feltovich, P.J., Spiro, R.J. and Coulson, R. (1993) Learning, Teaching and Testing for Complex Contextual Understanding. Ham, C. (1996) A primary care market? British Medical Journal, 313, 127-128. Koufogiannakis, C. (2004) Booth & Brice, Ch. 10, 126. Muir-Gray J.A. (2001) Evidence-based Healthcare: How to Make Health Policy and Management Decisions. London: Churchill Livingstone. Oakley (1998) Experimentation and social interventions: A forgotten but important history. British Medical Journal, 317, 1239-42 http://bmj.bmjjournals.com/cgi/content/full/317/ 7167/1239.

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Oxman & Flottrop (1998) An overview of strategies to promote implications of evidence-based health care. Silagy, C. & Haines, P. (eds.), Evidence-based Practice in Primary Care. London: BMJ Books. Parkes, J., Hyde, C., Deeks, J., and Mline, R. (2001) Teaching critical appraisal skills in health care settings. Cocharne Database Systematic Reviews, 3, CD00120. Reynolds, S. (2000) Evidence-based practice and psychotherapy research. Journal of Mental Health, 9, 3, June, 257-266. Sackett, D.L., Richardson, W.S., Rosemberg, W., Straus, and Haynes, R.B. (2000) Evidence-Based Medicine: How to Practice and Teach EBM. New York: Churchill Livingstone. Sackett, D.L., Rosemberg, W.M.C., Gray, J.A.M., Haynes, R.B., and Richardson, W.S. (1996) Evidence-based medicine: What it is and what it isnt. British Medical Journal, 312, 71-2. Trinder, L. & Reynolds, S. (2000) Evidence-Based Practice: A Critical Appraisal. London: Blackwell Science.

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