08/23/2013

Practice Research in Social Work: To what end?

By Assoc Prof Timothy Sim

 

Tim01

This article is developed from the keynote speech delivered for the Singapore Association of Social Workers’ Day celebration on 23rd March 2013, with the aim to review the need for social workers to conduct practice research in social work. It begins by reviewing the development of evidence-based social work and the controversies involved. In response to the difficulties and controversies of evidence-based social work, the paper turns to the alternatives provided by practice-based evidence. This paper concludes by persuading Singapore social workers to carry out practice research by embracing both evidence-based practice and practice-based evidence so as to serve our clients more adequately and continue to learn and grow professionally.

Evidence-based social work

Social work has long been troubled by the adequacy of its claims to professional status and about its possession of appropriate levels of knowledge and expertise. Inevitably, many social work researchers and practitioners attempted to address this inadequacy by turning to evidence-based practice [EBP] movement (Taylor & White, 2003).  As early as 1978, Brian Sheldon articulated that the relationship between theory and practice in social work was inconsistent and muddled and needed to be put on a much firmer footing and produced suggestions to draw the essential principles of science, particularly bio-medical science, to improve the situation in social work (Sheldon, 1978). The promotion of EBP in social work continued to develop steadily at the turn of the millennium (e.g., Gambrill, 1999, 2003; Howard & Jenson, 1999a; Proctor & Rosen, 2003). Apparently, definitions of EBP in the field of social work mostly paraphrase Sackett and colleagues’ (1996) definition in the medical field (van de Luitgaarden, 2009), who  first defined evidence-based practice (EBP) in the medical field as ‘the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients’.  They described the process of evidence-based practice as:

The practitioner, when presented with a case, has to formulate an answerable clinical question. Next, they need to do a search for relevant empirical findings and meta-analyses, and critically appraise the research that is found. This critical evaluation should be done in terms of impact, validity and relevance to the case at hand (Sackett et al., 1997).

 

There are five essential steps of EBP (Jenson & Howard, 2008; Sim & Ng, 2008):

  • Step 1: Converting practice information needs into answerable questions to do with effectiveness, prevention, assessment, description, prediction, harm, and cost-benefit.
  • Step 2: Track down, with maximum efficiency, the best evidence with which to answer the questions, mostly through books and journals, systematic reviews organized by client problem or treatment approach that detail the effects of interventions on specified outcomes, published ‘lists’ of effective programs by federal entities and research centers, practice guidelines that offer treatment protocols based on empirical evidence.
  • Step 3: Critically appraise the research evidence for its validity and usefulness.
  • Step 4: Apply the results of appraisal to practice/policy decisions, considering client values and preferences.
  • Step 5: Evaluate effectiveness and efficiency in carrying steps 1 to 4.

 

Some social workers consider EBP as a new and revolutionary practice approach that holds great promise for building stronger bridges between science and social work (Jensen & Howard, 2008). The requirement and rationale for EBP in social work are obvious to them. For example, Roberts and Yeager (2006) succinctly put across in the preface of their text ‘‘Foundations of evidence-based social work practice’’:

Social workers have always been concerned with improving the quality of life and restoring psychosocial and family functioning for all clients, and in some cases saving lives. … it is imperative for social workers to be prepared with the latest evidence-based practice protocols and research exemplars. We owe it to our clients and the social work profession to only use interventions that have systematic evidence of their effectiveness and efficacy (p. vii).

 

While three components of EBP – research evidence; clinical expertise; and clients’ values and characteristics – have been applied by social workers when defining evidence-based practice, we have also differed from other professions in emphasizing three other components given the broad scope of activities in social work: (a) social work’s traditional theoretical emphasis of person-in-environment; (b) promulgation of values such as respect of self-determination and individuality; and (c) the promotion of social justice (see, e.g., Gambrill, 2006). These additional components, however, could pose some challenges in being able to rationally and technically apply evidence in the strictest sense in social work. Conducting EBP is difficult. Even the founders of EBP and their most ardent supporters acknowledge that the evidence that has been found will have to be integrated with the expertise of the worker and the values and circumstances of the client (Sackett et al., 1997), which leads us to the opposing voices of EBP.

 

A major controversy relates to the perception that EBP is akin to practitioners being enslaved to the pursuit and application of ‘‘evidence’’ narrowly defined as randomized controlled trials (Upshur and Tracy, 2004; Webb, 2001; Goodacre, 2003; Gibbs and Gambrill, 2002). There are additional concerns that the research evidence is incomplete, misleading, unfairly biased, and detrimental to highly individualized practice. A frequently voiced criticism of EBP is that there is little relevant research available regarding most questions that a practitioner asks (Roberts and Yeager, 2006).

Further, it is often said that much of the research that is available is of little use because so many scientific studies are conducted in contexts that have little resemblance to realistic practice situations (Mullen and Streiner 2006).

Social workers and professionals from other disciplines (e.g., family therapists, psychotherapists, psychologists) who emphasize the uniqueness of clients and reject the medical metaphor of a prescriptive approach to working with people are the main antagonists of EBP. Others view EBP as a repackaged attempt to integrate research and practice that is fraught with educational and implementation problems (Webb, 2001). Furthermore, there are contentions and debates in social work about the theory and practice. Specifically, debates include [a] the possibility of straightforward application of abstract knowledge to everyday problem, [b] the power of professionals when applying their knowledge and expertise, as well as [c] the tension between the relationship between social workers and people they serve (Fargion, 2006).

 

We need to consider carefully that social work deals with decision tasks that concern the social rather than the physical world, and social reality consists of people attaching meaning to their own and others’ behavior, the basic elements that are needed to answer a clinical question or perform a decision analysis are not in any way ‘out there’, and thus can be subjective, relative and debatable (van de Luitgaarden, 2009).

The dual mandate of social work leads to more difficulties when conducting EBP because, on the one hand, it promotes emancipation and, on the other hand, is used as a means of social control and maintaining the social order. This shows that because criteria in social work practice are not singular, they cannot be turned into objectified numerical values.

 

Jordan (1978) argued that social work practice is influence by far more complex and remote forces than ‘a precise scientific knowledge for use can encompass, and it is vitally important that social workers understand some of these forces if they are to work effectively. Jordan concluded that ‘of course it is important for social work to try to evolve precise, testable theories. But it is also essential that it remains open to real moral, social and political dilemmas, and that it learns to live with inevitable uncertainty, confusion and doubt’ (p. 25). Along with Jordan, Parton (2000) added that ‘uncertainty, confusion and doubt’ are key elements in characterizing the nature of social work, and always have been. Rather than be embarrassed by this and try to define them out via increasingly scientized and rationalized approaches, social workers should recognize that they are at the core of what it is to do social work and are a significant factor in what makes it distinctive. This provides, perhaps, a real opportunity for social work to draw on its experience to help and inform other areas of social science. This leads us to discuss the recent development of practice-based evidence.

 

Practice-Based Evidence [PBE]

A new paradigm of practice-based evidence is well established in recent years (Margison et al., 2000). Inferences are drawn from naturalistic unselected clientele or clinical populations. The sample may be large, particularly when services pool routinely collected data through locally organized practice research networks. This group of researchers seeks different methods to learn about practice. They include:

  • surveys of clients and practitioners
  • studies of the impact of general processes in treatment that transcend orientation
  • effectiveness research that examines the impact of typical treatments on specific client populations with specific kinds of difficulties in real-world settings
  • progress research, in which client gains are regularly tracked during the treatment by the practitioner, without regard to the kind of intervention

 

Typically, the practice is with complex cases where practitioner competence may be more important than intervention adherence. Here, the practitioner comes out of the planning shadows and is a stakeholder in the form of the service and its delivery. Routine monitoring of outcome is an essential component with performance feedback to the practitioners and the service as a whole. This facilitates quality management by charting the expected and actual course of clients in the service with various conditions. Benchmarks allow one service to compare and review outcomes with other similar services. Several reliable, relevant, and sensitive psychometric systems for routine use have been developed. Evidence, audit and quality management are essential complements to clinical judgement (and supervision) in maintaining good practice.

 

Schön (1983; 1987) advocated for the development of practice knowledge in social work that could be derived from ‘reflection-in-action’ and emphasizes interaction and dialogue with people about the situation concerned. As a result, practitioners can come to understand the uniqueness, uncertainty and potential conflicts that must be addressed and thereby reaches a ‘new theory of the unique case’ that informs actions. Such an approach recognizes that social workers are not so much theoretical in the sense of applying scientific knowledge, as they are practical, concrete and intuitive and incorporate elements of art and craft as well as disciplined reasoning. Social work characterized as art rather than science is a theme which has been lost in many recent discussions of social work, yet art has the virtue of being able to accommodate notions of ambiguity and uncertainty in ways which pose major problems for rational-technical approaches (Parton, 2000). Scanlon et al. (2002) suggested that ‘reflection enables practitioners to tap into knowledge gained through experiences. The practitioner gains a deeper understanding of the meaning of the experience by bringing to consciousness tacit knowledge’ (p. 137). On a practical note, van de Luitgaarden (2009) suggested that instead of developing practice guidelines and data bases, a focus should be placed on developing individual worker’s decision making in such a way that corresponds to the ways in which experts take decisions in real-life settings. In other words, development of expertise should be stimulated with both social work education and social work practice.

 

So, should social workers shun EBP because social work is an art?  Or should workers learn to be more ‘scientific’ and rigorous so as to be recognized by the other professions and be able to generate more ‘valid’ and ‘reliable’ evidence?  To me, social work is both an art and a science that call for different kind of evidence, and different kind of knowledge because the world, especially the world of our service users are too dynamic and diverse.  Allow me to quote a famous Sichuan aphorism: ‘‘It does not matter if it is a black cat or white cat; a good cat is one that can catch the mice’’ (不管白貓黑貓, 会捉老鼠就是好貓). To be effective, we need to carefully consider different perspectives, methods, and varied evidences that are helpful in social work practice and education (Sim & Ng, 2008). Be it evidence-based evidence or practice-based evidence, I would like to urge social workers in Singapore to be engaged in practice research.

 

Practice research in social work

A group of social work experts gather in Salisbury of the United Kingdom in 2008 and defined practice research as followed (Southampton Practice Research Initiative Network Group in Salisbury, n.d.):

Practice research involves curiosity about practice. It is about identifying good and promising ways in which to help people; and it is about challenging troubling practice through the critical examination of practice and the development of new ideas in the light of experience. It recognizes that this is best done by practitioners in partnership with researchers, where the latter have as much, if not more, to learn from practitioners as practitioners have to learn from researchers. It is an inclusive approach to professional knowledge that is concerned with understanding the complexity of practice alongside the commitment to empower, and to realise social justice, through practice.”

Practice research involves the generation of knowledge of direct relevance to professional practice and therefore will normally involve knowledge generated directly from practice itself in a grounded way.

 

In developing the relationship between practice and research, principles of collaboration, participation, ethical reflexivity, critical reflection, contextuality, and

the dynamic, fluid or relational nature of research were held as fundament and crucial.

When carrying out practice research, both existing and new methods may be relevant in continuing to develop the ways in which the complexities of practice are researched. An inclusive approach (recognising multiple perspectives) is important in articulating paradigms therefore purely quantitative or purely qualitative approaches are seldom applicable. Practice research may often require creating new methods or innovatively using existing methods in ways which are congruent with the principles of collaboration, complexity, dialogue, relationality and contextuality. For example, methods such as participatory action research, or involving reflection and reflexivity, may lend themselves more readily to the purposes of practice research. The group believed that if there is to be dynamic dialogue between practice and research, the methods for devising research problems and questions directly from practice, and the relative roles of practitioners and researchers require further attention (Southampton Practice Research Initiative Network Group in Salisbury, n.d.). If I may add, the roles of service users in practice research from the onset should also be emphasized, as they are after all the end users whose lives would be affected by what the professional do and think.

I have been privileged to spearhead several practice research projects in the past decade in Singapore, Hong Kong and China. In a nutshell, I would use the acronym [P-R-O-F] to sum up my awfully rich experience in working with the stakeholders of these practice research projects that included clients, fellow social workers, governments, professional bodies, as I am convinced that practice research is powerful, rewarding, original and fulfilling.

 

Practice research can be POWERFUL. The impact of practice research is evident when we are able to make changes to the social-political contexts that our clients live in and are affected by via our practice research. For instance, in the Family Research and Consultation Network which I had the privilege of developing from 2005 to 2008 in Singapore, we focused on working with the families of ex-offenders (Sim, 2011a). Through meticulous and careful documentation in working with three cases over a period of two years, we were able to feedback to the authorities on pertinent issues in our rehabilitation systems that were making it difficult for ex-offenders to start a new life. Through practice research, we were able to realize the fundamental social work principle to promote human rights and social justice via advocacy with trustworthy evidences.

 

Practice research can be REWARDING.  Apart from the obvious changes we witness in both the service users and workers as we carefully review what we do, the inspirational changes and insights of our service users can be life changing for those who work with them. For instance, in the past five years working in a post-earthquake situation (Sim, 2009; Sim, 2011b), the earthquake survivors I ‘served” have helped me appreciate the resilience of life, including that exhibited by very young children (Sim & Qi, 2012). I often felt humbled by the little social workers can do or need to do. Together with my clients, we are currently compiling useful lessons learned in post-earthquake situations for publications, with the aim to inspire and help others in crises.

 

Practice research can be ORIGINAL. As the group of social work researchers, educators and practitioner who gathered in the UK to discuss practice research in 2008 highlighted that practice research needs to incorporate both new and old approaches of working and researching (Southampton Practice Research Initiative Network Group in Salisbury, n.d.), social workers could systematically develop original and context sensitive models to promote change. In the Family Research and Consultation Network, my fellow social workers in Singapore were able to develop a model for engagement (Sim, 2011c), assessment and intervention for ex-offenders (Sim, 2011d) through critical reflection and discussion.  Delightfully, through the systematic documentation and reflection, we have developed the first ever Chinese model of disaster social work focusing on mental health in Chinese post-disaster context (Sim, 2009; 2011)

 

Practice research can be FULFILLING AND FUN. In the past research projects I had in Singapore, Hong Kong and mainland China, the opportunity to work with  young and aspiring social workers, and develop alongside them was most fulfilling and fun. Despite the challenges and struggles they encounter, I am particularly impressed by young but committed and dedicated social workers in serving earthquake survivors in the remotest areas in Sichuan (2011b).  Together, we struggled in learning about the unknown territory of disaster social work, and eventually developing a post-disaster social work model. Soon, we look forward to consolidating practice toolkits which could be useful for disaster situations should the need arise. These young social workers have risen to the call despite the formidable challenges of working in a post-disaster situation (Sim et al., in press).

 

Through practice research, social workers can become more convincing, more accountable, and more respectable by stakeholders. But more importantly, through practice research, social workers could promote social change, problem solving in human relationships and the empowerment and liberation of people to enhance well-being. We ought to utilise theories of human behaviour and social systems, social work intervenes at the points where people interact with their environments (IASSW, IFSW), if I may add, cautiously, systematically, and reflectively through practice research.

 

The theme for this year’s Social Workers’ Day  Symposium is:  “One Vision, One Team”, which aims to underscore the importance of providing seamless care for our clients. The Singapore Association of Social Workers’ calls for social workers to provide client centric care is indeed a worthy and beautiful mental picture where social workers in Singapore shall work closely together, whether we believe in evidence-based practice or practice-based evidence. My hope for our field as we contemplate on practice research is that we will be different, diverse, and dynamic, so as to better serve our clients.

 

Dr. Timothy SIM

Associate Professor, The Hong Kong Polytechnic University