For this week, let's begin a discussion about evidence-based practice. After reviewing the lecture material on EBP, please post here. Please write an initial response and then return and respond to two of your classmates' comments. First - based on your readings and your experiences in the field, what is your definition of evidence-based practice? How is your current field agency applying the concept of evidence-based practice? Moreover, how do you see yourself as a professional social worker engaging in practice that is evidence-based? And finally - apart from what you have read - how do you feel about the idea of evidence-based practice?
Sunday, October 25, 2015
Evidenced Based Practice
For this week, let's begin a discussion about evidence-based practice. After reviewing the lecture material on EBP, please post here. Please write an initial response and then return and respond to two of your classmates' comments. First - based on your readings and your experiences in the field, what is your definition of evidence-based practice? How is your current field agency applying the concept of evidence-based practice? Moreover, how do you see yourself as a professional social worker engaging in practice that is evidence-based? And finally - apart from what you have read - how do you feel about the idea of evidence-based practice?
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My understanding of evidence based practice are those practices which are provided to a client and are inclusive of patient needs, social worker abilities, and have been repeatedly tested to insure validity and that these practices indeed are helpful to clients. In my current internship I am certain that there are a variety of medical evidence based practices that are continuously used by the medical staff including doctors and nurses in order to not only treat a client but to determine appropriate length of stay, eligibility for level of care, etc. I am also certain that each floor of the hospital must have their own practices they follow and are dependent upon patient needs. I have notice that my supervisor is great at providing motivational interviewing and this idea of rolling with resistance, especially with those clients who arrive to the ER with substance abuse issues or terminal illnesses. Psychosocial assessments are provided on the most high risk clients but the form we utilize has been developed by the hospital and entered manually into the medical records system that we utilize (referred to as EPIC). I am interested to learn how more EBPs can be utilized in the medical social work field, especially in the ER where clients are seen very briefly before either being helped with a discharge plan or admitted to a different floor. I think this is a great supervision topic. I really like the idea of EBP. I think it allows a specific format and detail about what topics should be covered and how a professional should present the specific material or information that is being relayed to the client. It provides guidelines for appropriate use of a particular practice and has been shown to work and be effective through replicated studies and research projects, ensuring that programmatic guidelines are justly followed, therefore making the practice valid which is essential.
ReplyDeleteRebecca
That's great, Rebecca, that your supervisor is well skilled in "motivational Interviewing." Pay close attention. It just seems to me that the best therapy is often futile if the client lacks motivation. This is a "tool" we all need in our "shed."
DeleteI appreciated the lecture on EBP because it included the distinction that in order to be "Best Practice" all three components need to be present: practitioner experience and acquired knowledge; client values and wants, and the best evidence- empirically- of what works. I also appreciated the McCracken & Marsh article addressing the research on human "information processing, perception, and problem solving as it relates to clinical decision making." This brings in the human element, woven from experience and education, but also including the intuition and reading of a situation up close and personal. I think EBP includes parts of what precipitated its advent to begin with: practitioner perception and relationship with the client. My internship revolves around piloting interventions, inclusive of other interventions which are already EBPs to ask questions and look for answers which may be new or better practices. My role may remain as researcher, in which case I see my role as social worker to help provide studies and pilot new ideas, striving always to find the evidence suggested works which can become Evidence Based Practices. I have some mixed feeling about Evidence Based Practice, generally around issues relating to what will be reimbursed and what won't be reimbursed by insurance. In fact, insurance can be very thorny territory and may at times invite a "one size fits all" mentality.
ReplyDeleteHi Gail,
DeleteThank you for mentioning the issue of insurance, I spent a lot of time talking about this with my co-workers yesterday. I also appreciate your comment about the "one size fits all" approach that EBP is forced to take on. I think this is really important to consider, especially in regards to culture, socioeconomic status, gender etc. As I continue to work with a more diverse population, I also feel iffy about how EBPs, in general, can be applied.
Christine George
Gail. You raise very interesting questions: How do insurance companies define EBP? And what are the practice implications of this interpretation given their considerable power (control of reimbursement?
DeleteHi Gail –
ReplyDeleteYou bring up an excellent point regarding insurance reimbursement for evidence based practice programs. When I first started in the field I worked in an adolescent intensive outpatient program where we developed our own curriculum based on the knowledge we thought it was important for the adolescents to know. Since leaving the program I have heard that insurances stopped reimbursing as it was not evidence based and therefore the program had to be reformatted. I understand why insurances do this to make sure that they are paying for practices that are researched and have been validated but sometimes I feel like it prevents the clinician from providing other information that might be more helpful for a client. Great insight.
Rebecca
Hi Rebecca,
ReplyDeleteHere is a good article about evidence based versus cultural competence: http://tps.sagepub.com.libproxy.unh.edu/content/52/2/150.full.pdf+html
I understand the need and desire for evidence based, but I think there is a good argument for the marginalized, or folks who are do not fit the "general population" idea. I liked the article's reference to practitioners, as 'cultural beings' bringing their whole selves into the encounter. Naturally, there is room for both perspectives an life is usually best lived in the middle.
Gail
Hi Gail,
DeleteThank you for posting this article. It provided some interesting points.
I find the opinions about EBP and other approaches such as psychodynamic interesting and I really believe a lot comes from training and educational backgrounds. I am currently working with another intern who attends Smith College. As he is new to the field, his opinion is completely shaped by his education. When I first started out this week, I saw things as black and white, either for or against EBP. After having several conversations with co-workers, I have found we are all somewhere on a spectrum of gray.
Christine
Hi All,
ReplyDeleteThis week's topic spurred a great conversation between myself and other social workers on my unit. Evidence based practice can be seen as a "three legged stool" approach to care (not only in the field of social work, but also for medical services and education). Approaches and programs that fall under this category must meet three basic principles: 1. research evidence, 2. clinical expertise and 3. client values.
Before reviewing the material for this module, I was only familiar with DBT as an evidence based practice program/approach/therapeutic model. This is certainly something that my placement uses in terms of a daily therapeutic group, however, that is the extent of it's use. CBT worksheets are also given to some adolescents based on their needs and behaviors. I asked my co-social workers what EBP approaches the Brattleboro Retreat uses in general and the only one we could agree on is a Wellness Approach in regards to employees, however, this is not directed at substance abuse. CMS (stands for something pertaining to Medicaid/Medicare services) monitors the Retreat and I would imagine there are specific EBP guidelines or materials we are required to use. My fellow intern on the unit expressed his dislike for EBP approaches stating that they are merely for insurance purposes, so agencies can get reimbursed. Like Gail mentioned, there are many people that "fall through the EBP cracks". We had a great discussion about research formulations surrounding human behaviors and whether this is objective or truly realistic or not.
I remain on the fence in terms of EBP. Going through the list, it looks like a lot of these programs are applicable to outpatient settings, specifically in schools or parenting programs. It is my understanding based on my experience with DBT, formal training can be difficult to come by and materials are often expensive. Again, speaking specifically for DBT, I truly believe that this therapeutic approach works, not only for individuals with BPD, but for anyone. I have used several of the DBT techniques in my own life with great results. Is this because it is an EBP? I'm not sure.
I'm not sure whether I answered the questions for this week's blog post or not, I feel that I need more experience using EBP materials and seeing the outcomes. There are so many factors to consider when implementing these materials that it is more complicated than reading about them and saying yes or no they are effective.
Christine
Christine George
DeleteSorry my new Google account is not accessible at work. :)
Hi Christine -
DeleteThis conversation also came up yesterday in my work setting and the pressure from insurers (specifically medicare/Medicaid) to ensure that evidenced based practices are recorded in each encounter note and completed with the client. I struggle with this going back to sort of an agenda and needing to accomplish certain tasks during the session, which may take away from its authenticity especially in situations where clients are in crisis. I also struggle with the idea that one EBP does not fit all and it seems nearly impossible for every clinician to be competent in each and every EBP in different settings they may encounter during their professional career. It would be nice to just provide therapy without feeling the force of an EBP, although I understand why they are important for validity reasons, sometimes I think they may not be beneficial or appropriate to certain therapeutic situations.
Rebecca
Hi Rebecca, Yes in Vermont Medicare and Medicaid will always want to know what EBP's are being used to approve payment for services. When we offer new none traditional therapies at HCRS we must provide the EBP's information for review to insure payment.
DeleteMy definition of evidence-based practice had been, with respect to intervention, that it had been empirically tested and stood up to peer review.
ReplyDeleteIn the agency where I am employed, my unpaid internship still mired in an orientative state, the clinicians seem to be taking the advice of supervision, exclusively, when it comes to intervention, specifically therapeutic practice.
As a professional I expect that I'll want to make-up my own mind, ultimately. I say as much not to suggest that I won't take supervision. I most certainly will. I just won't be taking it blindly, nor unconditionally. I simply won't be able to ignore my own experience/expertise.
I like the idea of taking client values into consideration as well. And so, I feel very good about EBP, my definition now broadened.
Hi William,
DeleteI think you're making a reasonable decision about supervision. I think it's always important to include your own personal judgement into the equation. Your supervisor may be knowledgeable, but s/he is not going to be in the moment with you while you are dealing with clients. Also, you may have a different strength style than s/he does, or may be aware of personal client details. Are you expecting any organizational resistance if you choose not to rely exclusively on your supervisor's decisions like the clinicians are doing?
William,
DeleteI agree with you about taking into client values into consideration. The agency that I work for stresses client centered treatment. I feel after conducting more evidence on EBP, that I have been following the model. I hope to get to use it during my current placement. I already completed my learning contract, but I will address it in supervision with my supervisor.
Christine McGovern
In thinking some more on this topic, a line from Epstein caught my attention. In discussing the EBP versus RP (Reflective Practice) he wonders whether "one reason, current-day, real opposition many practitioners voice against EBP [is] as it is generally implemented, discounts the knowledge-producing function of the practitioner in favor of assessment, consumption, and application" (p.222). I am personally intrigued by the discussion of EBP vs PBR (Practice-Based Research). My understanding of the elemental differences are EBP: prior research (deductive), privileges RCT's (randomized clinical trials), prefers quantitative methods, summative, and research is driven by academics); PBR: can be based on practice wisdom, rejects RCT's, qualitative and quantitative methods, research is formative, and research is driven by the practitioners. I also understand that EBP is a model of RBP, one that uses research-based concepts, theories, designs to structure practice and so that outcomes may be rigorously tested. I suspect, like most of what we have learned in SW, there needs to be a blend and a medium for harmony as Epstein claims, rather than disharmony.
ReplyDeleteEvidence-based practice, as noted in the lecture, has three components. There's the obvious "evidence" part, which is that the practices a social worker uses should be drawn from research that has been done in the field and proven effective. But it also integrates the tried and true things that the social worker has found to be effective in her/his own experience and that she/he may incorporate. It is also important to incorporate aspects that the client thinks are important. Indeed, it's impossible not to, because it is likely the client will only participate fully in practices that they feel comfortable with or that they believe will actually help them.
ReplyDeleteAs Aaron Rosen pointed out it is also important to be aware of potential factors that impede proper use of EBT. An example he uses is the "laypersons" knowledge of how to solve the problem. Since a lot of social issues are mirrored in less extreme forms by personal problems a lot of us face, it can be hard to think logically about the best EBT practices to aid in solving the problem, instead of falling back on common wisdom. This was only one of the potential roadblocks he mentioned, but it was a thought provoking one for me. I can certainly believe that some therapeutic techniques might seem counterintuitive at a surface glance, and it might be important to stop oneself from falling back on habit.
Alice, You have articulated this post really well. I keep coming back to what role insurance reimbursement plays in choosing appropriate therapeutic interventions. I know a person who is seeing a counselor for addiction to pornography, and the therapist cannot code it for billing for what it is, but must bill for something which it is not. Not tryin to muddle the waters, but I know insurance has become a force in the lives of Psychiatrists and other mental health practitioners
ReplyDeletethough I do not know the whole story.
Gail
Hi Gail,
ReplyDeleteThat's a really good point. A lot of the less well-known practices might not be covered by the insurance companies. Or, as with your example, less well understood (or societally accepted) client problems might be difficult to "justify" to them. I don't think that should be included in the EBT model, though. It's less about the ideal practice situation and more of a stumbling block. But you're absolutely right; it's probably a pretty universal problem.
The most common explanation of Evidence-Based Practice (EBP) is from Dr. David Sackett. EBP is “the meticulous, unambiguous and sensible use of present-day best evidence in making conclusions about the care of the individual patient. Which means integrating individual clinical expertise with the best available external clinical evidence from logical research” (Sackett D, 1996).
ReplyDeleteEBP is the incorporation of clinical proficiency, patient beliefs, and the best research evidence into the decision making process for patient care. Clinical proficiency refers to the clinician’s gathered experience, education and clinical skills. “The patient brings to the intervention his or her own personal preferences and exclusive anxieties, opportunities, and ethics. The best research evidence is usually found in clinically significant research that has been conducted using sound methodology” (Sackett D, 2002).
After only working their two days, I have not really had a grasp on how they incorporate evidence based practice into their work. It does not mean it is not taking place. But I was shadowing and going through procedural forms, completing and reviewing my learning contract with my supervisor that needed to be done, prior to her leaving permanently today at 4:00pm.
I could see myself as a Social Worker and using the EBP with the clients that I work with. I can see it being helpful and making sure that clients are receiving the best care that they deserve. I still feel that I need more practice before I could begin to use it one on one in therapy. Although I think in my work I may be following part of the EBT model and not even realizing it.
Christine McGovern
Christine, I wondered if the company you work for or where you intern they ever talk about EBP? At HCRS we talk frequently about it to ensure staff are well informed. We are also just a few months away from an audit by Joint Commission on the Accreditation of Healthcare Organizations- JHACO which will ask random staff what EBP's we use.
DeleteGreater Nashua Mental Health Center, the last psychiatrist that was my boss always talked about following this model and we have had trainings about it as well.
DeleteChristine McGovern
Sorry I am posting so late in the week, I really wanted to learn more about Equine Therapy and what was considered best practice. When I think about best practice, its something I ask staff I supervise to always be mindful of. For us, its a multiply dimensional approach to using person centered language, practices that have been researched and proven to be effective and following all laws and regulations. Because Equine is so new I had no idea what best practice would look like so I did a little on line research. I have attached an on line PowerPoint for anyone who's interested. Equine Therapy is no different, it just approaches emotional growth using horses to build confidence, safety and trust. I am excited to see how this approach benefits the resistant client.
ReplyDeletewww.horsescanhelp.com/.../2010/02/OT-Equine-Assisted-Therapy.pdf
Jennifer- thanks for sharing this information on Equine Therapy- Its wonderful that you are able to apply an evidence based practice in the work you are doing. Very interesting that Equine uses horses as a therapeutic way to build emotional growth, confidence, safety and trust.
DeleteHi Jennifer,
DeleteI never stopped to think of Equine Therapy as a EBP, however, it makes sense that the same information (research, client input and clinical knowledge) would be incorporated in order for this approach to provide the greatest results to the largest amount of individuals. I look forward her hearing more about your experience with this approach. I would be interested to hear about more "non-traditional" EBP approaches as well. I can't think of any at the moment, but I'm sure there are a lot of them.
Christine George
Evidence Based Practice in a clinical setting involves the practitioner’s individual expertise, best scientific evidence and the client’s values. As social work students I think it’s important to be informed about the current evidence based research available. I also think it is up to the therapist to integrate these methods into their practice. The opening line in the Epstein reading says practice and research, agency and university, practice wisdom and research-based knowledge, positivist and interpretivist research methods, relevance and rigor, science and art, and so on, are commonly constructed, written about, and taught as conflicting terms. This resonated with me because as an undergraduate student I studied visual art, and just like an art student, a social work student needs to know all the different methods in order to develop one’s own personal style and approach. Like an artist, I imagine for a therapist it takes time to build on one’s craft which is forever evolving based on new scientific research. When it comes to learning about all the different proven scientific methods, it can be very overwhelming but I think important to try to self-educate and stay informed and up to date. When it comes to applying different methods to a specific case, I think it is ultimately up to the clinician but also I imagine good clinician considers the patients’ needs and goals for therapy. I am conflicted because the development of Emotionally Responsive Practice (which is what I was trained to do at my last internship) is very much used in the field, but is not a proven evidence based practice. I imagine it takes time and lots of research, and publications to get an intervention recognized as evidence based practice.
ReplyDeleteI kind of like the way that Okpych defines Evidence Based Practice, “EBP taps into a long-standing ambition that has captivated and eluded the field since its inception: to forge a service profession grounded in empirical research” (Okpych, 2014, pg 3). I have found that even whether I am running a psychosocial education group or even working with clients one on one, they like when you can explain to them where the information that you are giving the came from. This is understandable because when we are trying to trust someone that we don’t know very well we want to know that they are not just making things up. Being able to share research information with client can be very helpful in making them more comfortable when you are challenging the way that they think or act.
ReplyDeleteReference:
Okpych, N., & Yu, J. (2014). A historical analysis of evidence-based practice in social work: The unfinished journey toward an empirically grounded profession. Social Service Review, 88(1), 3-58.