Social work practice research: The question of questions

Enola Proctor George Warren Brown School of Social Work Washington University in St. Louis

September 17, 2005 San Antonio, Texas Prepared for the National Association of Deans and Directors (NADD)

Looming crisis in professional stature

Quality and sufficiency of applications to schools of social work Areas of practice defaulted to other professions Growing demands for accountability and evidence

Significance of social work practice research

Evidence = root of societal sanction for professional activity Profession has responsibility for knowledge base

Social work research and the profession’s knowledge needs

• The question of questions: – What research questions should we be asking?

Strides in social work knowledge development

• Growth in externally funded research • Increase in thematic research centers – Hartford initiative in gerontology – NIDA & NIMH funded research centers – School-initiated centers • Specialization of profession – NASW member sections • Practice research conferences • Recent publication of research agendas – Aging, quality of care, practice guideline development

Key questions in social work practice research

• What are the “practices” in social work practice?

• How does social work practice vary?

• What is the value of social work practice?

• What practices should we use?

• How do we improve social work practice?

Caveats:

• Working definition of “practice”: – Interventions – Outcomes “Practice” comprises professional action at all levels: individual, group, team, community, societal

Q 1: What are the “practices” in social work practice?

•

What do we do?

•

How much do we know about “what we do”?

Percentages of Social Work Articles by Type & Replicablity of Intervention (Total Articles n=1849) Research Intervention Articles, Interventions not Replicable 7% Research Articles with Replicable Interventions 3% Non Research Articles 53% Descriptive & Exploratory Research Articles 37%

Rosen, Proctor, & Staudt, 1999

Research on interventions

• Can we name our interventions?

– Issues of • Nomenclature: • Common language • Procedure codes • Is there a taxonomy of social work interventions?

– Rosen, Proctor, & Staudt, RSWP 2003 – Staudt, Cherry, & Watson, SWR in press

Associated questions:

• About intervention knowledge: – Are interventions standardized (manuals & protocols)?

– Do SW practice researchers direct their attention to priority interventions?

• Interventions corresponding to priority outcomes • About practice itself: – What interventions do social workers employ most frequently?

– Are interventions used with fidelity?

Q 2: How does social work practice vary?

• Interventions are not universally appropriate

How does social work practice vary?

• What factors are associated with variability in use of interventions?

• Do interventions vary by – Problem (severity, duration, comorbidity?) – Clients?

– Providers?

– Training?

– Payment source and structure?

Practice variation research:

• Examples of practice variation questions: – Detection of problems: depression, substance abuse, domestic violence, child abuse • How does social workers’ recognition of these problems vary? • Examples of practice variation researchers: – Bentley: medication practices – Proctor & Morrow-Howell: 24% of client depression noted by social workers in agency record

Research to identify sources of variability in interventions used

What variability is observed?

Is the observed variability rational?

What variability is OK? What variability is desired?

– juxtapose observed patterns with • theory, best practices, assumptions about who should get what kind of care.

– Health Services research: • Andersen model: variability from factors other than need and preference = inequitable care

Research on practice variation:

• Extends social work’s historic social justice perspective to disparities research – McMillen: racial variations in mental health care for children in child welfare • Foundation for quality of care research:

Q 3: What is the value of social work practice?

Metrics for social work’s value

Cost of service as market issue: Social work has long been recognized as among the cheapest profession Value: How can we become the “high value” profession?

 What is our profession’s value added?

 With social work, “what?”  Without social work, “what is missing?”

Research to capture social work value: taxonomy of outcomes

• Research on the most salient outcomes in social work practice (Proctor, Rosen, Rhee, 2002) – Documentation • Frequency • Variability across practice settings, sectors of care • Factors associated with variation – Classification Taxonomies • Descriptive, typology categories – Conceptualization of impact, value • Do SW practice researchers focus on outcomes most important to profession?

– Potential to enhance relevance of intervention research

Proctor, Rosen & Rhee (2001)

Differential Focus on Outcome Domains in Practice and Research 45 40 35 30 31.3

38 38.5

25 20 21 15 12 11 10 11 10 8.4

5 2.9

3.9

6 3 0.7

0

Clinical Functional Life Satisfaction Welfare & Safety Knowledge & Info.

Prep. Adjustment Resource Management

Effort in Practice: % of outcomes focused on by a sample of health and mental health social workers Effort in Research: % of outcomes focused on in studies of social work interventions

Research to capture the value of social work practice

• Measurement of the “increment” attributable to social work intervention • Quantification of value • Cost to deliver • Cost-benefit • Cost of care studies • Comparative costs of interventions.

• Studies of value, or cost-effectiveness, cost-benefit

Q4: What practices should we use?

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Fundamental “building block” research: effectiveness of interventions for outcome attainment

Research questions to inform, “What practices we should use”

• What interventions are effective?

• What interventions are effective for a priority outcome?

• Which interventions are most effective for a given outcome?

• What interventions correspond to client preferences?

• Which interventions are most effective for the client group at hand?

• What interventions are most cost-effective?

Challenge for social work research community

• Identify practices with strong evidentiary base • Review, synthesize, consolidate • Construct practice guidelines useful to social workers • Built from social work research

Q5: How do we improve social work practice?

•

Assessing and improving quality of care may become this decade’s most pressing challenge for social work

– Proctor, 2003; – McMillen, Proctor, et al. (SWR, in press)

Research to improve social work practice

• Identify and develop quality indicators • Target quality improvement – Focus professional training around best practices – Develop improvement strategies • Advance quality improvement research – Partner with field to roll-out and test quality improvements

Q5: How do we improve social work practice?

Needed research designs & methods: – Decision support research – Dissemination research – Models of agency partnership • What methods are effective? – Implementation research • Distinct outcomes: – Acceptability – Feasibility – Sustainability – Fidelity

Challenges

• Breadth of field • Limits of research training – Too few doctoral graduates – Too little post-doctoral training – Limited scope of research expertise • Weaknesses in research infrastructures – Research is investigator driven – Most research is small in scale – Multiple funding agencies – Poor fit of professional priorities to funding agencies

What to do about the question of questions in practice research?

• Rationalize our research endeavors – Pursue research purposively around priorities – Social work research/ academy becomes knowledge resource to practice • Organize practice research around agendas – Social work research is too often piecemeal – Agendas need to be • comprehensive, • substantively differentiated • long-range research • Establish “centers of excellence” around research agendas

Research agendas enable:

• “Stock-taking” – What do we know?

• Basis of confidence in professional practice • Foundation for advocacy on behalf of profession – What do we NOT know?

• knowledge gaps • Cautionary notes • Establishing research priorities • Shape research around profession’s needs