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Abstract

Evidence-based practice (EBP) is an orientation to practice that values evidence as a resource for clinical decision making while recognizing that evidence alone is never sufficient to make a clinical decision. Critics of EBP typically ignore, negate, or misrepresent the role of practitioner thinking processes and expertise in clinical settings. The authors believe that, far from being a mechanistic process that ignores practitioner expertise, reflection and critical thinking are essential to implementing EBP in real-world clinical practice. The purpose of this article is to provide guidance for how practitioners bring their expertise to bear when engaging in the process of EBP. The authors use a social work practice scenario to illustrate the application of practitioner expertise in each of the five steps of EBP.
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Research on Social Work Practice
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The online version of this article can be found at:
DOI: 10.1177/1049731507308143
2008 18: 301 originally published online 29 October 2007Research on Social Work Practice
Stanley G. McCracken and Jeanne C. Marsh
Practitioner Expertise in Evidence-Based Practice Decision Making
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Practitioner Expertise in Evidence-Based
Practice Decision Making
Stanley G. McCracken
Jeanne C. Marsh
University of Chicago
Evidence-based practice (EBP) is an orientation to practice that values evidence as a resource for clinical deci-
sion making while recognizing that evidence alone is never sufficient to make a clinical decision. Critics of EBP
typically ignore, negate, or misrepresent the role of practitioner thinking processes and expertise in clinical set-
tings. The authors believe that, far from being a mechanistic process that ignores practitioner expertise, reflection
and critical thinking are essential to implementing EBP in real-world clinical practice. The purpose of this article
is to provide guidance for how practitioners bring their expertise to bear when engaging in the process of EBP.
The authors use a social work practice scenario to illustrate the application of practitioner expertise in each of
the five steps of EBP.
Keywords: evidence-based practice; practitioner expertise; clinical decision making; research implementation;
social work practice; clinical research
301
Evidence-based practice (EBP) is a process of using
research findings to aid clinical decision making. EBP
promotes the collection, interpretation, and utilization
of evidence that has been derived from client reports,
clinician observations, and empirical research. EBP is
an orientation to practice that values evidence as a
resource for clinical decision making while recogniz-
ing that evidence alone is never sufficient to make a
clinical decision (Berlin & Marsh, 1993; Guyatt &
Rennie, 2002; Sackett et al., 1996; Weisz & Addis,
2006).
Practitioner expertise is an important element in EBP
decision making. Although there has been an increasing
interest in the functioning of experts and expertise in a
variety of settings (Dreyfus & Dreyfus, 2005; Ericsson
et al., 2006; Mieg, 2001), little of this work has focused
on social work practice or EBP in social work. Sheppard
et al. (2000) provide an example of social work scholar-
ship concerned with the role of expertise. They identify
specific thinking processes related to social work decision
making. Berlin and Marsh (1993) also examine the knowl-
edge and information as well as the thinking processes
required to draw inferences and make decisions in prac-
tice. They review the research on human information
processing, perception, and problem solving as it relates to
clinical decision making to understand how the practi-
tioner shapes, organizes, and uses information in practice.
To make sense of large quantities of information that we
are confronted with on a daily basis, clinicians, like all
human beings, rely heavily on judgmental heuristics or
rules of thumb. Clinical decision making, and human
information processing more generally, is vulnerable to
predictable sources of bias and improved by both evidence
and decision aids that guide and formalize the decision-
making process.
Critics of EBP typically ignore, negate, or misrepresent
the role of practitioner thinking processes and expertise in
clinical settings. Rather than contributing to routinized,
automatic decision making that can characterize conven-
tional approaches to practice, EBP requires reflection and
critical thinking. Although the exigencies of everyday
helping require some reliance on shortcuts or tried and
true methods, EBP pushes the practitioner to improve the
quality of decisions made by systematically reviewing
information from rigorous data-gathering efforts instead
of relying on customary practice or agency policy.
Authors’ Note: This manuscript was based in part on a presentation by the
second author at the conference titled What Works: An International
Conference, held at the University of Bielefeld, Germany, on November 10-
12, 2005. The authors would like to acknowledge the contribution of Bridget
Colaccio Wesley and Elisabeth Kinnel who initially presented the case study
used as the basis for the case discussed in this article. While the case mater-
ial has been further modified and is an amalgamation of cases seen in their
program, the clinical question, search, and decisions reflect those made by
Ms. Colaccio Wesley with the assistance of Ms. Kinnel. The authors are
grateful for the comments of Chris Leiker on an earlier draft of this article.
This article was invited and accepted by the editor.
Research on Social Work Practice, Vol. 18 No. 4, July 2008 301-310
DOI: 10.1177/1049731507308143
© 2008 Sage Publications
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We define practitioner expertise as a set of cognitive
tools that aid in the interpretation and application of evi-
dence. This set of tools for thinking develops over a
period of extended practice such that the individual with
experience in a decision area is likely to respond very dif-
ferently from the novice. We suggest that practitioner
expertise includes three overlapping knowledge and skill
sets: clinical, technical, and organizational. The clinical
component includes knowledge, skills, and experience
related to direct practice with client systems and includes
diagnostic, assessment, and goal/problem formulation
skills; engagement, relationship enhancing, and other
knowledge and skills related to the communication of
empathy, warmth, and genuineness; and knowledge of
theory and mastery of skills related to specific models and
interventions (Barlow, 2004; Lambert & Barley, 2001).
Technical knowledge and skills related to formulating
questions, conducting an electronic search, and evaluat-
ing validity and reliability of findings are needed in order
to use evidence to make real-time decisions about prac-
tice (Gibbs, 2003). Finally, practitioners who deliver ser-
vices in a team or agency context need skills and
knowledge related to teamwork, organizational design
and development, and leadership, particularly when EBP
is used to inform decision making in program develop-
ment (McCracken & Corrigan, 2004).
The purpose of this article is to provide guidance for
practitioners seeking to bring their expertise to bear when
engaging in the process of EBP. Practitioners not only
need to be able to identify the best evidence to address the
clients’ concerns but also must use their expertise to inter-
pret the evidence and apply it appropriately to their
client’s situation (Haynes, Devereaux, & Guyatt, 2002).
We will use a practice scenario to illustrate how clinical,
technical, and organizational expertise are used in each of
the steps of EBP. We will begin each section with the
practice scenario and then comment on the decisions and
actions taken by the practitioner.
SOCIAL WORK PRACTICE SCENARIO
1
Ms. W is a social worker in a community agency that
provides in-home and agency-based services to parents
and children involved with the state department of child
and family services and the foster care system. She was
referred a 5-year-old, Mexican American girl, Marie,
who was living with foster parents and was in the
process of being adopted by them. Marie had been
removed from her mother a year earlier because of
physical abuse, neglect, and allegations of having been
fondled by her mother’s boyfriend. At the time she was
removed from her biological mother, she was malnour-
ished and had bruises and burns on her body. Prior to
bringing Marie to live with them, the foster parents had
expressed an interest in adopting an infant. Marie was
referred to the agency because her foster parents (in
their early 20s) wanted to adopt her but were concerned
because she was engaging in sexualized play with her
toys. The client/family presenting problems include
Marie’s anxious and inappropriate sexual behavior at
home and school, foster parents’ fear and anxiety about
parenting Marie, foster parents’ lack of understanding of
child development and inappropriate expectations of
Marie, disrupted attachment to her biological mother,
and concerns about the lack of attachment between
Marie and her foster parents. In the course of her evalu-
ation, Ms. W gathered data from Marie, her parents, and
her teachers; she observed Marie alone and interacting
with her parents in the office and at home; and she
reviewed department of child and family services
records. Clinical questions: How should the presenting
problems be prioritized? What intervention would most
effectively address these problems?
Decision-Making Steps in EBP
EBP can be defined in terms of five steps that serve
to structure decision making and ensure optimum use of
practitioner expertise (Sackett et al., 2000). In the
remainder of the article, we move through the steps indi-
cating specific skill sets required and how practitioner
expertise comes into play at each point in the decision-
making process. The steps are as follows:
1. convert the need for information into an
answerable question;
2. track down with maximum efficiency the best
evidence with which to answer that question;
3. critically appraise that evidence for its validity
and usefulness;
4. integrate the critical appraisal with practitioner
clinical expertise and with the client values,
preferences, and clinical circumstances and
apply the results to practice; and
5. evaluate the outcome.
STEP 1: CONVERTING INFORMATION
NEEDS INTO A WELL-FORMULATED
ANSWERABLE QUESTION
Practice Scenario
The first clinical decision for Ms. W was, “How
should Marie and her family’s presenting problems be
prioritized?” Specifically, she wondered whether the
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problems could be prioritized and clustered in such a
way that one intervention could address several of the
most important problems simultaneously. She deter-
mined that her information needs included the clinical
information about Marie, her foster parents, and their
interaction; parent preferences for treatment; and depart-
ment of child and family services expectations for treat-
ment. Ms. W was able to form a collaborative working
relationship with Marie and her foster family during the
assessment. In addition to the other information gathered,
Ms. W learned that Marie’s biological mother had made
no attempt to contact the child or the foster family during
the ten months after Marie was removed from the home.
Based on the information gathered during assessment, she
determined that the clinical priorities were (a) monitoring
and strengthening the attachment between Marie and the
foster parents and helping Marie process the abuse trauma,
(b) teaching parenting skills and providing information to
the parents, and (c) modifying/regulating Marie’s anx-
ious and inappropriate sexual behavior at home and
school. Based on a previous search for background
information about child abuse, Ms. W’s reasoning for
prioritizing the problems in this order is that both the
anxious and inappropriate sexual behavior and the
problems with attachment were probably related to
Marie’s history of physical and sexual abuse and dis-
rupted attachment to her biological mother. She also
believed that it might be possible to identify activities
that would address both the bond between Marie and
her foster parents and the lack of parenting skills.
Agency expectations were that treatment would be
provided in the client’s home, initial treatment would
be short term, and ethical standards and legal responsi-
bilities would be upheld.
The second clinical decision for Ms. W was, “What
intervention would most effectively address the problems
identified?” Ideally, this intervention should either include
the parents or be taught to the parents so that they would
increase their parenting skills and so that changes would
be maintained. Information needs were external evidence
about whether there is an effective (home-based) treat-
ment (involving the parents) to help reduce the effects of
trauma in Mexican American preschool children who
have been physically or sexually abused and to increase
bonding between the child and foster parents. Ms. W for-
mulated the following initial question to guide her search
of the literature: For a Mexican American, preschool
child in foster care who has been physically and sexually
abused, what is the most effective home-based treatment
involving the parents to increase bonding between the
child and the parents and to decrease anxious and sexu-
ally inappropriate behaviors.
Comment
The clinical decision-making question at this step is,
“Is there a need for additional information in order to
identify and apply the most effective intervention for my
client (system),
2
and if so, what information do I need?”
EBP begins with a well-formulated question based on a
thorough evaluation of the client’s condition. However,
before that can occur, the therapist must engage the
client and establish a collaborative working relationship
using empathy, warmth, congruence, genuineness, and
other factors that influence therapy outcome (Lambert
& Barley, 2001). The therapist’s approach to engaging
and assessing the client may be influenced by back-
ground information
3
about individual development, cog-
nitive processing, and cultural influences on the
experience and presentation of problems and on the
development of interpersonal relationships (Comas-
Diaz, 2006; Guyatt & Rennie, 2002).
Any clinical encounter may yield a number of poten-
tial practice questions, and expertise in assessment and
diagnosis is needed to identify and help the individual
prioritize problems and goals. Once these are identified,
the practitioner draws upon expertise to consider
whether evidence exists that would be useful to guide
decision making and to formulate a question that is
likely to provide relevant information to guide work
with that particular client. One frequent complaint of
practitioners engaged in EBP in community agencies is
that there is a lack of research addressing populations
seen in practice, for example, individuals with dual dis-
orders and economically disadvantaged and minority
clients (McCracken, Steffen, & Hutchins, 2007). A
practitioner working with specific groups may need to
use a multi-pronged approach to identify useful evi-
dence, such as formulating both a problem-focused
question, for example, what sort of intervention is most
likely to reduce suicidal thinking and parasuicidal
behaviors in an adolescent with depression, and another
question about client characteristics, for example, what
sorts of approaches have been found to be effective with
Hispanic adolescents.
STEP 2: TRACKING DOWN WITH MAXIMUM
EFFICIENCY THE BEST EVIDENCE WITH
WHICH TO ANSWER THE QUESTION
Practice Scenario
Ms. W had used a wide variety of search engines in
her graduate training; however, she had access to none
of these search engines (e.g., OVID, PsychInfo, Social
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Work Abstracts) at her current place of employment.
She conducted her searches in PubMed and Google
Scholar. Ms. W initially included all of the terms, with
synonyms as alternate search terms, from the original
question in her search in hopes that she would locate
studies that would be specific to Marie and her situation.
However, given her previous experience in searching lit-
erature on treatment of young children, she was not sur-
prised that search terms from the question as initially
formulated failed to yield any relevant studies. This led
her to reduce the number of terms in her search. Given
Marie’s circumstances (e.g., the foster mother was second-
generation Cuban American and the foster father was of
non-Hispanic, White ancestry), Ms. W felt that the age
of the child and her history of abuse were the most
important and most fruitful components of the portion
of the question addressing client characteristics and
problem. While the fact that the child was in foster care
was an important clinical consideration, Ms. W felt that
it was likely that an intervention that would improve
bonding in parents also would increase bonding in fos-
ter parents. She decided that she would drop this from
her question, though she would note whether samples
included foster children and, if so, weight these more
heavily in her assessment of relevance of the literature to
her client. Finally, she felt that it would be wise to search
for the most effective intervention regardless of whether
or not the research was on home-based services and
whether or not it included parents. She decided that in-
home delivery of services involving the parents could be
addressed as implementation issues and should not
restrict the range of studies examined. Her revised ques-
tion was, therefore, “For a preschool child who has been
physically or sexually abused, what intervention is most
effective in increasing bonding between the parents and
the child and in decreasing anxiety and inappropriate sex-
ual behaviors?” Ms. W also added search terms that
would identify high-quality research (e.g., controlled,
random, double-blind, meta-analysis, systematic review).
When she searched terms related to the broader question,
she identified several studies that appeared appropriate.
This search also led her to the Web site for the National
Child Traumatic Stress Network, which allowed her to
access the full text of several useful articles.
Comment
Once it is determined that additional information is
needed and a practice question is formulated, the clini-
cal decision-making issue is, “What is the best place to
get this information, and how do I structure my search
to efficiently get the information I need?” Both the
effectiveness of the search (i.e., locating the evidence
needed to inform the clinical decision) and efficiency in
conducting the search are important. Practitioner exper-
tise is necessary at this step to identify potentially use-
ful search terms and to reject those which do not fit the
client’s condition. Experience and expertise also guide
selection of the level of evidence most appropriate to
answering the question (e.g., single studies, systematic
reviews, synopses, or systems), as well as the research
design, and thus the methodological search terms most
appropriate to the question (Guyatt & Rennie, 2002;
Heneghan & Badenoch, 2006). Expertise at this step
also is important to conduct searches efficiently. The top
priority for practitioners is providing services to clients,
while the incentive system often rewards the quantity of
care provided (Weisz & Addis, 2006). Efficiency is
essential for EBP to be a realistic tool for clinical deci-
sion making in the real world. Expertise at this step
helps avoid dead ends in the search and provides the
practitioner with the confidence that the results of the
search are an accurate reflection of the state of the evi-
dence on the question being asked.
STEP 3: CRITICALLY APPRAISING
THE EVIDENCE FOR ITS VALIDITY
AND USEFULNESS
Practice Scenario
Ms. W successfully located randomized controlled
trials of interventions that addressed the treatment of
children who have been abused or who were targeted for
increasing the bonding/attachment between child and
parent. She evaluated the quality of several of these
studies using the Quality of Study Rating Form (Gibbs,
2003) and found promising research supporting two dif-
ferent interventions—cognitive behavioral treatment
(CBT; e.g., Cohen et al., 2004) and child parent psy-
chotherapy (CPP; Lieberman, Van Horn, & Ippen, 2005;
Toth et al., 2002). She found that the external evidence
supporting CBT for symptoms of posttraumatic stress
disorder in children was much stronger, including sev-
eral randomized clinical trials plus a meta-analysis, than
the evidence supporting CPP, which consisted of two
randomized clinical trials, a six-month follow-up study,
and a study examining different outcome measures.
However, when she considered the relevance of the
study for her clients, she found several factors that sug-
gested CPP might be a better choice. First, CPP has
been studied with preschool children while most of the
literature on CBT has examined older children. Second,
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CPP specifically focuses on the relationship between the
mother and the child. Finally, the sample in the study by
Lieberman and colleagues (2005) was multi-ethnic,
from mixed socio-economic levels. On the other hand,
CBT has been studied in children in whom the symp-
toms of posttraumatic stress disorder result from abuse
of the children, while the children in one of the studies
of CPP experienced symptoms of posttraumatic stress
disorder as a result of abuse to their mothers (Lieberman
et al., 2005). When considering both the research evi-
dence and applicability factors, Ms. W gave particular
weight to the age of the child and the fact that the heal-
ing within CPP is hypothesized to occur within the con-
text of a safe and secure attachment between mother and
child in arriving at her decision that CPP would be the
better intervention to use in this case.
Comment
This step includes two equally important questions
for clinical decision making: “Did my search yield high-
quality information? If so, does it apply to my client?”
As was true of Step 2, practitioners need to be both
accurate and efficient in rating the quality of the evi-
dence located in their electronic search. Accuracy may
be enhanced by training and review on research design
and data interpretation and by use of user-friendly
research rating forms (Gibbs, 2003; Moher, Schulz, &
Altman, 2001). Efficiency requires regular practice, for
example, through participation in a journal club in
which quality ratings are included as part of the journal
discussion. Even though evidence suggests that social
workers infrequently read or use research as a source of
practice knowledge (Mullen & Bacon, 2003), we have
found practitioners to be quite receptive to training in
research design and data interpretation if presented con-
textually using research addressing questions generated
from their own practice (McCracken et al., 2007).
Even though evidence from studies and syntheses iden-
tified in the electronic search is of high quality, it may not
clearly identify one specific intervention to use with one’s
client. Practitioners must use their expertise when they con-
sider the magnitude and precision of the effect of the study,
determine the likelihood of benefit, balance the potential
benefit versus harm, and assess the feasibility of the inter-
vention both with the client and in one’s practice setting
(Guyatt & Rennie, 2002; Straus et al., 2005). If it appears
that the results do apply to the client, the practitioner will
draw upon knowledge of both the client and the relationship
in considering whether the client is likely to find the inter-
vention acceptable and, if so, whether the client is likely to
be able to follow through with the intervention. In some
cases, the evidence may address one clinical decision
but raise another. The practitioner may find that the
most effective intervention is not feasible in the practice
setting. For example, while there is considerable evi-
dence to support the delivery of community-based inter-
ventions, like supported employment, for individuals
with severe and persistent mental illnesses, these ser-
vices may not be available in a hospital-based, fee-for-
service, outpatient psychiatry department (Bond &
Jones, 2005). In this case, the practitioner faces a
dilemma: Should the practitioner recommend the client
be referred to another agency that can offer the services
supported by literature, recommend an alternative inter-
vention targeting a different problem (e.g., reduction of
delusions instead of employment), or recommend paral-
lel services in two agencies? In either case, the practi-
tioner is ethically obligated to discuss the evidence and
the options with the client (Gambrill, 2006).
STEP 4: INTEGRATE THE CRITICAL
APPRAISAL WITH PRACTITIONER
CLINICAL EXPERTISE AND WITH THE
CLIENT VALUES, PREFERENCES, AND
CLINICAL CIRCUMSTANCES AND APPLY
THE RESULTS TO PRACTICE
Practice Scenario
Ms. W found that the integration of her critical
appraisal and the evidence was more straightforward
than the decision about which of the two interventions
was likely to be more appropriate to Marie and her fos-
ter parents. The timing of this clinical decision was for-
tuitous; Ms. W’s agency had recently received a grant
that would provide training and supervision in CPP. So
even though she had studied CBT during her graduate
education, it also was feasible for her to provide CPP.
Similarly, she did not expect any problem using CPP in
the context of her agency since clinicians in her program
were expected to deliver services in the client’s home
(compatible with CPP), and her agency was participat-
ing in the CPP project. The only concern that Ms. W had
about using CPP was that it requires a substantial com-
mitment of both time and effort on the part of the
mother. Without this commitment, CPP would not be
feasible, and Ms. W would need to consider an approach
that required less of the parents. Given their clear com-
mitment to making things work out with Marie, their
eagerness for information about parenting and child
care, and the fact that they had developed a collaborative
and trusting relationship with her, Ms. W decided that
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she would conduct a detailed discussion of the research
findings, the applicability factors, and the details of
implementing CPP. Their discussion included the
amount of time and effort needed from the foster mother
and the fact that Ms. W would be learning the approach
while she was delivering services to the family. The
parents responded well to the amount and type of infor-
mation provided and to the fact that they were included
in the decision about which intervention would be used.
They noted that this was very different from the sorts of
discussions that they were accustomed to having with
their health care and social service providers. In the end,
the parents agreed that CPP was the better approach,
and Marie’s foster mother was quite willing to devote
the time and effort needed by this approach.
Comment
There are a series of clinical decisions at this step.
“How do I present this information to my client? Will
the approach suggested by this information need to be
modified—how? What will I need to do to apply this
approach with my client—what specific skills will I
need to use/learn, what is the specific implementation
sequence?” Educating the client about his/her problem
and the various options for intervention is one of the fun-
damental principles and skills of EBP (Gill & Pratt,
2005). However, while the principle of client involvement
is clear, how to actually determine the role that the client
would like to play in decision making, assessing the
client’s preferences, and providing the client with the
information that he or she needs to make decisions
requires considerable expertise, in spite of the develop-
ment of clinical decision-analysis aids (Guyatt & Rennie,
2002; Straus et al., 2005). For example, some individuals
prefer detailed information about options—others may be
overwhelmed by too much information; some individuals
seek equal partnership with the provider—others prefer to
see the provider as the professional expert who makes
specific recommendations (Comas-Diaz, 2006). Some
clients, such as individuals with chronic illnesses who
have received services over many years from many
providers, may be surprised by the fact that a provider is
offering to discuss the evidence for their treatment or
even the fact that different treatments exist. The practi-
tioner may need to be sensitive to the need to educate the
client about how to participate in such a discussion.
The practitioner must also decide whether the inter-
vention can be used as described in the literature or in a
practice guideline or whether it needs to be adapted to
one’s client or practice environment and if so, how.
There is risk both in adapting and failing to adapt an
intervention (Proctor & Rosen, 2006). The risk of adapt-
ing is that the intervention may be less effective if one
does not maintain fidelity to the intervention. The risk of
failing to adapt is that there may be elements of the
intervention that make it inappropriate for a particular
client or not feasible in a particular practice situation.
There are several factors that suggest an intervention
may need to be adapted, though the presence of one or
more of these factors does not necessarily mean that it
must be modified: First, it may have been designed and
tested with individuals whose problem configuration,
personal characteristics, or situation is different from
the client’s. Second, the outcomes tested, while similar,
may differ from those desired by the client. Third, the
intervention was tested in a different setting or with dif-
ferent types of practitioners (Proctor & Rosen, 2006).
Interventions may be modified or augmented in a
number of ways. For example, many interventions do
not address how to establish or maintain a therapeutic
relationship with the client, and the practitioner needs to
supplement the guidelines with relationship expertise as
described above. The manner of delivery of the inter-
vention may need to be adapted to individuals with cer-
tain characteristics or for certain clinical situations. For
example, homework assignments may need to be modi-
fied for individuals who are unable to read or write,
skills may need to be taught in smaller steps to individ-
uals with cognitive impairment, or provision for crises
may need to be built into the guidelines. The frequency,
intensity, duration, modality, or site of delivery may
need to be modified for a particular client or practice
context. For example, individual interventions may need
to be adapted for use in groups if they are to be used in
programs that rely heavily on this form of treatment.
Modifications must be well reasoned, thoughtfully
implemented, and carefully evaluated. The particular
modifications will depend upon practitioner expertise
and the reasons for making the modification (Proctor &
Rosen, 2006).
Finally, when EBP is used for clinical decision mak-
ing in program development, practitioner organizational
expertise will be needed to implement the intervention
(Fixsen et al., 2005; McCracken & Corrigan, 2004). The
fact that an intervention is supported by evidence does
not mean that staff will want to use it. Staff buy-in and
ownership of the new intervention is essential to suc-
cessful adoption and implementation. Staff must be
adequately prepared before and supported during the
change process (Corrigan & McCracken, 1997). Before
adopting the intervention, staff must be made aware of
the intervention, must have sufficient information about
what it does and how to use it, and must be clear about
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how the intervention will affect them personally. During
adoption, staff must have sufficient training (preferably
on-site) in how to use the intervention and the effects of
the intervention. Finally, successful adoption is more
likely if the established users are provided adequate
feedback about the consequences of adoption and have
the resources and support to adapt the intervention to
their particular situation (Hall & Hord, 1987). In addi-
tion to preparing the team for change, the practitioner
will need to decide how best to sequence the implemen-
tation of the intervention. This is important because
many interventions have multiple components that need
to be implemented and because implementing a new
intervention will have an effect on previously existing
elements of the program (Corrigan & McCracken,
1997). This entire process will be easier if the team and
other relevant stakeholders have been involved in all of
the steps from identifying the practice question to eval-
uating the evidence and if there has been administrative
support for the process. In other words, both top-down
and bottom-up support for the process is required for
successful implementation (Corrigan & Boyle, 2003).
STEP 5: EVALUATING THE OUTCOME
Practice Scenario
Ms. W used the Child Behavior Checklist (Achenbach,
1991), the Randolph Attachment Disorder Questionnaire
(Randolph, 1997), and behavior logs completed by the
teacher and the parents to evaluate the outcome of her work
with Marie and her foster mother. Her decision to use the
Child Behavior Checklist was an easy one—because it was
used both in the CPP research and by a number of
programs in the agency where she worked. The decision to
use the Randolph Attachment Disorder Questionnaire was
less clear and was made after she conducted a search of the
literature for a clinically useful, reliable, and valid measure
of parent-child attachment. Ms. W found several instru-
ments that had been used in dissertations and other
research, but she did not feel that any of them were feasi-
ble for her to use with her client. While the Randolph
Attachment Disorder Questionnaire focused on behaviors
associated with reactive attachment disorders, there were
several behaviors of interest in Marie. Furthermore, this
instrument was brief and was sensitive to change. Finally,
Ms. W asked both the teacher and the foster parents to
keep a daily record of Marie’s sexualized play with toys
plus several anxious and fearful behaviors. Ms. W audio-
or videotaped treatment sessions and completed a thera-
pist fidelity checklist as part of her participation in the
grant-supported CPP training. It should be noted that
while Ms. W was primarily interested in the data from
the outcome measures to monitor and assess the effec-
tiveness of her intervention, the agency clinical direc-
tor and the director of her program used data from the
Child Behavior Checklist and the Randolph Attachment
Disorder Questionnaire for program development and
quality assurance.
Comment
Regardless of whether the intervention is used as
described in the literature or practice manual or whether it
is adapted to the client and situation, it should be evalu-
ated. The clinical decisions at this point are, What mea-
sures provide the best indicators of the implementation
and results of the intervention? How can this information
be gathered in a way that is both accurate and user
friendly? Ideally, both process and outcome should be
evaluated—without some measure of process, it can be
hard to interpret the meaning of outcomes. Corrigan and
associates (1994) proposed evaluating process and out-
come for both clients and staff. We would propose a
third—organizational—level of evaluation particularly
when using EBP as an approach to program development.
At the client level, the process question is whether the
individual is participating in and adhering to the interven-
tion. The client outcome measure is what impact the inter-
vention has on the client’s life. For staff, the process issue
was traditionally related to the quantity of services such as
the number of sessions or contact hours. An equally
important staff process issue for EBP is the quality of ser-
vice delivery (e.g., treatment fidelity, the extent to which
the service has been delivered as intended). Staff outcome
measures address the impact of service delivery on the per-
son(s) delivering that intervention, for example, job satis-
faction, level of burnout, and job-related social support
(Corrigan et al., 1994). Staff outcome data are important
when using an EBP approach to program development
since staff reactions to the intervention influence the likeli-
hood that the intervention will be adopted and maintained
over time (Corrigan et al., 1998; McCracken & Corrigan,
2004). Organizational process measures address the cost of
developing and implementing the services and the degree to
which organizational factors either facilitate or impede the
delivery of services. Organizational outcome measures
include the impact of service delivery on fulfilling the mis-
sion and accomplishing the goals of the organization.
Evaluating the intervention provides data that not only
are used in assessing the effectiveness of the EBP on the
client but can be used in subsequent practice decisions.
Organizations should develop a mechanism for sharing
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the data among practitioners in the program. As men-
tioned earlier, EBP is an iterative process. The best
available data are not always from the research litera-
ture; they may be from the practitioner’s own practice or
program (Gellis & Reid, 2004).
DISCUSSION AND CONCLUSIONS
The case illustration of EBP decision making reveals the
importance of both evidence and expertise. By moving
through the five steps of a structured decision-making
process for an actual clinical case, the way that expertise
comes into play in EBP is vividly portrayed. In general,
the case indicates that three types of expertise come into
play: clinical, technical, and organizational.
In the case scenario, the practitioner exercised signifi-
cant clinical expertise. The need for a positive, collabora-
tive working relationship in any clinical encounter is well
documented (Lambert & Barley, 2001). Clinicians seek to
communicate empathy, warmth, and genuineness to
engage the client in a productive relationship. As seen
from the case above, clinician expertise in relationship
development derives from information and experience
clinicians may rely on related to the client’s individual
characteristics and cultural background, developmental
stage, and relationship history. A positive, collaborative
relationship derives from the ongoing work of the clini-
cian to understand and respect client preferences and val-
ues. In the case of Marie’s foster family, the clinician’s
work to engage the family in prioritizing the problems and
selecting the interventions represents examples of clini-
cians’ efforts to elicit and respect client preferences and
values and, in the process, to develop the relationship.
Thus, clinician expertise comes into play in understanding
that a positive, collaborative working relationship is fun-
damental to any clinical encounter and, then, in develop-
ing the relationship throughout work with the client.
Another area where clinical expertise came into play
in the scenario was in problem formulation, goal setting,
and intervention selection. Throughout the therapeutic
encounter, clinicians and clients refine priorities and select
and evaluate interventions. This process of understanding
the client’s problems and identifying the resources available
to resolve them requires a high level of expertise. Research
on human information processing helps us to understand
that these types of decisions are based on somewhat pre-
dictable thinking processes and judgmental heuristics
(Berlin & Marsh, 1993; Hogarth, 1987; Nisbett & Ross,
1980). Clinical expertise derives from approaching decision
making with a critical stance toward the analytic processes
we use. In the case of Maria’s family, Ms. W. sought to indi-
vidualize her intervention and to avoid a customary, cookie-
cutter approach by identifying evidence about effective
interventions for a preschool child who had been
physically or sexually abused. Thus, clinician expertise
comes into play throughout the process as the clinician
critically appraises the thinking processes used in inter-
preting and applying the evidence.
A major area where technical expertise was exercised
was in the appraisal of data and information. Once spe-
cific evidence was identified, the practitioner needed the
tools to evaluate the quality and relevance of the data
and the likelihood the approach would be beneficial
with a particular client in a particular practice setting.
The practitioner in the scenario used judgment and
expertise to determine whether a particular approach
could be adapted to a client’s environment and whether
it could be implemented in the context of the client-
provider relationship. In the case of Maria’s family, Ms. W.
ultimately selected CPP over CBT after appraising available
data, considering organizational context, and consulting
with her clients. Thus, we see that technical expertise
comes into play throughout the process as the clinician
critically appraises both the evidence and the processes
used in applying the evidence.
Finally, the use of organizational expertise was apparent
in the scenario in several instances. The practitioners
needed to consider fit of intervention with organization val-
ues and practice and of organizational capacity to imple-
ment the specific intervention. In selecting CPP over CBT,
the fact that the organization had received a grant for super-
vision and training with this model ensured the choice was
congruent with organizational practice. The existence of
this grant also ensured that staff training and supervision
would increase the likelihood that the intervention would
be implemented with fidelity. Finally, any evaluation of an
intervention is more likely to be conducted if the results are
of interest for quality assurance and program development.
In this scenario, the practitioner’s knowledge of the agency
and expertise in its functioning contributed to effective
decision making.
In conclusion, practitioner expertise is an essential ele-
ment in EBP decision making. Although we are only
beginning to understand how expertise operates in human
information processing generally and in social work prac-
tice decision making more specifically, a step-wise analy-
sis of EBP decision making reveals the thinking tools and
processes that support the use of research findings to aid
judgment in practice. Through every step in the decision-
making process, the application of clinical, technical, and
organizational expertise can be identified.
308 RESEARCH ON SOCIAL WORK PRACTICE
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NOTES
1. This scenario is provided with the permission of Bridget
Colaccio Wesley (therapist) and Elisabeth Kinnel (evidence-
based practice project coordinator), who initially presented the
case study used as the basis for the case discussed in this article.
Ms. Wesley and Ms. Kinnel work in a large family service
agency serving Chicago and surrounding suburbs. The case
material, including names, identifying characteristics, and spe-
cific details, has been changed to protect confidentiality and is
best considered an amalgamation of cases seen in their program.
However, the clinical question, search, and decisions reflect
those made by Ms. Colaccio Wesley with the assistance of Ms.
Kinnel. The clinical questions were initially formulated and
searched in 2005.
2. A note about language: Recipients of services may be
referred to in a number of ways, such as “patient,” “client,
“consumer,” or “an individual” with a certain problem or cer-
tain characteristics. In this article, we use the term “client” to
refer to a recipient of services. While the term “client” is sin-
gular, we use this term to mean client system, which may
include one or many individuals and those around them.
3. Background questions provide basic information about
client characteristics and different kinds of problems and are
distinguished from foreground questions, which address the
specific clinical issue at hand (Guyatt & Rennie, 2002).
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