Evidence-based practice is defined as the "conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients" [5]. Various terms have been used to describe evidence-based practice, including evidence-based treatment, evidence-based intervention, and evidence-informed intervention. These terms are generally used interchangeably [6]. However, for the purpose of this course, the term "evidence-based practice" will be used.

Some assert that evidence-based practice privileges certain knowledge—specifically, knowledge that is quantifiable and measurable [30]. Studies that use experimental designs that feature randomization and control and experimental groups are valued in evidence-based practice [79,84]. However, other types of quantitative and qualitative methods have value as well and can provide insight into clients' realities [26,30]. Social work as a field deals with diverse social problems, and change in clients' lives frequently occurs gradually and in small ways that cannot always be captured using the experimental designs favored by evidence-based practice [30]. Statistical significance in research cannot be equated with practice significance, and it does not take into account context, with the complexities and subtle nuances of clients' lived experience [79,84]. Furthermore, the insights and opinions of social workers and other service providers are valuable [57].

There are five steps to practicing evidence-based social work [11]. First, a question must be posed around the practice area or need, and the question must be answerable. For example, "What can be done to solve homelessness?" is not an easily answerable question. Next, the best available evidence should be searched in order to find an answer to the question that has been posed. The evidence should be critically evaluated regarding its scientific validity and usefulness, using systematic reviews whenever possible [50]. The evidence is then evaluated and integrated based on the practitioner's experiences, observations, and client values and situation before being applied to the practice decision. Finally, it is vital to evaluate the outcomes of the decision, if possible using single case designs. Some assert both quantitative and qualitative studies should be used, depending on the question posed [51]. Ideally, these steps are done with all clients—integrating evidence to make an informed intervention plan. For client problems that are not necessarily unique or that occur frequently (e.g., abuse), some experts recommend that evidence can be generally collected and analyzed without being applied to a specific client [12]. For problems that are more unusual, practitioners should always search for available current evidence formulated by others [12]. These steps do not divorce or devalue the "person" out of the practitioner or the client; the practitioner's values, biases, experiences, and worldviews and the client's strengths, cultural beliefs, religion/spirituality, and self-identified needs are still considered [73,75,76].

There are five steps to practicing evidence-based social work [11]. First, a question must be posed around the practice area or need, and the question must be answerable. For example, "What can be done to solve homelessness?" is not an easily answerable question. Next, the best available evidence should be searched in order to find an answer to the question that has been posed. The evidence should be critically evaluated regarding its scientific validity and usefulness, using systematic reviews whenever possible [50]. The evidence is then evaluated and integrated based on the practitioner's experiences, observations, and client values and situation before being applied to the practice decision. Finally, it is vital to evaluate the outcomes of the decision, if possible using single case designs. Some assert both quantitative and qualitative studies should be used, depending on the question posed [51]. Ideally, these steps are done with all clients—integrating evidence to make an informed intervention plan. For client problems that are not necessarily unique or that occur frequently (e.g., abuse), some experts recommend that evidence can be generally collected and analyzed without being applied to a specific client [12]. For problems that are more unusual, practitioners should always search for available current evidence formulated by others [12]. These steps do not divorce or devalue the "person" out of the practitioner or the client; the practitioner's values, biases, experiences, and worldviews and the client's strengths, cultural beliefs, religion/spirituality, and self-identified needs are still considered [73,75,76].

As noted, the concept of evidence-based practice is not necessarily a new one. Even dating back to ancient times, there are some indications of attempts to make decisions regarding medical interventions based on prior testing. In the 1850s, Florence Nightingale's efforts to sanitize hospital conditions were based on evidence-based practice steps—Nightingale identified the problem and critically evaluated and appraised the evidence [20,52]. Evidence-based practice as it is known today can be traced back to World War II [2]. In the 1960s, there was a movement in the public service sector to evaluate welfare programs and interventions for efficacy, referred to the New Public Management Model [77]. However, it was not until 1972, and the work of Dr. Cochrane, then director of the Medical Research Council Epidemiology Research Unit in Cardiff and involved in an evaluation research project to assess a governmental agency, that the concept of evidence-based practice began to gain notice [2]. He also published a book titled Effectiveness and Efficiency: Random Reflections on Health Services. These steps laid the foundation for evidence-based practice in a variety of disciplines today. The underlying goal was to advocate for interventions supported by scientific evidence, placing medicine on a more secure scientific foundation [78].

In 1988, the National Institute of Mental Health created a task force to examine social work research and social work faculty's level of involvement in social work research [24]. This Task Force on Social Work Research published a report recommending that seven Social Work Research Development Centers be housed in social work programs, with each center testing intervention models and approaches for different population groups [24].

Debates about evidence-based practice in social work abound. First, there is a question of the context in which it should be employed. For example, should evidence-based practice be used in a micro (with individuals) or macro (with organizations) context [1]? The terms used are also a source of controversy; semantics in employing the term "interventions" versus "treatment," or "client" versus "client systems" have emerged. The term "evidence" alone has raised questions regarding ownership of data and expertise. In evidence-based practice, evidence is defined as research findings of various quality (levels of evidence) according to the study structure and statistical weight of the resultant data [13]. Some experts differentiate between hard and soft data. Hard data refers to quantifiable evidence that is supported by research studies that follow the empirical process, while soft data refers to qualitative studies and anecdotes from clients' experiences; observations from interviews with clients, service providers, and other stakeholders; and formal and informal observations [14]. It is also unclear how practitioners should act if evidence does not exist or if there is conflicting evidence regarding a particular intervention [13].

The term "empirically supported intervention" is also used in the social work literature. However, empirically supported interventions utilize even more rigid criteria than evidence-based practice. For example, an evidence-based practitioner can use literature on systematic reviews to understand the effectiveness of an intervention or treatment, but in order for an intervention to be considered empirically supported, it must be based on evaluation of randomized clinical trial study data by at least two independent investigators [16]. Unlike psychology, social work does not tend to use descriptors such as strong, modest, or controversial to differentiate the evidence [56]. The empirically supported interventions paradigm has been advocated by the National Association of Social Workers, the National Association of Public Child Welfare Administrators, the National Institutes of Health, the Joint Commission, and the Council on Accreditation [16]. However, empirically supported interventions are still not well-distinguished in the literature [56]. Other terms are used, including research-supported, empirically supported, evidence-driven, or evidence-guided. However, the emergence of these new terminologies has introduced more confusion [51]. Further, some consider manualized and other standardized interventions to be examples of evidence-based practice, but standardization does not necessary equate with evidence-based practice [80].

As evidence-based practice was originally derived from medicine, some argue that differences between the two professional fields mean that the practice cannot be applied to social work [26,79]. Often, medical interventions can be broken into distinct steps or rules to be followed for all or most patients [79]. However, social work takes into account all social, biologic, psychologic, cultural, and institutional factors, making developing a set of universal steps for interventions much more difficult [26,52]. In social work, with its emphasis on working with those who are marginalized and vulnerable, the rules-based characteristics of evidence-based practice may appear at odds with core social work values [80]. Medicine is also highly positivistic (i.e., focusing on measurability), while social work is interpretivistic/constructivistic, relying on reflexivity and the social context [29,52]. This leads to unpredictability and difficulty in quantification of social work experiences.

Opponents argue that the empirical knowledge base in social work is narrow and limited—meaning empirical information is not available for every clinical issue and every client population. It is important to note that if practitioners are unable to locate literature that meets evidence-based criteria, this does not necessarily mean that an intervention is "bad" [26]. The reality is that research topics are influenced by a host of factors, including funding sources and priorities, perception of what is "important," and other hidden social values [26].

The importance of practitioners' clinical experiences and intuition in shaping practice decisions should not be ignored [20]. Opponents of evidence-based social work practice posit that the essence of the art of clinical work with clients (e.g., use of self, intuition, rapport building with clients, past experiences) is not captured in evidence-based practice. Frequently, top-down decision-making does not take into account the context and complexities of human problems. So, practitioners must use discretion, making it challenging to standardize clinical practice decision-making [85].

Some experts maintain that a focus on evidence-based outcomes could potentially risk the client autonomy that social work values [30,56,81]. For example, evidence-based literature may demonstrate that a certain medication is effective, but a client may rather avoid pharmacologic interventions and employ alternative treatment. In this case, should the practitioner push for what the literature supports despite the client's wishes?

Opponents of evidence-based social work practice maintain that agencies often have limited resources (e.g., money, time, expertise) with which to promote evidence-based practice. In some cases, evidence-based practice interventions are inconsistent with the norms of a particular organization or employer. Social workers may find the status quo to be simpler and more aligned with daily operations [81]. This raises the issue of fidelity, or the degree to which agencies implement an evidence-based intervention or program and the degree to which it can be adapted to a specific setting [85].

Proponents of evidence-based social work argue that professionals are expected to practice good social work, which entails providing clients the best treatment possible [14]. In order to do so, social workers should amass and evaluate the available evidence before making informed decisions and formulating a client's intervention plan. In a climate that emphasizes efficiency, transparency, and accountability, social workers are also expected to demonstrate effectiveness to their funders [58]. The National Association of Social Workers Code of Ethics states [32]:

Social workers practice within their areas of competence and develop and enhance their professional expertise. Social workers continually strive to increase their professional knowledge and skills and to apply them in practice. Social workers should aspire to contribute to the knowledge base of the profession.

Although there may be challenges to implementing evidence-based practice, ethical codes demand that practitioners address these challenges rather than avoid them [19].

As noted, one of the criticisms of evidence-based social work is that it is too mechanistic and procedural. In response to this, proponents claim that the steps in evidence-based practice are focused on each individual client. If followed correctly, the decisions that result from the process are deliberate and client-centered [19,86].

In addition, evidence-based practice does not violate client self-determination. All collected evidence is synthesized taking into account the client's background, characteristics, environment, support system resources, and preferences [19,86].

Some experts object to the argument that evidence-based practice ignores the practitioner's vast clinical experience and background. One of the steps in evidence-based practice is the evaluation of evidence based on experience and the specific situation, which highlights the role of the practitioner's clinical background and intuition [19].

Taking a broader definition of evidence-based practice and using a range of "hard" and "soft" data as best evidence, evidence-based clinical practice is advantageous because it moves away from client insight as being a sign of progress. Instead, it focuses on observable behavioral change [28]. This behavioral change can trigger clients' understanding of their emotional life [28].

A mixed-methods study found that social workers relied on and valued knowledge that came from their work experience and their colleagues and supervisors [80]. Practitioners are not necessarily rational, failing to use critical thinking skills and objectivity in their clinical decision-making. Consequently, the rigorous and systematic process of evaluating the "why" in professional practice inherent in evidence-base practice would ensure that personal biases and human error are mitigated [73].

In an increasingly technology-oriented society, consumers have greater access to information and are becoming more educated about the services they receive. Because of this, they expect service providers and professionals to be updated on the latest developments in their field [51]. For example, 80% of adult Internet users (18 years of age and older) search online for information on a health topic each year [33]. Among individuals with diagnosed psychiatric disorders who use the Internet, 64.7% have proactively employed the Internet to find more health-related information [34]. Because social work clients are active consumers, they can be encouraged to use the Internet to research and can offer feedback in terms of what they discover [9]. This becomes a vehicle for empowerment, improving communication and reducing the power disparities between practitioners and clients. However, this easy access to information increases the risk that clients will obtain erroneous information; it is the responsibility of social workers to educate clients to critically evaluate information [51].

Using the definition that evidence-based practice is the "integration of the best research evidence with clinical expertise and client values in making practice decisions," some experts advocate for an evidence-based practice model that bridges the viewpoints of proponents and opponents [1]. Best research evidence may refer to employing both applied (e.g., intervention and outcome research) and basic research studies [1]. Clients' values are based on their culture, upbringing, expectations, and environment, and these values are not discarded when using evidence-based practice. Evidence-base practice can be context sensitive [87]. It is not merely about the outcome or about what is perceived to work. Rather, the question of what works should be extended to: "What works for whom and in what context?" Instead, they should be at the forefront, shaping decisions made by both the client and social worker [1]. The practitioner's clinical expertise is also part of this equation. Similarly, Gilgun suggests that [18]:

There are four cornerstones of evidence-based practice in social work: (1) what we know from research and theory; (2) what we and other professionals have learned from our clients, or practice wisdom, which also includes professional values; (3) what we, as social workers, have learned from personal experience; and (4) what clients bring to practice situations. All four come into play and mutually affect each other as we go about our daily work with clients. In sum, evidence-based practice promotes a high degree of practitioner reflection and mindfulness.

There are logistical barriers for social workers and practitioners to fully implement evidence-based practice. Some social service organizations do not have the technology, hardware, datasets, and informational technology specialists to assist practitioners to access information needed for evidence-based practice [35]. Implementing evidence-based practice well requires social workers to spend time learning how to use resources, search for literature, and develop research skills, but social workers and other practitioners often have heavy caseloads and are extremely busy seeing clients [26,59,60]. One study with licensed master social workers found that perceived lack of time and expenses associated with evidence-based practice were prominent barriers [83].

Social workers' fears may also influence the willingness to employ evidence-based models. Many anxieties involve the perception that evidence-based practice is a top-down, mechanistic, one-size-fits-all approach that devalues client autonomy and clinical experience and wisdom [29]. Furthermore, perception of limited self-efficacy and resources needed to effectively implement evidence-based practice are barriers [82]. However, if used correctly, evidence-based practice supports client and practitioner expertise.

Not surprisingly, social workers who are willing to alter their interventions in light of new evidence are more open to implementing evidence-based practice [35]. Social workers' desire and readiness for change should be supported by colleagues, employers, and the profession as a whole. When staff perceive that an organization is committed to fostering change and when practitioners are encouraged to take on challenging tasks that will help them grow, use of evidence-based practice increases [35]. When there is an organizational culture of continuous quality improvement and collaboration between clinicians, researchers, and policymakers, adoption rates for evidence-based practice increase [60]. Practitioners who are given external positive incentives (e.g., monetary bonuses, extra vacation time) for learning new skills and interventions are more likely to adopt evidence-based practice [35]. Because time and energy are often constrained due to heavy caseloads, social workers may feel more motivated if the time they put into implementing a new intervention is rewarded in the incentive structures of an agency [35]. Organizations may also provide education on the principles of evidence-based practice. Practitioners who participate in education and training that focuses on specific skills, such as research, library database searches, and critically appraising intervention studies, are more likely to incorporate evidence-based models into their practice [35]. Studies indicate that time and resources are important facilitators to evidence-based practice; practitioners with high levels of self-efficacy and time/resources are more likely to carry out evidence-based practice [61]. Social work educators and recent social work graduates tend to be most familiar with evidence-based practice [82]. This is mostly due to the Council on Social Work Education's mandate on the inclusion of evidence-based practice in social work curricula. This speaks to the need to train and empower social workers to execute evidence-based practice.

It is important that social work practitioners and researchers explore the ethical implications of conducting evidence-based practice [36]. Specifically, this type of practice can involve the ethical principles of beneficence, self-determination, conflict of interest, and confidentiality [37,62,90]:

Beneficence: Beneficence refers to the duty to do good, and practitioners should consider the benefits of conducting evidence-based research. What specific benefits will the group being studied obtain? What are the risks and does it have any negative outcomes for vulnerable populations? What additional safeguards can be implemented to promote the welfare of the client(s) and mitigate risks?

Self-determination: Self-determination refers to the duty to maximize an individual's rights to make his/her own decisions. Clients' self-determination and autonomy should be protected. For example, when implementing an intervention, do the clients feel they have no choice but to comply or risk having services somehow negatively affected? What information is shared about best available research when planning interventions? To what extent do clients understand the information to make an informed decision? The informed-consent process should not discount clients' values and preferences.

Conflict of interest: Potential dual-role issues and conflicts of interest can arise when a social worker is both the practitioner working with the client and the researcher collecting evidence about his/her own practice and interventions. What will the social worker report to the agency if the findings about the intervention are negative? When a practitioner is evaluating his/her own practice, he/she must ask whether the client's interest are prioritized.

Confidentiality or anonymity: All social workers should implement adequate safeguards to promote clients' privacy, anonymity, and/or confidentiality.

Study design: The study design and data collection procedures should serve to answer the research question. If not, this raises the issue of inconveniencing the clients, which is not ethical. Do the study design and procedures ultimately serve to empower the clients?

Historically, there are four ways that intervention studies have dealt with the issue of diversity [39]. These four categories may be viewed as existing along a continuum, with one end of the continuum consisting of full involvement of the cultural group (the most culturally sensitive) and the other end not recognizing the importance of including racial and ethnic minorities in the sample (the least culturally sensitive). The categories are:

Full partnership: With this approach, researchers collaborate with the community and consider the diverse interests of the group when formulating a culturally sensitive and competent intervention, identifying the research question(s), collecting data, analyzing and interpreting data, and disseminating research findings.

Ad hoc involvement: In this category, the population of interest and the community are asked to provide input after the intervention has been implemented or after the research question has been posed. The targeted group may be viewed as an ad-hoc advisory group.

No involvement in the process: In some cases, researchers include racial and ethnic minorities in the sample, but they do not attempt to target the intervention to the specific group, nor do they attempt to gain insight into the group's perspective about the intervention.

No diversity represented in the sample: Some researchers do not actively recruit diverse racial and ethnic minorities in the study sample. If there is some diversity in the sample, there are no sufficient numbers to be able to conduct statistically valid analyses.

Another way to explore the issue of cultural competency is through the debate about emic and etic perspectives. The etic perspective maintains that, along important dimensions, all humans are basically similar. On the other hand, the emic perspective argues that it is vital for professionals to begin from the paradigm that unique cultural characteristics exist in various cultural groups. This emic orientation acknowledges individual differences within culturally different populations while simultaneously viewing clients/patients within the context of their primary cultural group [40]. It is believed that etic interventions can be used for all groups and if modification is necessary, it would be minimal. This is also referred to as universal psychotherapy, which argues that the mechanism for change is the same for all clients. According to this perspective, all individuals share common denominators (e.g., psychological qualities or attributes) [91]. In contrast, emic interventions focus on formulating interventions that reflect the group's characteristics and value systems, with the belief that these interventions will be more effective for the target group [41]. The emic perspective calls for racial/ethnic psychotherapies or cultural adaptation treatments, whereby interventions are specifically tailored to the specific group [91]. Either approach may be taken when conducting evidence-based practice. However, the emic perspective is considered culturally sensitive and ethically sound, and these interventions may have a greater likelihood of success.

The first step in conducting evidence-based practice is to formulate a question that will drive the research [69]. This research question is a descriptive clinical inquiry of an intervention and potential outcome(s) [60]. The question will dictate the evidence used to answer and should be succinct, clear, and as specific as possible. One way to develop the question is to use the PICO formula: population, intervention, comparison, and outcome [45]. Some use PICOT, with the T representing time period of data collection [69]. Using this approach, the first step is to pinpoint the client population. The more detailed one can be regarding the attributes or characteristics of the client population, the more helpful the question will be and the more applicable the research findings will be. If possible, the practitioners should identify gender, socioeconomic status, racial/ethnic minority status, health conditions, religion, and other factors. Examples of strong population component include:

Male clients diagnosed with generalized anxiety disorder

Chinese immigrants who came to the United States in the last five years

Hispanic adolescents residing in single-parent households

Several databases are available for social workers to use in their search for articles and reports to use when adopting evidence-based practice. Some are free, while others require a paid subscription. Please note that this is far from a comprehensive list, and practitioners are encouraged to explore other options provided by their agency or organization.

The key to searching and learning how to best use the different databases is to practice. As an additional resource, the article "Evidence Searching for Evidence-Based Psychology Practice" provides a summary of the different types of databases and their strength and weaknesses [45]. The article may be accessed online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3077562.

With the increased use of the Internet, there have been more open-access sources for information that has not been peer reviewed. It is important to ensure that the information is credible. Experts recommend assessing the following elements in any potential source of information [60]:

Credentials and affiliations of the authors

Abstract containing a summary of the research

Reference list