Evidence-based Research

Recent Social Work Practitioners’ Understanding and Use of Evidence-Based Practice and Empirically Supported Treatments Melissa D. Grady, Traci Wike, Caren Putzu, Sara Field, Jacqueline Hill, Sarah E. Bledsoe, Jennifer Bellamy, and Michael Massey

ABSTRACT The aim of this study was to evaluate how CSWE’s 2008 shift placing more emphasis on research have affected newly trained social workers’ use of evidence-based practice (EBP). This qualitative study examined the educational and practice experiences of newly trained social workers and how those experiences influence the use of EBP and empirically supported interven- tions/treatments in the field. Thirteen newly graduated social workers were interviewed using a semi-structured interview. Twenty-three codes emerged from the interviews, with the most prominent theme being a sense of overall confusion about EBP. Other themes included lack of educational preparation, lack of agency resources, and prohibitive agency culture. Implications for social work education and practice are discussed.

ARTICLE HISTORY Accepted: May 2016

The rise of evidence-based practice (EBP) in social work has resulted in social work education programs incorporating more EBP knowledge and skills into curricula to prepare students to be evidence-based social work practitioners (Bledsoe-Mansori et al., 2013; Edmond et al., 2006). Yet, social workers continue to struggle with incorporating EBP into practice settings (Bellamy et al., 2008; Wike et al., 2014). Although numerous studies have examined individual practitioner barriers to implementing EBP (Wilke et al., 2014), few, if any studies have examined how these educational policy shifts affect newly trained social workers’ use of EBP or how specific educational experiences influence a practitioner’s use of EBP. This article presents qualitative findings from a study that explored the experiences of 13 newly trained social workers and their perceptions of the factors that influence the use of EBP postgraduation.

Definition of EBP

EBP is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual clients (Sackett et al., 1996) by integrating best research evidence with clinical expertise and patient values (Institute of Medicine, 2001). Implementing the EBP process in practice decision making commonly consists of six steps: conducting a thorough assessment of client needs; converting information needs into answerable questions and locating the best available evidence; critically appraising the evidence; integrating critical appraisal with practitioner practice experience, client’s strengths, values, and circumstances and discussing these findings with the client; co-developing a plan of intervention with the client; and implementing the intervention (Drisko & Grady, 2012). To effectively engage in the EBP process, practitioners need strong clinical and assessment skills, a capacity to access and interpret research (Drisko & Grady, 2012), and the ability to integrate assessment and research evidence for clients to make collaborative intervention decisions.

CONTACT Melissa D. Grady [email protected] National Catholic School of Social Service, Catholic University of America, Shahan Hall, Washington, DC 20064. © 2017 Council on Social Work Education

JOURNAL OF SOCIAL WORK EDUCATION 2018, VOL. 54, NO. 1, 163–179 https://doi.org/10.1080/10437797.2017.1299063

To support and increase the use of EBP across the social work profession, a full and accurate definition of EBP is necessary. Unfortunately, the term is often conflated with empirically supported interventions (ESI) or empirically supported treatments (EST; Simmons, 2013), thus creating disparities in how EBP is defined (Rubin & Parrish, 2007). Although interrelated with EBP, ESIs and ESTs refer to specific interventions with evidence indicating efficacy or effectiveness in identify- ing, reducing, or improving specific problems (Chambless, 2007). ESIs and ESTs represent products, which are distinct from the process of EBP. Understanding this distinction is crucial to training social workers in carrying out EBP in practice rather than choosing and applying a particular intervention or program.

EBP and social work education

As a result of the move toward increased training in EBP, ESIs, and ESTs (Brekke, Elle, & Palinkas, 2007; Grady, Werkmeister Rozas, & Bledsoe, 2010), social work programs have included more content on EBP processes and specific ESIs and ESTs (e.g., cognitive behavioral therapies) into social work curricula (Bledsoe et al., 2007; Howard, Allen-Meares, & Ruffolo, 2007; Jenson, 2007; Shlonsky, & Gibbs, 2004), such as assignments requiring EBP to be used or how to consume research as the focus of research courses. The Council on Social Work Education (CSWE, 2008) stated that graduates from MSW programs should be able to “distinguish, appraise, and integrate multiple sources of knowledge, including research-based knowledge, and practice wisdom” (p. 4). These standards included an increased emphasis on the use of empirical evidence to inform practice and practice evidence to inform research (CSWE, 2008). The CSWE (2015) revised these standards to include more explicit statements that social workers should “understand the processes for translating research findings into effective practice,” and “use and translate research evidence to inform and improve practice, policy, and service delivery” (p. 8). The current accreditation standards set forth by the CSWE have made it essential for social work education programs to not only emphasize the importance of using research evidence in practice but also train students on how to recognize, evaluate, and apply current research knowledge to inform practice decision making with clients (CSWE, 2015).

Reflecting this shift, studies suggest that social work education programs are incorporating EBP principles and content into their training curricula by integrating EBP principles into existing course work, providing courses specific to ESIs and ESTs (e.g., cognitive behavioral therapy and assertive community treatment), fostering partnerships with field agencies conducting EBP, and strengthening students’ abilities to connect acquired research knowledge and skills with their practice decisions (Bledsoe et al., 2007; Bledsoe-Mansori, Bellamy et al., 2013; Grady et al., 2010; Howard et al., 2003; Weissman et al., 2006; Wike et al., 2013). Findings from two national studies of schools of social work demonstrate that various programs do include training in ESIs and ESTs in their curricula (Bledsoe et al., 2007) and endorse the value and benefits of implementing agency-university partner- ships to support EBP (Bledsoe-Mansori, Bellamy, et al., 2013).

Training phases of EBP and associated barriers

Although social work programs have increasingly focused on integrating EBP, ESI, and EST training into their curricula (Bledsoe et al., 2007; Bledsoe-Mansori, Bellamy et al., 2013; Grady et al., 2010; Howard et al., 2003; Weissman et al., 2006; Wike et al., 2013), variability exists in the type and amount of training students receive (Drake, Hovmand, Jonson-Reid, & Zayas, 2007; Drisko, 2014; Grady et al., 2010; Howard et al., 2007; Jenson, 2007; Mullen et al., 2005; Shlonsky, & Gibbs, 2004; Springer, 2007). The majority of MSW program administrators report that they teach at least one ESI or EST and focus on building EBP skills, yet they also report struggling to integrate the concepts into their curricula (Bertram, Charnin, Kerns, & Long, 2014). Additionally, research suggests social work educators do not clearly distinguish EBP from ESIs and ESTs (Rubin & Parrish, 2007) and are unsure how to use these approaches in curriculum decisions (Grady et al., 2010). The lack of

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consensus and clarity regarding how EBP, ESIs, and ESTs should be integrated into social work education results in a lack of consistency in teaching EBP, ESIs, and ESTs, producing practitioners with disparate levels of knowledge.

Barriers associated with MSW classroom learning

Classroom teaching provides the foundation for entering practice and represents a critical component of training students in EBP, ESIs, and ESTs (Drisko, 2014). Discrepancies in the definition of EBP (Bertram et al., 2014; Drake et al., 2007; Rubin & Parrish, 2007) and percep- tions of its practice utility by instructors influence how the EBP process is or is not integrated into the curriculum. Many conceptualize EBP as a product and do not teach students to critically move through the steps of the EBP process (Drake et al., 2007). Studies on EBP have also reflected this product-oriented definition of EBP, contributing to further confusion (see Bertram et al., 2014). This definitional uncertainty leads to questions about how to provide training and preparation to social work faculty (including adjuncts) who are interested in teaching EBP but have little formal training in how to do so. As faculty are being strongly encouraged to teach EBP in their courses, a consensus has not been reached on whether they should teach the process of EBP, specific manualized interventions (ESIs, ESTs; Howard et al., 2007; Springer, 2007), the skills needed to carry out the EBP process (Howard et al., 2007; Shlonsky, & Gibbs, 2004), or some combination thereof (Drisko, 2014).

An additional consideration for incorporating EBP into classroom teaching is where in the curriculum EBP training should be located (Bertram et al., 2014; Drisko, 2014; Howard et al., 2007; Jenson, 2007; Mullen et al., 2007; Pollio & Macgowan, 2010). Although opinions vary (Crabtree & Miller, 1992; Drake et al., 2007; Drisko, 2014; Gilgun, 1998; McDowell, 2000; O’Connor & O’Neill, 2004; Sar, Yankeelov, Wulff, & Singer, 2003; Shaw, 1999; Yin, 2013), several scholars have suggested ways for MSW programs to better infuse EBP into their curricula (Drake et al., 2007; Drisko, 2014). Drisko (2014) emphasizes the need for research to be effectively taught in social work programs and highlights the critical need to tie research to clinical practice. Drake et al. (2007) emphasize that using the EBP process, practice is the application of research; therefore, practice and research are inseparable, and thus need to be infused throughout MSW curricula. From this perspective, every MSW class should adopt EBP and refer to EBP throughout the course. Drake et al. (2007) offer steps toward the creation of a research-practice integrated social work education program, including (a) introducing students to EBP, (b) refocusing course content (infusion of EBP in all MSW classes), and (c) evaluating students’ EBP-related competence. Drake et al. (2007) also advocate for more effective education in research, including increased focus on qualitative case evaluation and integrating EBP in classes focusing on micro-, mezzo–, and macro-issues, like human behavior in the social environment and social policy. Specifically, Drake et al. state that EBP should be infused throughout the curriculum by tying practice courses to research and by having faculty model their own use of EBP in their teaching and research.

Barriers associated with MSW field experiences

Although classroom teaching provides foundational learning, EBP cannot be fully integrated into curricula (Drake et al., 2007; Drisko, 2014; Gilgun, 1998; O’Connor &O’Neill, 2004; Yin, 2013) without incorporating EBP into field learning (Davis et al., 2013; Drake et al., 2007; Drisko, 2014; Mullen et al., 2007). It is well documented that practitioners struggle with implementing EBP, ESIs, and ESTs (Bellamy et al., 2013; Bledsoe-Mansori, Manuel, et al., 2013; Nelson, Steele, & Mize, 2006; Pollio, 2006; Proctor et al., 2007) for a variety of reasons, including inconsistencies in EBP training experi- ences (Franklin & Hopson, 2007; Mullen et al., 2005), uncertainty about what constitutes adequate evidence (Rubin & Parrish, 2007), lack of training in the skills required to carry out EBP (Bledsoe- Mansori, Manuel, et al., 2013), practitioners’ and educators’ personal views against the use of EBP

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(Bellamy, Bledsoe, & Traube, 2006; Bledsoe-Mansori, Bellamy, et al., 2013), and practice in agencies resistant to using EBP, ESIs, and ESTs (Proctor et al., 2007). Because field experiences strongly influence MSW student training, field instructors’ inability or aversion to EBP may limit students in gaining EBP knowledge or being able to transfer skills learned in the classroom to practice.

To address this issue, Mullen et al. (2007) emphasize using process-based classroom learning in collaboration with field agencies to promote and develop students’ ability to use EBP in practice. In this model, field supervisors are brought in for training, and faculty visit agencies and provide professional development training to promote trainee learning as well as support agencies invested in using EBP. Likewise, Davis et al. (2013) highlight the importance of students’ being able to apply EBP to their own cases and settings. Finally, Drake et al. (2007) emphasize integrating EBP with field experiences and offer suggestions for field agencies to promote and teach EBP, including providing field instructors and students with continuing education and integrative seminars.

The current study

Although many challenges exist in incorporating EBP in social work curricula, evidence suggests that schools of social work highly endorse the benefits of EBP and have implemented a variety of strategies to increase students’ skills (Bledsoe-Mansori, Bellamy, et al., 2013; Howard et al., 2003). These strategies include project-based course work whereby students work with agencies to implement EBP projects, training for field instructors to support student learning and the application of EBP, and capstone projects that address EBP. However, we were unable to identify any study that has examined the perspectives of recent MSW graduates to consider how their training experiences combined with their postgraduate practice experiences have influenced their use of EBP, ESIs, and ESTs in their current practice. The purpose of this descriptive, qualitative study was to explore the perceptions of social work practitioners educated under the previous version of the Educational Policy and Accreditation Standards (EPAS; CSWE, 2008) . The specific research questions guiding this study were, What are the educational and practice experiences of newly trained social workers in EBP, ESIs, and ESTs? and How do those experiences influence the use of EBP, ESIs, and ESTs in social work practice? The study was approved by the institutional review boards of the principal investigators’ universities.

Method

Participants

Social workers who obtained their MSW after 2009 were recruited through clinical society electronic mailing lists, state social work licensing board lists, alumni electronic mailing lists, and individual faculty contacts using a convenience snowball sampling method from May 2014 to October 2014. Each social worker received an e-mail invitation to complete a Web-based survey about his or her use of EBP, ESIs, and ESTs. At the end of the survey, participants were asked to provide their names and contact information if they were interested in participating in an in-depth telephone interview about their experiences in learning about and adopting EBP, ESIs and ESTs. Eighteen survey participants indicated interest and were contacted by the study team; five individuals were contacted three times. Thirteen survey participants agreed to participate in the qualitative interviews and made up the final sample for this study. Descriptive data for the sample is provided in Table 1.

Study design

Interested participants were contacted by phone or e-mail by a member of the research team consisting of two coprincipal investigators, two doctoral-level research assistants, and two master’s-level research assistants. On initial contact, a research teammember provided information about the interviews, reviewed the informed consent form, and answered any questions posed by the participant.

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Once consent was obtained, the interviewer and participant agreed on a time for a telephone interview conducted through a conference call service that digitally recorded the interviews. Interviewers informed participants through the consent process about the conference call service. Each interview lasted about 1 hour, was conducted by a member of the research team, and followed a semistructured interview format. The interview guide was developed by the lead investigators based on previous research regarding known barriers and promoters for the adoption of EBP, ESIs, and ESTs in the field.

On completion of the interview, each participant received a $10 Amazon gift card. Interviews were transcribed verbatim by a member of the research team who did not conduct the interview. All interviews were stored in a password-protected software program with all identifying information removed.

Analyses

Data were analyzed using the constant comparative (Strauss & Corbin, 1998) method of analysis. Under the direction of the coprincipal investigators, the research team documented themes that emerged from the data from each transcribed interview using a grounded theory approach. These codes were combined and then discussed among all team members to reach an agreed-on set of codes and respective definitions. During the initial phase of coding, the research team reviewed the same two transcripts and identified the number of times each code appeared, as well as defined the unit of inquiry.

Table 1. Participant demographics.

Characteristic N

(n = 13) %

Year of graduation 2009 4 30.8 2010 3 23.1 2011 1 7.7 2012 2 15.4 2013 3 23.1

Practice state California 3 23.1 District of Columbia 2 15.4 Minnesota 1 7.7 New York 2 15.4 North Carolina 1 7.7 South Carolina 1 7.7 Texas 3 23.1

Current social work license Yes 10 76.9 No, but in process of obtaining 2 15.4 No, but plan on pursuing 1 7.7

Gender Female 11 84.6 Male 2 15.4 Race, or ethnicity Caucasian or White 12 92.3 Hispanic or Latino 1 7.7

Age 26–35 9 69.2 36–45 3 23.1 46–55 1 7.7

Length of tenure at current agency >1 year 4 30.8 1–3 years 5 38.5 3–5 years 4 30.8

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In the case of discrepancies, the team revised the codes or definitions and then recoded each transcript until reaching 90% or greater interrater reliability. The final list consisted of 23 codes. Each transcript was then assigned two coders who coded the transcripts following the three steps described next.

In Step 1, transcripts were individually coded by two coders. In Step 2, interrater reliability was calculated. If interrater reliability was less than 90%, the reviewers identified coding discrepancies, such as differences in how one coded a unit of analysis or interpreted a code. Where large discrepancies emerged, codes, constructs, and definitions were adjusted as necessary in conference. Step 3 involved each coder recoding the transcripts. When completed, the coders reconvened again to compare coding and identify any additional discrepancies. If interrater reliability was less than 90%, discrepancies were resolved by conference. The codes were captured using Microsoft Excel spreadsheets that tracked each coder’s counts.

Table 2 provides the frequencies for the number of participants that noted each theme. Table 3 shows the total number of times each theme was mentioned across the interviews. These numbers are used in the presentation of the qualitative results to demonstrate pervasiveness of each theme across the interviews. For each category, we provide a brief description of the theme, its associated subthemes, and selected comments that illustrate the themes.

Results

Our study was guided by two specific research questions: What are the educational and practice experiences of newly trained social workers in EBP, ESIs, and ESTs? and How do those experiences influence the use of EBP, ESIs, and ESTs in social work practice? The following results address both overarching questions.

Table 2. Frequencies for numbers of participants who identified each theme.

Total %

Themes and Codes 1. Pre-MSW 3 23.08 2. Educational preparation Good educational prep 8 61.54 Lack of educational prep 11 84.62 3. Field experience No exposure in field 8 61.54 Inaccurate or confused field exposure 5 38.46 Accurate field exposure 4 30.77 4. Lack of resources 13 100.00 5. Prohibitive agency culture and policies 11 84.62 6. Agency resource support 12 92.31 7. Supportive agency culture and policies 7 53.85 8. Supervision Included in supervision 3 23.08 Excluded in supervision 8 61.54 9. Social work schools as resources and supports 7 53.85 10. Confusion 11 84.62 11. Never heard of ESI 10 76.92 12. EBP is limiting 7 53.85 13. Expectations 12 92.31 14. Good for agency 11 84.62 Other codes 15. Education mismatch 5 38.46 16. Silo of research 2 15.38 17. Connection 4 30.77 18. Ethics 3 23.08 19. Accountability 3 23.08

Note. EBP = evidence-based practice; ESI = empirically supported interventions.

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Table 3. Frequencies of overall theme counts across all interviews.

Final Total

Themes and Codes 1. Pre-MSW 5 2. Educational preparation Good educational prep 33 Lack of educational prep 46 3. Field experience No exposure in field 16 Inaccurate/confused field exposure 5 Accurate field exposure 8 4. Lack of resources 68 5. Prohibitive agency culture and policies 53 6. Agency resource support 22 7. Supportive agency culture and policies 22 8. Supervision Included in supervision 5 Excluded in supervision 18 9. Social work schools as resources and supports 11 10. Confusion 76 11. Never heard of ESI 13 12. EBP is limiting 25 13. Expectations 39 14. Good for agency 20 Other codes 15. Education mismatch 9 16. Silo of research 2 17. Connection 3 18. Ethics 5 19. Accountability 6

Final Total Themes and Codes Theme 1 1. Pre-MSW 5 Theme 2 2. Good educational prep 33 3. Lack of educational prep 46 4. No exposure in field 16 5. Inaccurate or confused field exposure 5 6. Accurate field exposure 8 Theme 3 7. Lack of resources 68 8. Prohibitive agency culture and policies 53 9. Agency resource support 22 10. Supportive agency culture and policies 22 11. Included in supervision 5 12. Excluded in supervision 18 13. Social work schools as resources and supports 11 Theme 4 14. Confusion 76 15. Never heard of ESI 13 16. EBP is limiting 25 17. Expectations 39 18. Good for agency 20 Other codes 19. Education mismatch 9 20. Silo of research 2 21. Connection 3 22. Ethics 5 23. Accountability 6

Note. EBP = evidence-based practice; ESI = empirically supported interventions.

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Educational and practice experiences of newly trained social workers

Theme 1: Pre-MSW experiences Participants discussed primarily MSW program experiences that contributed to their EBP knowl- edge. However, five participants indicated having experience, especially research exposure or under- graduate educational experiences, prior to enrolling in their MSW programs, which increased their confidence in using research and EBP. Typical participant comments included the following: “When I was an MSW student, I sort of already had done some research coming into the program, so I had sort of a general idea about research and what sort of to be looking for and that sort of thing” and:

I was able to take advantage more of the literature studies in my MSW program because I had such [a] strong research component in my undergraduate studies. So I feel like I was better able to understand and read the literature, especially the statistical analysis. That helped me a lot.

These comments illustrate that the few participants exposed to research prior to entering an MSW program perceived an ability to understand the literature, interpret statistical analysis, and appreciate the research process.

Theme 2: Educational preparation Participants reported aspects of their MSW course work that promoted or hindered their ability to learn and use EBP. A lack of educational preparation in understanding EBP emerged as a common experience (n = 46). Participants felt that their MSW education did not go into adequate depth on EBP, which was only discussed in select classes or by certain professors, and EBP instruction was not comprehensive. The following are examples of typical comments citing a lack of educational preparation:

I don’t know how you were to learn to do any of these things in any kind of practical, useful way since there weren’t any classes on it and it was just kind of mentioned you should do these things. But, there wasn’t a lot of attention paid to it I felt. During the first year we had some exposure to it in our research class and generic, really basic exposure to it in our field class—in our first field placement class. Other than that, during the first year it was pretty much non-existent. I did have some professors who spoke about it more often but those were not the majority. . . . It just wasn’t taught and it wasn’t taught well because you’re trying to cram a lot of information into a very limited amount of time.

Some participants reported less frequently that EBP was only taught in research classes (n = 3) and indicated a mismatch between how EBP was taught in the classroom and how EBP is used in the field (n = 9). These participants emphasized that an inadequate educational foundation during their MSW programs now continues to be a barrier to using EBP in their current practice.

A minority of participants reported that they felt they received good educational preparation that facilitated their understanding and use of EBP (n = 3). Participants spoke of believing their MSW education adequately prepared them to use EBP in practice. The following comment that empha- sized the integration of EBP into the curriculum sums up this theme, “It was all integrated. The evidence-based practice was very emphasized in the curriculum and the research, and relating it. We did a grant writing class and we used the research for that.”

Another participant spoke of a particular class devoted to EBP and an accompanying project that taught students the EBP process throughout the semester.

You had basically all semester to research these presented problems and then decide which interventions you were going to use when, where, and why and then throughout the semester, [the professor] would sort of change up the scenario. So our scenario was a family and they were seeking therapy for I think a death and also someone had co-occurring drug use and a mental health issue and all of these other things. And then part-way through the semester, the scenario would change or there would be an added thing like “dad lost his job” or I don’t remember exactly what ours was . . . then each week you had to give sort of an update on what your decided intervention was for the scenario.

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Theme 3: Field experience In addition to course work, we asked participants about their exposure to EBP in field placements. In this subtheme, participants reported no exposure to EBP in field placements with the most frequency (n = 16). Fewer participants spoke of having accurate exposure to EBP in the field (n = 8), and a handful reported inaccurate or confused exposure to EBP in their field experiences (n = 5). Some comments that capture a lack of exposure to EBP in the field setting include, “So I felt like it was encouraged in the academic setting of my MSW, but not so much in the field placements that we had” and “my second field was [child welfare agency] so it’s such a big organization. I just don’t think there was such an emphasis on the evidence-based practice.” One participant who reported EBP was used properly in her field experience said,

We have a really limited number of sessions with our clients that we can have and we’re constantly sort of updating what our practices look like, and there’s a big emphasis on evidence based practice, so we definitely talked about it a lot in my 2nd year.

Theme 4: Lack of resources The most mentioned barrier to using EBP in practice was a lack of resources (n = 68). Interviewees reported lacking important resources that affect their ability to use the EBP process, including lack of access to journals, limited training, insufficient time to devote to EBP, and large caseloads. Typical comments about the lack of resources included the following:

The biggest barrier, of course is that we do not have regular access to academic research. So there’s not some great portal that I can log into and go see what’s in the latest psychology journal or latest whatever it might be. So the best sort of tool that I have at my disposal is Google.

So I would say the bigger constraint would be, given the clinical load work we’re expected to carry, having additional time to explore research and, you know, have that time be available and also valued. Having time to discuss it with peers.

Theme 5: Prohibitive agency policies and culture Participants also identified prohibitive agency policies and culture as a barrier to using EBP in their work with clients (n = 53). Participants reported feeling like agency policies or practices either explicitly or implicitly discourage the use of EBP. The following are examples of comments describing the prohibitive nature of agency policies and culture:

I don’t even have the time to think “well maybe I’ll do this external training” . . . or “I’m willing to sacrifice my billable hours to do that.” If I took a half day training, I basically get penalized. If I was going to go to some seminar on evidence-based practice, they still expect me to see the same number of clients even though I worked a half day. They don’t count a half day as a half day. They still count it as a full day. So just all those little things are, I think, they’re huge systemic issues in terms of me, you know, improving clinically based . . . evidence.

The agency that I used to work for didn’t have—or it wasn’t—a growth environment. And I know it seems like evidence based practice shouldn’t be a novel concept, but it is when it’s going against practice as usual, what’s always been done, even when what’s always been done hasn’t been working.

Theme 6: Agency resource support Fewer instances of agency resource supports promoting the use of EBP emerged from the interviews (n = 22). Some participants identified available resources in their agencies that promote EBP, including designated time for practitioners to attend workshops and training sessions and access to journals. One respondent described the resource support available in her agency:

Our agency provides both funding and time. They will pay for classes up to a certain point.We each have an amount we can spend per year. . . . For the full time people—I’mnot full time but it’s prorated—it’s $1000 a year, so it’s a good amount of money and we also get education days so, you know, we can attend. I think the full time people get three education days a year so they can attend a training on a work day and take the time off. Their productivity is obviously adjusted appropriately, and they don’t have to take vacation or personal days.

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Theme 7: Supportive agency policies and culture Similarly, some participants identified supportive agency policies and culture that encourage or facilitate the adoption of innovation and creativity in their work (n = 22). Although it was rare for the interviewees to identify EBP as an area for growth, it appears that some agencies have an agency culture or policies that are open to change, improvement, research, and different treatment mod- alities. One participant summarizes this subtheme in the following:

I think, on the agency level, I am fortunate to work at a place where there aren’t really rigid dogmatic perspectives about what or how we should do clinical work. We have flexibility to approach the work in the best way possible for the kids and also for adults and we have administrators that are very supportive of our work.

Theme 8: Supervision When asked about the inclusion of EBP in their clinical supervision, participants relayed instances when EBP was excluded from their clinical supervision (n = 8) with more frequency than when it was included (n = 5). Respondents cited a lack of time during clinical supervision to discuss EBP and described their supervisors as not being well informed about EBP. Common responses included,

If asked about using evidence based practice, I know my supervisor would probably say, “well, we use this, this, this, and this,” but in terms of exactly how it’s used, both in what settings or how often it’s used, that would be a little bit more difficult to say.

I see my supervisor once or twice a week, maybe, just when she comes around. When I want to discuss cases, it’s restricted to, is there a problem that I need to deal with right now? That’s her perspective. Like, is there something you can’t handle on your own at this moment.

One participant who felt EBP was a topic included in her clinical supervision stated,

I’m getting supervised still and that’s something I talk a lot with my supervisor about is sort of figuring out what’s going to be a good match as far as or [client] needs and symptoms as well as cultural background and just where that person is and what they’re willing to do.

Theme 9: Social work schools as a resource and support When asked what would need to happen in their agencies to improve their efforts to use EBP, participants stated that social work schools could be a significant resource for graduates (n=11). Specifically, interviewees suggested that MSW programs must do more to promote EBP and to support graduates in the field by providing them with access to the school’s resources, including training and journal databases. One comment reflecting the perceptions of a number of participants was, “Having access to the databases would be amazing. I think that would be a very simple thing that could be done.” Another respondent suggested another way MSW programs could continue to support their alumni in the following:

Let’s say if my MSW program had something for alumni, you know, to attend things they’re doing or if they had any other classes that were either for masters level students or post-masters to go back to. That would be an easy way to learn more.

Theme 10: Confusion Confusion was the dominant theme throughout the interviews, and it is clear that MSW programs are not adequately preparing students to use EBP. Participants used the term EBP inconsistently, confusing it with ESI or EST frequently in their answers. One respondent expressed her confusion when learning about EBP:

I would say that it most often wasn’t called that or if it was that wasn’t emphasized and so I am honestly a little unclear as to exactly when (laughs) I learned about it and what I learned and what was EBP and what wasn’t, and I know that’s maybe not helpful but that was my experience.

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The same participant later further demonstrated her confusion and terminology mix-up by saying, “I took an entire class on cognitive behavioral therapy, um, and so it was definitely addressed here and there during that class. You know, cognitive behavioral therapy is a quote-unquote evidence based practice.”

Theme 11: Never heard of ESI All but three participants stated that they never learned the distinction among EBP, ESIs, and ESTs or had ever heard of ESIs and ESTs. Instead, they reported learning to use the term EBP to describe EBP, ESIs, and ESTs. Multiple participants responded to our question about the definition of EBP and ESI with comments similar to this one: “The first time I’ve ever heard ESI was in participating in this survey.”

Theme 12: EBP is limiting Some participants felt that EBP limits the use of their clinical judgment as they equated the EBP process to specific ESIs and ESTs. Most appeared to believe that EBP encouraged them to work with clients using only an ESI or EST. One respondent summed this up by saying, “So, you know, they work for the client they were designed for but this world is so much bigger than the one client that these things are designed for.” The same participant further commented on her perception of the limiting nature of EBP by saying,

As we move farther and farther and deeper and deeper into an EBP environment, or an ESI environment, we are telling our clinicians, “Do not trust your clinical instincts. This is the only way you’re allowed to work or practice” and robbing them of the art of our practice.

Theme 13: Expectations When asked about the benefits of using EBP for the practitioner and for the client, participants felt that EBP, ESIs, and ESTs provide clinicians and clients with an expectation of better client outcomes. Respondents also stated that EBP instills confidence in the practitioner and the client when planning and implementing interventions. According to one participant,

There are just an infinite number of directions a person can go in any given clinical encounter with the hope of alleviating whatever discomfort or pain or whatever that the client has been presenting and I feel that with evidence based practice, it is an organized fashion of approaching a problem and investigating it in a way and then applying a body of knowledge that is demonstrably shown to be effective for a number of people . . . it also can be helpful if it helps the client understand that it is coming from a place that has shown efficacy which I think helps with that sort of buy-in.

Another participant emphasized how EBP instills confidence in social workers, saying, “In general, knowing that what I’m doing has some broad research support behind it always makes me feel more confident in what I’m doing and knowing that I’m serving my clients well.”

A third participant offered the following further comment on the benefits of EBP to the client:

Most clients that I’ve worked with are really interested in getting some sort of assistance or results to the work that they’re doing and they usually want it fairly quickly. So, whatever we can do as practitioners to use interventions that work well and have been shown to be helpful would be also beneficial to a client.

Theme 14: EBP as beneficial to the agency A final metatheme emerged regarding benefits of EBP for the agency. Participants provided examples of how the use of EBP benefits their agencies or how it might benefit their agencies if it was more thoroughly implemented. Representative comments included the following:

I think [EBP] really benefits our structure in that we can see more people because we’re using things that help people to get better quicker or at least are things that are more likely to get people better in general. The course of therapy would likely be, on average, shorter. I think that it would help the agency a lot and our community because we would have a shorter waiting list and we would get more people into therapy-through a course of therapy.

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Discussion

Our main findings reveal that the majority of participants did not feel that their MSW education adequately prepared them to be evidence-based practitioners. Further, agency policy and practice realities were perceived by our participants to create additional barriers to implementing EBP in practice.

Four main categories of themes were discussed: pre-MSW training experiences, MSW training experiences, post-MSW experiences, and metathemes that were not specific to any one phase of training. Educational experiences highlighted promoters and barriers to implementing EBP post- graduation. Participants with exposure to research during their undergraduate years expressed more favorable perceptions of research in general and were less intimidated by incorporating research into their practice, either through applying the process of EBP or using a specific ESI or EST.

On the MSW level, many participants noted a number of barriers, and only a few identified experiences that promoted the use of EBP. The barriers primarily focused on a lack of preparation for using EBP in their MSW programs. Specifically, participants noted they received little exposure to EBP content. If they were exposed, it was often limited to research courses with no exposure to EBP in practice courses. In addition, they said there was often a mismatch between what they were learning in the classroom regarding research and EBP and what they were exposed to in field placements. Many perceived the agencies in which they were placed also provided little exposure to EBP content. They perceived what was discussed as confusing and contradictory to their course work and reported hearing that using EBP is important but were not seeing it practiced in field training.

The number of individuals who reported MSW educational experiences that provided concrete and clear information about EBP, ESIs, and ESTs was quite low. However, those participants who did perceive education as adequately preparing them to use EBP, ESIs, and ESTs noted that the exposure to this content was either integrated throughout the MSW program or that a free-standing course emphasized EBP as a process. However, these experiences were the exception.

After graduating, participants reported that they continued to have limited exposure to or training on EBP, ESIs, and ESTs. The most commonly reported theme was a perceived lack of resources in their agencies to allow for the implementation of EBP. Participants noted most often perceptions of high workloads, limited access to research evidence, lack of time to implement EBP, and lack of time and support in supervision as barriers to EBP in practice. In fact, several participants noted that there were few instances when EBP was discussed in supervision and that when it was discussed, their supervisors were not well informed about EBP, ESIs, and ESTs. Some participants went so far as to note that they perceived agency policies as actually prohibitive even if they wanted to use EBP, such as not offering the flexibility to reduce billable hour requirements if they attended an EBP-related training or the agency’s focus on authoritative practice (Gambrill, 1999) instead of EBP.

Participants who reported perceiving their agency as helpful in providing them with opportunities to learn about EBP, ESIs, and ESTs were given access to academic and research materials and allotted time and workload reduction for training sessions. Several participants perceived that support from local schools of social work by offering such resources to their agencies would support their use of EBP, ESIs, and ESTs in practice. These individuals suggested that providing access to journals, training, academic databases, and classes for post-MSW graduates at the school could increase the use of EBP for recent MSW graduates.

One of the metathemes that emerged was that recent MSW graduates generally perceive EBP, ESIs, and ESTs positively. The majority of the participants perceived various benefits associated with incorporating research and evidence into their practices. However, a great deal of variability existed among the participants in terms of their depth of knowledge about EBP, ESIs, and ESTs and the accuracy of that knowledge. It was clear from the responses that a great deal of confusion remains about the terms and their meanings. Many of the participants used EBP, ESIs, and ESTs inter- changeably, and many participants reported they had never heard the terms ESI or EST prior to

174 M. D. GRADY ET AL.

participation in this study. It is likely that participants’ confusion reflects discrepancies in an understanding of EBP and the associated terminology among social work educators, including classroom teachers and field supervisors. This confusion on the MSW level results in a cycle of misinformation that is perpetuated within the social work field postgraduation through practitioner supervision or a lack of supervision.

Limitations

This study had a number of limitations. It included a small sample that was drawn from a self- selected convenience sample. The sample and sampling method should be considered when general- izing the results of the study. The small sample size also limited our ability to reach saturation with the data during the analysis phase.

Implications

In spite of these limitations, these findings have a number of implications for social work as a profession. First, even with the changes made to the 2008 EPAS, MSW graduates perceive that their programs of study did not adequately prepare them to be evidence-based practitioners and may have provided misinformation on EBP as well as ESIs and ESTs if included in their program’s curriculum. At the very least, participants in this study reported that as new social work practitioners, they are confused about what EBP is and how it is different from ESIs and ESTs. Based on our findings their perceptions regarding educational experiences raise a question about whether many social work educators and field supervisors remain confused about EBP, ESIs, and ESTs, which may contribute to our participants’ perception of a lack of attention or depth of EBP content in the curriculum of their MSW programs. Very few participants noted that they had exposure in any in-depth way to EBP, ESIs, and ESTs either in the classroom or in their field placements.

Second, although the profession has attempted to integrate EBP, ESIs, and ESTs into professional practice (Bellamy et al., 2008), our findings demonstrate that participants perceived that their agencies continue to struggle to move from a culture of authoritative practice to a culture that promotes and values EBP—providing time, training, supervision, and other resources dedicated to EBP, ESIs, and ESTs. In spite of the changes made to the 2008 EPAS, our participants’ perceptions support the perpetuation of a common cycle where few MSW graduates understand and feel able to adopt EBP in practice; these same practitioners become the supervisors of MSW students and new hires, and because they do not adequately understand or apply EBP, they do not infuse it into their supervision or into the wider agency culture, resulting in authoritative practice rather than EBP, which perpetuates the absence of EBP in social work agencies.

Recommendations

Research exposure Participants in our study who reported research exposure—didactic and working in research programs—prior to entering their MSW program also reported feeling more confident in applying EBP. As social work educators, we have the opportunity to capitalize on this knowledge in a number of ways. Accepting and training MSW-level practitioners is an investment on the part of the individual as well as the school that accepts the individual. If creating evidence-based practitioners is a priority for our profession, we should also make this a priority in our admissions procedures by favoring applicants who demonstrate research exposure either through academic success in multiple research courses or through experience working on research projects and in research programs. An ideal candidate would have both and could be prioritized for funding through scholarships and research assistantships. Further, in our BSW programs we can offer increased opportunities for research exposure through course work, assignments, and opportunities to be involved in faculty and

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doctoral-level research projects. Other disciplines, such as psychology, offer research practicums to bachelor’s-level students for course credit that are supervised by either faculty or doctoral students.

Once students have entered MSW programs we could prioritize opportunities for continued exposure to research by increasing research content in the curriculum, offering research practicums for course credit, and creating additional opportunities for MSW students to work closely with faculty and doctoral students on research projects or by looking for opportunities outside the school that would increase their exposure to research.

Classroom education Social work program directors need to first assess how they are addressing content on EBP and ESIs in their programs. This assessment should also include the faculty members’ knowledge and skills related to EBP and ESIs. It is essential for social work faculty to be clear on the definitions of these constructs to provide clarity for students. This may be in the form of new faculty training that would apply not only to tenure-line faculty but also contract faculty, adjunct faculty, and doctoral students teaching in MSW programs.

Based on this assessment, faculty members should develop concrete plans aimed at increasing students’ knowledge and skills with regard to EBP, ESIs, and ESTs. Program administrators should also consider adopting an integrated curriculum that incorporates EBP into multiple aspects of the curriculum beyond the research course.

An additional option would be for administrators to consider a stand-alone course dedicated to understanding the EBP process. These courses should be distinct from practice courses that teach discrete ESIs and ESTs, and this distinction should be highlighted to increase clarity among the students. Further, any courses teaching or addressing specific ESIs and ESTs should place them within the context of EBP.

Other specific educational recommendations include emphasizing research evaluation skills among MSW students and exposing EBP- and ESI/EST-related content early in MSW programs. It is essential for any content related to EBP and ESI/ESTs to discuss the potential challenges and barriers students might encounter in the field as well as tools they can use to address those challenges. At a minimum, faculty should consider how to integrate EBP into assignments and course readings.

Field education There are several tasks that program directors can adopt to address the field education issues raised by the participants in this study. One recommendation is for schools to provide mandatory training, particularly with continuing education credits attached to incentivize their attendance, to field supervisors and field liaisons on EBP and ESIs so that they have a clear understanding of the content. After such exposure, it is then critical that programs reinforce the importance of this content by incorporating it into field assignments and learning plans.

Social work program administrators should also encourage their field agencies to conduct internal assessment regarding the knowledge and skills of their employees regarding EBP- and ESI/EST- related content, and provide the supports, tools, or technical assistance to do so. If the agency management determines it is lacking information or resources, schools can develop partnerships with agencies to address these deficits, and it is hoped this will result in an agency culture that embraces EBP.

Schools of social work

Grady (2010) provides a number of concrete strategies that schools of social work can use to promote the adoption of EBP and use of ESIs and ESTs by the agencies in their communities. These include holding public seminars on the skills and knowledge needed for different aspects of EBP (such as how to conduct a literature search or interpret research) or on specific ESIs and ESTs, providing access to

176 M. D. GRADY ET AL.

libraries for journals and databases, creating summaries of existing research, posting syllabi on pubic websites, and working in partnership with agencies on various evaluation or training projects. Congruent with other studies, the participants in this study identified similar ideas, reinforcing that school administrators should consider some of these identified strategies (Bledsoe-Mansori, Bellamy, et al., 2013).

Conclusion

In spite of recent efforts to integrate EBP, ESIs, and ESTsinto professional practice, results from this study indicate that social workers still experience a number of barriers in integrating these research- based approaches into their practices. Although social workers believe that adopting EBP and using ESIs and ESTs are beneficial, they remain confused about what the terms represent and how they should be applied. Social work programs can play a critical role in supporting professional social workers by integrating EBP, ESIs, and ESTs more clearly and purposefully into curricula, as well as providing additional support for those already in the field through training and other resources. It is clear from this study that the profession needs to develop a more effective and systematic method of adequately training practitioners to fully integrate the use of evidence more holistically in the field.

Notes on contributors

Melissa D. Grady is associate professor at Catholic University of America. Traci Wike is assistant professor at Virginia Commonwealth University. Caren Putzu is assistant professor at Eastern Michigan University. Sara Field is an MSW graduate research assistant and Jacqueline Hill is an MSW graduate research assistant at Catholic University of America. Sarah E. Bledsoe is associate professor University of North Carolina. Jennifer Bellamy is associate professor University of Denver. Michael Massey is a doctoral student at Virginia Commonwealth University.

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