Identify the range of sources which constitute the evidence base for social work practice and how these sources inform decision making
In reviewing definitions of evidence based practice, a frequently cited one is the definition offered by Sackett, identified as the father of the evidence based medicine movement in England. He stated that evidence based practice is the conscientious, explicit and judicious use of current best evidence in making decision about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research (Gibbs, 2003). Evidence quality can be assessed based on the source type from meta analyses and systematic reviews of triple blind randomized clinical trials with concealment of allocation and no attrition at the top end, down to conventional wisdom at the bottom, as well as other factors including statistical validity, clinical relevance, currency, and peer review acceptance. EBM recognizes that many aspects of health care depend on individual factors such as quality and value of life judgments, which are only partially subject to quantitative scientific methods. Application of EBM data therefore depends on patient circumstances and preferences, and medical treatment remains subject to input from personal, political, philosophical, ethical, economic, and esthetic values. The Institute of defines evidence-based medicine as the integration of best researched evidence and clinical expertise with patient values. This evidence based medicine movement has morphed into a more generic focus on evidence based practice, and the discussions can now be found in the broad health and behavioral health arena, as well as in the context of education, criminal justice, and child welfare services (Institute of Medicine, 2001). In the social work profession, evidence based practice is receiving increasing attention. The scholar has been addressed several basic premises that support a social work focus on EBP, including commitment to clients best interest, values guided practice, goal directed practice, accountability, and commitment to scientific standards of evidence. Some scholars suggested that placing the client’s benefits first, evidence based practitioners adopt a process of lifelong learning that involves continually posing specific questions of direct practical importance to clients, searching objectively and efficiently for the current best evidence relative to each question and taking appropriate action guided by evidence. In response to this call to use evidence-based interventions, concerns arise that evidence based interventions might be too prescriptive because services will be developed according to guidelines without attention to individual client needs (McCall and Green, 2004). A comprehensive definition of EBP is intended, however, to take into account the values, ethics, and individual situation of the client. Evidence based practice is a process for making practice decisions in which practitioners integrate the best research evidence available with their practice expertise and with client attributes, values, preferences, and circumstances. Evidence based practice involves a practitioner bringing their own knowledge and skills together with best quality evaluation research to make a decision about selecting what programme/intervention is most appropriate to the parents/children they are working with. The results of population based research form the foundation of evidence based medicine. It aims to use the experience of a population of patients reported in the research literature to guide decision making in practice. This practice of evidence based medicine, which later evolved to evidence-based health care, requires the application of population based data to the care of an individual patient. In the past, we have relied on the experience of physicians or other health care workers to make decisions about therapy. In the current information era, this approach would be suboptimal as health care workers rapidly find themselves unable to cope with the influx of a huge variety of new information, from the irrelevant to the very important (Rosen, 2003). Therefore, Evidence-based decision making gradually emerged as a solution to integrate the best research evidence with clinical expertise and patient values and expectations as practiced by the individual health care provider. The concepts and ideas attributed to and labeled collectively as EBM/EBHC have now become a part of daily clinical lives, and health care professionals increasingly hear about evidence-based guidelines, care paths, questions and solutions. The controversy has shifted from whether to implement the new concepts to how to do so sensibly and efficiently, while avoiding potential problems associated with a number of misconceptions about what EBM/EBHC is and what it is not. The EBM/EBHC related concepts of hierarchy of evidence, meta-analyses, confidence intervals, study design, and so forth are so widespread, that health care professionals have no choice but to become familiar with EBM/EBHC principles and methodologies (Sackett et at., 1996).
Recognise the usefulness of inquiry reports as sources of evidence for the development of future social work practice
Inquiries, in my view, should be conducted as far as possible in the public domain. This issue arose recently in respect of the Shipman Inquiry in which a decision to hold a substantial part of the inquiry in private was overruled by the High Court (Collins, 2000) It is important that inquiries are carried out in such a way that there can be no appearance of a cover up, while ensuring that the proceedings are not a substitute for a criminal or disciplinary process. It is also necessary to make sure that individuals’ rights are protected as far as possible. However, a balancing of a number of peoples’ rights will often have to be undertaken. Relevant to that difficulty is whether inquiries should be conducted in an inquisitorial or adversarial manner. Many inquiries, it has been said, claim to prefer the former approach (Carr and Kemmis, 2006). In other words, the inquiry is not restricted to evidence produced by the parties and the way they present it. The inquiry can, through a counsel to the inquiry, carry out its own thorough investigation. However, it is essential, in my view, that there is cross-examination of witnesses. The trend recently has been only to permit counsel to the inquiry to question witnesses. The reality is probably that inquiries, apart from internal ones, are mostly a mixture of the inquisitorial and adversarial approaches. The introduction of ‘Salmon Letters’, named after a well-known judge, has ensured that potential witnesses are informed of allegations which may be made against them and of possible criticism. This has become standard procedure in inquiries. The messages from the Care Inquiry evidence sessions, that the system should be one that enables positive relationships to be established and maintained, are absolutely consistent with by feedback from the research in practice network. This year our members have asked us to focus on relationship based practice, managing contact, working effectively with families at risk of entering the care system, and supporting carers (Dingwall, 2003). What of the practical impact of inquiries? In the child care field, we have learnt of the terrible abuse that has taken place in, for example, residential children’s homes. As a result, some children and young people have been able to come to terms with what happened to them and, in some cases, to obtain compensation in the civil courts. Some very necessary reforms have taken place. Some remain gathering dust. Overall I believe there is a feeling that we are still generally awash with recommendations that have not been implemented, or effectively implemented. No one can doubt that there will be more scandals in the future and there are bound to be more recommendations about more effective inter-agency working in the child care field (Fahl and Markand, 2007). It has been mooted that child care inquiries have failed at great cost to the public purse and should, therefore, be discontinued. There has certainly been a trend towards many more internal reviews which, unfortunately, have far less public exposure. I do not think that public inquiries should, or will, be made redundant. Their role is still, in appropriate circumstances, of great importance and it is vital that energetic people of integrity are prepared to carry out thorough investigations. There is a clear desire within the sector to understand how to improve these areas and it is a real privilege to be working alongside people to this end. To get a complete picture, it is important to take a systematic and ongoing approach to collecting, analysing, and interpreting data in order to gain a wide variety of useful evidence. Useful evidence is evidence that helps provide answers to the questions or hypotheses being investigated (Fisher, 2009). This means that the tools and approaches used to gather data must relate to the purpose of the inquiry and the context in which it is taking place. Site based inquiry can draw on informal evidence, such as observations and interviews, and formal evidence, such as standardised achievement data. Related research findings by others from outside the immediate context are another valuable source of evidence, provided it too is collected and actively interpreted for the purpose and the context. The distinction between inquiry and research also points to the centrality of research to a culture of inquiry. Published research should be a rich source of information for those engaged in reflecting on their work practices or in developing policy, provided that it is not simply transferred un problematically but is read in the context of the issues being explored through inquiry. Once the inquiry report is completed and handed over, matters are then left in the hands of central and/or local Government and so often seem to get lost. It has been suggested that recommendations from inquiries should become legislative proposals immediately. I think that this is too ambitious and, constitutionally and practically, too difficult (Hall, 2006). However, there is scope for a small body to be set up to monitor the progress of the implementation of the results of inquiries on a regular basis. In respect of children, this is another important function that could be carried out by an independent children’s commissioner. Such a post is, in my view, urgently required in England.
Analyse against an identified framework the relationship between agency policy, legal requirements, research, practitioner knowledge and the voice of service users.
Good quality of care requires competently delivered services that meet the client’s needs by practitioners who are appropriately supported and accountable. Practitioners should give careful consideration to the limitations of their training and experience and work within these limits, taking advantage of available professional support (Kirk and Reid, 2007). If work with clients requires the provision of additional services operating in parallel with counselling or psychotherapy, the availability of such services ought to be taken into account, as their absence may constitute a significant limitation. Good practice involves clarifying and agreeing the rights and responsibilities of both the practitioner and client at appropriate points in their working relationship. Dual relationships arise when the practitioner has two or more kinds of relationship concurrently with a client, for example client and trainee, acquaintance and client, colleague and supervisee. The existence of a dual relationship with a client is seldom neutral and can have a powerful beneficial or detrimental impact that may not always be easily foreseeable. For these reasons practitioners are required to consider the implications of entering into dual relationships with clients, to avoid entering into relationships that are likely to be detrimental to clients, and to be readily accountable to clients and colleagues for any dual relationships that occur. Practitioners are encouraged to keep appropriate records of their work with clients unless there are adequate reasons for not keeping any records (Lang, 2004). All records should be accurate, respectful of clients and colleagues and protected from unauthorised disclosure. Practitioners should take into account their responsibilities and their clients’ rights under data protection legislation and any other legal requirements. Clients are entitled to competently delivered services that are periodically reviewed by the practitioner. These reviews may be conducted, when appropriate, in consultation with clients, supervisors, managers or other practitioners with relevant expertise (McIvor, 2005).
All counsellors, psychotherapists, trainers and supervisors are required to have regular and on-going formal supervision/consultative support for their work in accordance with professional requirements (Gibbs, 2003). Managers, researchers and providers of counselling skills are strongly encouraged to review their need for professional and personal support and to obtain appropriate services for themselves. Regularly monitoring and reviewing one’s work is essential to maintaining good practice. It is important to be open to, and conscientious in considering, feedback from colleagues, appraisals and assessments. Responding constructively to feedback helps to advance practice. A commitment to good practice requires practitioners to keep up to date with the latest knowledge and respond to changing circumstances. They should consider carefully their own need for continuing professional development and engage in appropriate educational activities. Practitioners should be aware of and understand any legal requirements concerning their work consider these conscientiously and be legally accountable for their practice (Institute of Medicine, 2001).
The practice of counselling and psychotherapy depends on gaining and honouring the trust of clients. Keeping trust requires:
Attentiveness to the quality of listening and respect offered to clients
Culturally appropriate ways of communicating that are courteous and clear
Respect for privacy and dignity
Careful attention to client consent and confidentiality
Clients should be adequately informed about the nature of the services being offered. Practitioners should obtain adequately informed consent from their clients and respect a client’s right to choose whether to continue or withdraw. Practitioners should ensure that services are normally delivered on the basis of the client’s explicit consent. Reliance on implicit consent is more vulnerable to misunderstandings and is best avoided unless there are sound reasons for doing so (McCall and Green, 2004). Overriding a client’s known wishes or consent is a serious matter that requires commensurate justification. Practitioners should be prepared to be readily accountable to clients, colleagues and professional body if they override a client’s known wishes. Situations in which clients pose a risk of causing serious harm to themselves or others are particularly challenging for the practitioner. These are situations in which the practitioner should be alert to the possibility of conflicting responsibilities between those concerning their client, other people who may be significantly affected, and society generally. Resolving conflicting responsibilities may require due consideration of the context in which the service is being provided (Rosen, 2003). Consultation with a supervisor or experienced practitioner is strongly recommended, whenever this would not cause undue delay. In all cases, the aim should be to ensure for the client a good quality of care that is as respectful of the client’s capacity for self-determination and their trust as circumstances permit. Working with young people requires specific ethical awareness and competence. The practitioner is required to consider and assess the balance between young people’s dependence on adults and carers and their progressive development towards acting independently. Working with children and young people requires careful consideration of issues concerning their capacity to give consent to receiving any service independently of someone with parental responsibilities and the management of confidences disclosed by clients. Respecting client confidentiality is a fundamental requirement for keeping trust (Sackett et at., 1996). The professional management of confidentiality concerns the protection of personally identifiable and sensitive information from unauthorised disclosure. Disclosure may be authorised by client consent or the law. Any disclosures should be undertaken in ways that best protect the client’s trust. Practitioners should be willing to be accountable to their clients and to their profession for their management of confidentiality in general and particularly for any disclosures made without their client’s consent. Practitioners should normally be willing to respond to their client’s requests for information about the way that they are working and any assessment that they may have made. This professional requirement does not apply if it is considered that imparting this information would be detrimental to the client or inconsistent with the counselling or psychotherapeutic approach previously agreed with the client. Clients may have legal rights to this information and these needs to be taken into account. Practitioners must not abuse their client’s trust in order to gain sexual, emotional, financial or any other kind of personal advantage. Sexual relations with clients are prohibited. ‘Sexual relations’ include intercourse, any other type of sexual activity or sexualised behaviour (Carr and Kemmis, 2006). Practitioners should think carefully about, and exercise considerable caution before, entering into personal or business relationships with former clients and should expect to be professionally accountable if the relationship becomes detrimental to the client or the standing of the profession. Practitioners should not allow their professional relationships with clients to be prejudiced by any personal views they may hold about lifestyle, age, gender, disability, gender reassignment, race, sexual orientation, pregnancy and maternity, religion or belief, marriage and civil partnership. Practitioners should be clear about any commitment to be available to clients and colleagues and honour these commitments (Collins, 2000).
Principles direct attention to important ethical responsibilities. Each principle is described below and is followed by examples of good practice that have been developed in response to that principle. Ethical decisions that are strongly supported by one or more of these principles without any contradiction from others may be regarded as reasonably well founded. However, practitioners will encounter circumstances in which it is impossible to reconcile all the applicable principles and choosing between principles may be required (Dingwall, 2003). A decision or course of action does not necessarily become unethical merely because it is contentious or other practitioners would have reached different conclusions in similar circumstances. A practitioner’s obligation is to consider all the relevant circumstances with as much care as is reasonably possible and to be appropriately accountable for decisions made. Being trustworthy is regarded as fundamental to understanding and resolving ethical issues. Practitioners who adopt this principle: act in accordance with the trust placed in them, regard confidentiality as an obligation arising from the client’s trust; restrict any disclosure of confidential information about clients to furthering the purposes for which it was originally disclosed (Fahl and Markand, 2007). Practitioners who respect their clients’ autonomy: ensure accuracy in any advertising or information given in advance of services offered; seek freely given and adequately informed consent, engage in explicit contracting in advance of any commitment by the client, protect privacy, protect confidentiality, normally make any disclosures of confidential information conditional on the consent of the person concerned; and inform the client in advance of foreseeable conflicts of interest or as soon as possible after such conflicts become apparent. The principle of autonomy opposes the manipulation of clients against their will, even for beneficial social ends (Fisher, 2009). It directs attention to working strictly within one’s limits of competence and providing services on the basis of adequate training or experience. Ensuring that the client’s best interests are achieved requires systematic monitoring of practice and outcomes by the best available means. It is considered important that research and systematic reflection inform practice (Hall, 2006). There is an obligation to use regular and on-going supervision to enhance the quality of the services provided and to commit to updating practice by continuing professional development. An obligation to act in the best interests of a client may become paramount when working with clients whose capacity for autonomy is diminished because of immaturity, lack of understanding, extreme distress, serious disturbance or other significant personal constraints (Kirk and Reid, 2007).
The practitioner’s personal moral qualities are of the utmost importance to clients. Many of the personal qualities considered important in the provision of services have an ethical or moral component and are therefore considered as virtues or good personal qualities. It is inappropriate to prescribe that all practitioners possess these qualities, since it is fundamental that these personal qualities are deeply rooted in the person concerned and developed out of personal commitment rather than the requirement of an external authority. Personal qualities to which counsellors and psychotherapists are strongly encouraged to aspire include (Lang, 2004) (McIvor, 2005):
Empathy: The ability to communicate understanding of another person’s experience from that person’s perspective.
Sincerity: A personal commitment to consistency between what is professed and what is done.
Integrity: Commitment to being moral in dealings with others, personal straightforwardness, honesty and coherence.
Resilience: The capacity to work with the client’s concerns without being personally diminished.
Respect: Showing appropriate esteem to others and their understanding of themselves.
Humility: The ability to assess accurately and acknowledge one’s own strengths and weaknesses.
Competence: The effective deployment of the skills and knowledge needed to do what is required.
Fairness: The consistent application of appropriate criteria to inform decisions and actions.
Wisdom: Possession of sound judgement that informs practice.
Courage: The capacity to act in spite of known fears, risks and uncertainty.
The challenge of working ethically means that practitioners will inevitably encounter situations where there are competing obligations. In such situations it is tempting to retreat from all ethical analysis in order to escape a sense of what may appear to be un resolvable ethical tension. These ethics are intended to be of assistance in such circumstances by directing attention to the variety of ethical factors that may need to be taken into consideration and to alternative ways of approaching ethics that may prove more useful. No statement of ethics can totally alleviate the difficulty of making professional judgements in circumstances that may be constantly changing and full of uncertainties. By accepting this statement of ethics, members of the British Association for Counselling and Psychotherapy are committing themselves to engaging with the challenge of striving to be ethical, even when doing so involves making difficult decisions or acting courageously (Sackett et at., 1996).
It is now widely understood that professional practice must be informed by research and that students should also learn how to take this approach. This idea is not new, but the idea of evidence based practice has gained a higher profile in recent years. For example, Rosen, (2003) asserted that many of the processes and skills used in professional practice also support research work. He drew a parallel between the main tasks of the social worker and the researcher:
|Determine intervention plan||Research strategy|
|Implement intervention||Collect data|
|Evaluate intervention effects||Analysis of data|
|Review and termination||Conclusions|
Others have made a philosophical argument about the inter-dependence of professional practice and research, including how the combination can be mutually enriching. This resource aims to show you how to build those bridges between research, learning and practice, so that research-mindedness becomes an every-day perspective that informs what you do and how you do it. A care manager in an elderly person’s team in a Social Services Department wanted information on local voluntary groups willing to visit elderly people to provide a friendly contact, especially in cold weather (Gibbs, 2003). A list of such groups already existed in the office, but the care manager suspected it was out of date and possibly incomplete. She wrote to each of the groups on the list to ask whether they still visited elderly people, and if so how many volunteers they had available (Institute of Medicine, 2001). She also wrote to local faith organisations and other relevant groups, as well as asking her colleagues, in an effort to identify new groups. The care manager used local knowledge and contacts to spread the net for new groups, and asked a couple of questions of each so as to establish whether they did visiting and how much they could take on. Once gathered the data was used to provide a resource for all staff in the office (McCall and Green, 2004).