By Torben Clausen (toc@dpu.dk)

"How many of you pretty much know what is meant by evidence-based practice?" Ed Mullen's gaze wanders among the audience in the lecture hall and he starts counting. A few hands go up with steely confidence, followed by a few more tentative ones. A grand total of five is reached.

Next question: "How many of you have heard the term evidence-based practice but just don't know what it's all about?" The spectacularly few hands are instantly joined by a sea of other hands shooting up. "Most of you," Ed Mullen notes. "That's an indication of where the profession is. If I asked the same question in the United States, the answer wouldn?t be any different. This is a fairly new development," Ed Mullen says soothingly to the audience, which today comprises some forty students from the Danish University of Education's Master of Social Work, all of whom have agreed to spend the day in an attempt to find out exactly what evidence-based practice is all about.

Endangered professionalism?

Although evidence-based practice is a new development, it has already caught the attention of politicians and practitioners alike - and not just for positive reasons. There is a certain trepidation among professional teachers and pedagogues that evidence-based practice means that the professional skills will suffer from the introduction of 'cookie-cutter methods'. These are detailed descriptions of best practice, and teachers and pedagogues are supposed to follow the recipes to the letter without an examination and evaluation of the individual child or client they may be facing. This reservation has been voiced by the chairman of the Danish Union of Teachers, Anders Bondo Christensen:

"If we apply knowledge the wrong way, we risk de-professionalising the teachers, although the opposite was the intention. It is important that we support the teachers? basis for understanding research. I believe there is a need for a research teachers can recognise from their practice."

Ed Mullen is familiar with this reservation. He is a professor at Columbia University, where he has specialised in social work. He has recently completed a pilot study in New York, which aimed to transform trained social workers into evidence-based practitioners. To Ed Mullen, evidence-based practice does not imply that practitioners should feel restrained in their work by forcing certain methods on them, quite the contrary. Evidence-based practice means to apply modern technology to acquire and identify the best scientific findings and applying that knowledge. Unfortunately, that is not always how the term is interpreted at the political level.

Get off the bandwagon

Both in Europe and the United States we find numerous examples that evidence-based research is applied in ways that has little to do with the actual meaning of evidence-based practice, Ed Mullen explains. Among the examples are edicts from central political authorities that bind professional social workers and pedagogues to certain standardised procedures. Nothing could be further from Ed Mullen's interpretation of evidence-based practice.

"In the US and many northern European countries we see that central government identifies five or six interventions and then go on a bandwagon to promote them to local government and agencies by providing training or financial incentives: Do multisystemic therapy! Do ACT-programs! Do this and do that! That's not evidence-based practice."

In Ed Mullen's view, evidence-based practice begins with a question the professionals ask of themselves: "What should I do in this situation where a client may be on the verge of suicide or a child is hurt by its parents? You need to formulate a genuine question for which you don't have the answer, and where there are alternative interventions to be considered," he says.

Research, experience and individual measures

To an evidence-based practitioner, a politically promoted method must be one among several under consideration when a situation of doubt occurs. The grand old man of evidence-based practice in the field of medicine, David Sackett, shares this view. In 1996, he and his colleagues wrote in an article called 'Evidence based medicine: what it is and what it isn't':

"Evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research? Evidence based medicine is not 'cookbook' medicine.?

This is the same demands Ed Mullen has to social workers: To combine research-based knowledge about the most efficient methods with an expertise that enables the professional to correctly understand the particular client's unique health situation and risk, and with an ability to understand the individual client's specific values and wishes concerning choice of treatment. To exemplify the last point, Jehovah's Witnesses are forbidden by their faith to receive blood transfusions, and some cancer patients have different opinions than their doctors about whether or not they want chemotherapy due to the side-effects.

Pose a question, search for the answer

An inquisitive mind is the outset, but the first practical step for the evidence-based practitioner is to transform this curiosity into a question that can be examined and answered. The trick is to be specific about the problem you are focused on, about the possible interventions under consideration, and about the end result you are aiming for. Mullen distinguishes between different types of questions that can be examined through different types of evidence:

• What is the best way to describe the client's situation?
• What is the best procedure for measuring the scope of the client's problem?
• What is the best procedure for evaluating the risk of certain undesirable consequences, such as suicide or abuse?
• What is the best procedure to prevent a specific problem from occurring?
• What is the best procedure for alleviating an existing problem?

Now you are ready to search through the literature and to examine the results you find. At best, you find a wide range of answers, but you may also find nothing at all, Mullen warns.

"It is often a criticism of evidence-based practice that we don't have enough evidence, but that's beside the point. The point is that you have to find out what the evidence actually is, and sometimes the hardest part is sharing that with the client and considering options, especially when the evidence is not very good."

The final step is, according to Mullen, very important; to make sure the entire organisation benefits from the new knowledge. This means you must accept the role as someone who instructs your colleagues.

Do it in teams, use the time, spend the money

The pilot study in New York demonstrated that there are several organisational conditions that must be in place to facilitate evidence-based practice. The first one is, according to Ed Mullen, that the work must be in teams. The process calls for different sorts of expertise, so it is recommended that the professional social worker is accompanied by a librarian or another kind of specialist on searching for information to assist in hunting down research findings.

It is also important to include someone from management in the process. He or she can ensure that the knowledge found can be embedded in the organisation. Another advantage of teamwork is that one person's idiosyncrasies do not dominate the project. Several people working together can sometimes help in avoiding preconceptions from getting in the way of the formulation of questions and the evaluation of available evidence.

Another insight that the practitioners in the pilot study have pointed to is that time pressure plays a big role. To meet, formulate questions, conduct searches and to evaluate the evidence ? it all takes time. In evidence-based medicine, it is recommended that time is set off to each day think about whether questions have come up during the day's contact with the patients. On the other hand, Ed Mullen believes Internet searches can be carried out very quickly, once you have mastered the technique. "But time is a major barrier. Organisations that want to become learning organisations have to structure the time and protect a certain amount of time for this."

A third insight is that organisations have to make computers and search engines available, and this is often costly. Many search facilities come with a subscription fee, and far from all organisations willingly pay for this service. One alternate route is to locate a library with access to the search engines, which may take additional time, but there is no way around it ? to be an evidence-based practitioner means to use modern information resources to gather knowledge.

A tall order, indeed

"Integration of current best evidence with expertise and client values: Wouldn't you like to do that? Doesn't that sound pretty good?" Mullen sounds as if he knows full well he is teasing the students. He knows it is a 'tall order', as he says. One key challenge for the dissemination of evidence-based practice is that many professionals lack the scientific training necessary for critical reading and application of scientific inquiries. Concepts such as 'test of significance, absolute risk reduction, relative risk reduction, number needed to treat' have to be familiar to the user, if the scientific effort is to make any sense.

Just adding scientific thinking to the professional insight is, however, not enough in and of itself. The practitioner must also master what many academics do not, which is to transform the research into actual practice. Evidence-based practice is, in other words, dependant on a successful fusion of competencies related to both research and practice. And if that was not enough, the methodology in social sciences is still under development, according to Ed Mullen, which makes it even more of a challenge for practitioners to understand the nature of the knowledge the researchers can provide.

"There is significant growth in sophistication in social science research methodology, and it's going to continue to get more complex. We can't expect practitioners to have knowledge and sophistication of these complex social science research methods."

Therefore it is important that new generations of social scientists are trained with a comprehensive understanding of the methodology of social sciences, and who are also able to make their knowledge relevant. One step in this direction would be that researchers focus on the questions that practitioners point out as important.

Despite these challenges, Mullen is convinced that evidence-based practice is the name of the game for the future, because "how could it be any different in an information age?" The question is merely how long it will take for this concept to become dominant. One generation's time is probably not far off, says Mullen, but continues: "The upside is that in the information age, a generation is much shorter than it used to be. I'm struck by my students, I have to work to keep up with them. They are computer literate, they are used to searching, and they challenge the old faculty members. I expect there is going to be a very rapid movement towards evidence based practice," he closes.

Become an evidence-based practitioner in ten steps

In connection with the New York pilot study, Ed Mullen and his colleagues developed training materials that provide the knowledge and skills necessary to begin to work evidence-based. "It's how to become an evidence-based practitioner in ten lessons. And it worked," as Mullen says with a grin. The material is available at the homepage of The Musher Program at Columbia University under "Evidence-based Policy and Practice."

Boks: A new professionalism?

You can read more about evidence-based social work in the book 'Evidence-Based Social Work ? Towards a New Professionalism?' The book was edited by Peter Sommerfeld, who is the Professor for Social Work at the University of Applied Sciences in Northwestern Switzerland, and who also paid the Danish University of Education a visit this October.

Peter Sommerfeld considers evidence-based practice the seed for a new professionalism, and a welcome alternative to the managerialism that currently dominates social work. According to Sommerfeld, managerialism represents the politicians' response to a disappearance of confidence in the professionals. Joe Public no longer takes for granted that trained professionals know what they are doing, and social workers have very little authority as a result. One reason is that modern ICT provides lay people the means to question the treatment they receive from the state, e.g. by finding information on the Internet after a doctor has provided them a diagnosis. The response should, says Peter Sommerfeld, be to turn to evidence, which may serve as the basis for a new professionalism. This would put the professions back in charge of their own work, says Peter Sommerfeld. And the means is a collaboration between practice and research:

"We need to develop 'the interface': People at the frontline, the knowledge managers, the ones who work on the border between science and practice and who have the skills to do the job of translation and transformation of knowledge. This changes the professional skills needed and also the 'gestalt' of professional work."

This should not be construed as a merger of research and practice. Rather it's a call for exchange and dialogue, says Peter Sommerfeld.

Read more about Peter Sommerfeld's work in the anthology published by Peter Lang in 2005. Interested readers can find another view on the breakdown in trust and managerialism at universities in this Quarterly article.