Evidence-Based Practice: A Common Definition Matters

More than a decade ago, a national survey of social work faculty suggested that although the majority (73%) were favorable toward the evidence-based practice (EBP) movement, a collective definition and understanding of EBP was lacking (Rubin & Parrish, 2007). Despite multiple efforts since that time to disseminate the EBP process model as originally defined by Sackett Richardson, Rosenberg, and Haynes (1997) and Sackett, Straus, Richardson, Rosenberg, and Haynes (2000) in field education (Edmond, Megivern, Williams, Rochman, & Howard, 2006; Matthieu, Carter, Casner, & Edmond, 2016; Parrish & Oxhandler, 2015; Tennille, Solomon, Brusilovskiy, & Mandell, 2016), social work educational programs (Bender, Altschul, Yoder, Parrish, & Nickels, 2013; Howard, McMillan, & Pollio, 2003), and the broader social work community (Bellamy, Bledsoe, Mullen, Lin, & Manuel, 2008; Mullen, Shlonsky, Bledsoe, & Bellamy, 2005; Parrish & Rubin, 2011), a broad sampling of the social work literature continues to reflect confusion with the term.

Much of this confusion has resulted from misconceptions about EBP based on inaccurate depictions in the literature, which discount key aspects of the EBP process, fail to cite or integrate the original EBP sources, or propose new models of EBP that share the same key elements as the original proposed model (Gambrill, 2016; Gibbs & Gambrill, 2002; Thyer, 2013). What is unfortunate about this discourse is that self-identified proponents and skeptics often seem to agree about the important elements of research-practice integration. The hang-up tends to lie in misunderstandings of how the EBP process model was originally defined and operationalized almost 2 decades ago. In fact, one may need to consume the original sources in medicine (Straus, Richardson, Glasziou, & Haynes, 2010) or in social work (Gibbs, 2003) to truly understand the entire model and how and why each step is implemented.

EBP was originally defined in the late 1990s as the “conscientious, explicit and judicious use of current best evidence in making decisions about the care of individuals [clients]” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p. 71) and “the integration of best research evidence with clinical expertise and [client] values” (Sackett et al., 2000, p. 1). As such, it is a decision-making process for practice that includes the following five steps: formulating an answerable practice question; searching for the best research evidence; critically appraising the research evidence for its validity and applicability; implementing a practice decision after integrating the research evidence with client characteristics, preferences, and values; and evaluating the outcome (Mullen, 2004; Shlonsky & Gibbs, 2004; Thyer, 2006). It is also notable that the original EBP process sources (Gibbs, 2003; Straus et al., 2010) clearly describe the application of this process to all kinds of practice questions including background questions on general knowledge about a condition, practice-related issue, or population (e.g., etiology, assessment, client experience and meaning) and foreground questions, which ask for specific knowledge to inform practice-related decisions (or effectiveness questions, also described as population, intervention, comparison, outcome questions).

The EBP process definition and decision-making approach differs greatly from the EBP definition, which refers to interventions, programs, or policies that certain entities (e.g., Society of Clinical Psychology, Division 12 of the American Psychiatric Association [APA]; Substance Abuse and Mental Health Services Administration; National Registry of Evidence-Based Programs and Practices) have deemed to have a desired level of research support regarding effectiveness. To help mitigate the confusion this term has had in the field, Division 12 of the APA stopped using the term evidence-based practices in 2006, noting these guidelines were not intended to support the dictation of specific forms of treatment (APA Presidential Task Force on EBP, 2006). The APA Presidential Task Force on EBP (2006) also shared its support of the original EBP definition: “Evidence-based practice in psychology (EBPP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture and preferences” (p. 272). Those in the fields of psychology and social work have noted the confusion and controversy the EBP definition has created, much of which can likely be traced to the way it was adopted and implemented by state, federal, and health care funding entities to mandate and restrict service delivery to those approaches deemed evidence based. Unfortunately, these parallel efforts to disseminate two very different definitions of EBP have led to great misperceptions regarding the kinds of research and practice-related expertise, skills, or interventions that are valued by the EBP process model. To clarify, this model: 1) values all forms of high quality inquiry (qualitative and quantitative) depending on the EBP question posed, 2) prioritizes the selection of interventions or programs based on research validity, applicability to the client and clinical/practice expertise, and 3) defines clinical expertise as the ability to think critically about these multiple sources of information (research, practice context and client characteristics) and then select and deliver the intervention using essential therapeutic relationship skills (e.g., common factors) (Gambrill, 2016; Straus et al., 2010). This model also emphasizes the evaluation of the EBP process and client outcomes (Gambrill, 2016).

Major efforts have been undertaken in social work and psychology over the past decade to correct such misconceptions of the EBP process by distinguishing the evidence-based process from the EBP definition and by referring to these practices as research supported or empirically supported (APA Presidential Task Force on EBP, 2006; Gibbs & Gambrill, 2002; Thyer & Myers, 2010). Given the lack of clarity about EBP terminology, many proponents of the EBP process (e.g., Gambrill, 2010) have adopted the term evidence-informed practice as a synonym of the EBP process, in part because the term evidence-based has taken on the connotation, by some, to imply that nonresearch factors are not important in the EBP process. Others have suggested the use of new labels (and new models that do not differ from the EBP process model) such as evidence-driven practice or evidence-guided practice. However, the continued proposal of additional terms is problematic as it serves to muddy the waters and adds to the lack of clarity and misunderstandings about the original EBP model.

Why does a common definition of the EBP process matter?

A common definition matters given the potential of the EBP process framework to teach students to engage in critical and reflective thinking, ethical practice rooted in client empowerment, and practice decisions that have the most promise for helping the clients they serve. Teaching the EBP process consistently across the curriculum can equip students with the following valuable skills: critical thinking and questioning of the status quo or authority; consideration of the best available research in the context of client preferences, values, and culture, as well as the larger environment; critical appraisal of different kinds of high-quality research to answer all kinds of EBP questions (e.g., effectiveness, general knowledge of a client population, effective assessment) related to practice; collaborative decision making, cultural sensitivity, empowerment, and informed consent with the client; and skills to evaluate practice decisions and improve the course of intervention as needed.

It emphasizes critical thinking and evaluation of practice

In an era of alternative facts and propaganda (Gambrill, 2010, 2016), as well as a proliferation of credible and noncredible sources on the Internet, there is no more important skill for social work students than to be critical consumers of information. EBP offers a framework for teaching critical thinking as a key element of practice decision making given its focus on questioning, curiosity, open-mindedness, analysis of multiple information sources, reflection, unbiased evaluation of outcomes, and thinking beyond agency protocol and practice wisdom (O’Neill, 2015; Profetto-McGrath, 2005). A bonus of the EBP approach, consistent with critical thinking, is teaching students to objectively evaluate their practice decisions, often using single-system designs, and to use that information to make ongoing decisions about practice. The integration of such evaluations—an important aspect of ethical social work practice—can also serve as a tool to collaboratively assess client progress and explore reasons for improvement or lack thereof.

It teaches social workers to be critical consumers of practice-related research

The most challenging part of teaching the EBP process is helping students understand how to pose useful EBP practice questions and critique the research they have identified. However, if research is taught from a consumer’s perspective (Rubin & Bellamy, 2012; Straus et al., 2010) in which students are taught to use rather than produce research, it can greatly influence their interest in research and their perceived efficacy with the process (Parrish & Rubin, 2011). Undergraduate and graduate social work students rarely get opportunities to do research during their programs, but if the EBP model is taught across courses, they will have several opportunities to practice and build their skills by asking varied kinds of EBP questions and critiquing the literature for its validity and applicability. Such an understanding of research is critical, as underscored by the National Association of Social Workers’ (2017) ethical mandate to keep current with emerging knowledge relevant to social work. If social workers continue to fear research or are unable to critically evaluate the literature, this may have serious consequences for their practice, including doing harm in the process of helping (Gambrill, 2001, 2006, 2007). Likewise, clients increasingly have access to reliable and dubious sources of information online and may present such findings to the practitioner. In these cases, social workers must be informed enough to answer or correct misconceptions or disinformation. Finally, the consistent critical analysis and integration of the most valid and applicable research for all populations can help achieve social justice and health equity by providing the very best services (McMillin, 2014; O’Neill, 2015).

Students learn to consider and respect client differences and self-determination and engage in informed consent

The EBP process emphasizes informed consent, or a shared decision-making process whereby the client is fully informed about the evidence supporting different approaches (including when there are none), potential risks and benefits, and what is involved with the interventions and any associated feasibility issues (Straus et al., 2010). Such an approach empowers clients and attends to the dynamics of power that may preclude a client from questioning practitioner-driven decisions (O’Neill, 2015). In addition, the client’s acceptance of an agreed-on approach in which the client’s unique preferences and characteristics are an equally important aspect of the decision is more likely to increase that client’s engagement and goal collaboration, which are potent common factors contributing to positive outcomes identified in psychotherapy research (Wampold, 2015). Finally, the EBP process emphasizes integrating the client’s unique background (e.g., culture, spirituality, age, gender) and preferences as key sources of information when making practice decisions. Specifically, a key aspect of the EBP process is to integrate these characteristics and relevant synonyms (e.g., youth, adolescent, teen) as literature search terms (Rubin & Parrish, 2015). This ensures the identification of the best available research for a specific client or population.

Conclusion

We need a common definition of EBP so that our profession can move past this circular debate that conflates the EBP process and EBP definitions. Moving forward with clarity will allow our profession to focus more energy on using the EBP process model to better prepare our students to think critically about the world and their practice, and purposely apply social work values, ethics, practice, and research in an integrated manner. Given the potential of the EBP process model as a truly integrated social work practice model, it is my sincere hope that it does not become a passing fad. After a decade of confusion, it is time for a consistent definition and understanding of the EBP process.