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Hospital admitted patients with complex health and social needs: what knowledge do social workers tell us they draw on in order to know what to do? Health Social Work Directors Symposium, September 2016 Carol Quayle A/Prof Fiona Mc. Dermott Annabel Henderson Project funded by the Lyra Taylor Fund, AASW
Background Two research projects: 1. U 65 ED: Emergency department patients with complex health and social needs: what do social workers do? • Focus on patients under 65 years, admitted through ED, multiple health & social issues • Patients’ multiple problems & age pose challenges • Limited services • Tendency to become ‘stranded’ 2. The Evidence Based Bank project
The Evidence Based Bank project • Since 2012 supervisors & students building the Bank • On-line readily-accessible resource: • 400+ systematic reviews of empirical studies pertaining to social work interventions frequently undertaken in health settings eg discharge planning, family work, psychosocial support etc relevant to different disease groups and populations • Each review critiqued & implications for SW identified • 2014 input provided to inform & support SWs in using the Bank: – Student & supervisor forum – Professional Development seminar – Workshops on using the Bank
Study design: U 65 ED • mixed method study • MH HREC approval as Q&SI project • Total of 8 SWs invited to participate in case selection & interview • inclusion criteria for case selection: – Patient admitted and discharged between 01/07/2014 and 30/06/2015 – Presented through a Monash Health Emergency Department – Aged under 65 years – Multiple health problems and/or disabilities – Few social supports • RA conducted data mining of files selected using template developed from literature review, focused around research question • RA interviewed social workers re cases they selected • • Interviews analysed thematically Data interpretation: team meetings
The Questions we asked • Part 1: practice issues • Part 2: knowledge issues Replication of questions asked in Gordon & Cooper 2010; familiar with similar studies by Fook et al 2000; Osmond & O’Connor 2006 • What did you need to know in order to assist this patient? • What is/was it in your education and training that helps you know what to do? • If you were/are not sure what to do, where do you seek information from?
Questions! • How would you answer these questions? • What do you think the answers might have been?
Findings • Six social workers at two Monash Health hospitals volunteered to participate • They identified thirteen patients as meeting the inclusion criteria
Findings - Who were the participants? Grade Experience (at Monash Health) Hospital Site Ward EBB Social Worker 1 2 5 years Hospital A Sub-Acute Social Worker 2 1 4 years Hospital B Sub-Acute Social Worker 3 Split – 2 4 years Hospital B Acute Social Worker 4 2 9 years Hospital A Sub-Acute Social Worker 5 1 6 years Hospital A Acute Social Worker 6 1 6 years Hospital B Sub-Acute
What knowledge social workers said they used: Four themes: 1. Past experience and situational knowledge informs practice decisions 2. Decision making in practice situations requires skills and education 3. Person-in-environment perspectives inform practice decisions 4. Empirical or other evidence is not sought (not relevant)
Theme 1: Past experience and situational knowledge informs practice decisions • • • hospital protocols legal procedures medical information, eg patient’s cognitive capacity Previous patient outcomes Supervision from colleagues …(how I prioritise) depends on the situation, what the patient needs. One thing we have to remember is we are in an organisation, we keep saying we’re here for the patients and we need to advocate for the patients, but we are responsible and have a duty of care to the organisation as well. Sometimes that can bring some tensions and conflict in myself, because I’m here to advocate and get good outcomes for my patients, but I have the pressures from above saying what are you doing to facilitate some discharges?
Theme 2: Decision making in practice situations requires skills and education • Reflection, empathy, relationship-building & counselling skills, flexible thinking, critical reflection ‘…being self reflective, what can I do to change to make this process easier for this family and patient…I needed to know how to read this situation, intuitive, reading body language…’ • SW training helpful re ethical issues but previous experience more important – ‘…a lot of it is experience…’ • Ability to link theoretical knowledge with practice – ‘…hopefully work this way because of theoretical influences…’ • Knowing how to do assessments ‘…having a good understanding of social work theories helps me gather …information and analyse it and draw on that information and make a proper clinical judgement…’
Theme 3: Person-in-environment perspectives inform practice decisions • Person-in-environment not specifically named but evidence that SWs were • Drawing on knowledge at micro (eg patient), meso (eg MDT), macro (eg laws, policies) • Indicating that a systems understanding characterised their theoretical perspective ‘…patients (have) different issues, and (I need to know) the different systems around those particular issues: knowledge of the resources available within …systems will give you a better idea of what impact they will have on discharge…’ ‘…I think in this particular case the mother and patient needed help to navigate their way through these systems and know what’s available for them and their rights and responsibilities’
Theme 4: Empirical or other evidence is not sought (not relevant) • Absence of reference to accessing any sources of empirical evidence • Absence of mention of use of EBB
In summary - Our study supported findings in other studies – Fook, Ryan and Hawkins (2000) Osmond & O’Connor (2006) Gordon, Cooper & Dumbleton (2009) Three key issues: 1. Centrality of person-in-environment 2. Absence of reference to use of empirical evidence 3. ‘Two communities’ – research & practice?
1. Centrality of person-in-environment • Good news! ‘…need to know systems of hospital environment, knowledge of services at practical level, knowledge of systems and agencies outside the hospital…. ’ • Practitioners are telling us about their sources of knowledge – ‘ordinary knowledge’ (Berger & Luckman 1967), ‘tacit knowledge’ (Schon 1983), ‘practice wisdom’ (Scott 1990), ‘clinical expertise (Sackett et al 1997) BUT ‘What can be done to encourage practicing social workers to draw upon research findings to help decide what social work services to provide? . . . clients have a right to effective treatments where such interventions are known to exist (and)…(t)his should be construed as both an ethical mandate and a legal one’ (Thyer 2014, p. 4)
2. Absence of reference to use of empirical evidence Not good news! Many reasons noted by many researchers re barriers to SWs doing EBP – time, client demands, lack of confidence, lack of knowledge, practitioner attitudes (Gray et al 2012; Gira et al 2004; Bender et al 2014; Cheung et al 2014; Gambrill 2014; Hart, in Webber 2015) But situation seems to be changing: (Gray et al 2013; van den Zwet et al 2014)………. .
Our student follow-up survey • e-survey to 18 students 8 months after final placement at MH & in first social work position • 50% response rate (9) Findings: • All noted that: • their final placement experience prepared them well for their first social work position • They retained their learning acquired about evidence based practice through the Evidence Based Bank Project • All agreed that: • they have a satisfactory or adequate understanding of Evidence Based Practice in social work • Knowing how to find evidence for social work interventions is very important in providing a good service to clients/service users/social work services • they looked for evidence to support what they were doing as a social worker as often as they could
3. ‘Two communities’ – research & practice? • Bridging the gap: • Discovering more about ‘other’ sources of practitioners’ knowledge: ‘…instead of ignoring clinical expertise and client values and expectations, the EBP process requires practitioners to extend themselves beyond the realm of practice wisdom and combine these elements with the best evidence…’ (Rubin & Parrish 2007, p. 409) • Greater emphasis on EBP in qualifying programs • Greater leadership within profession re bridging the gap • Potential of Pragmatism: knowledge as a vehicle for problem solving (Evans & Hardy 2010; Plath 2013; Flynn & Mc. Dermott 2016) – ‘…identifying useful evidence … to make informed judgements in practice…’ (Plath 2013, p. 236)
What have we learned? • Need for larger study • Need to capture ‘other’ sources of knowledge & find ways of teaching SWs how to integrate these with empirical knowledge • Re-think our strategies for increasing use of EB Bank?
References Bender, K. , Altschul, I. , Yoder, J. , Parrish, D. , Nickels, S. J. 2014 ‘Training Social Work Graduate Students in the Evidence-Based Practice Process’, Research on Social Work Practice, Vol. 24(3) 339 -348 Cheung, M. , Ma, A. K. , Thyer, B. A. , Webb, A. E. 2014 ‘Research–Practice Integration in Real Practice Settings: Issues and Suggestions’, Research on Social Work Practice, 1 -8, DOI: 10. 1177/1049731514540479 Fook, J. , Ryan, M. , & Hawkins, L. (2000). Professional expertise: Practice, theory and education for working in uncertainty. London: Whiting & Birch. Gordon, J & Cooper, B (2010) Talking Knowledge — Practising Knowledge: A Critical Best Practice Approach to How Social Workers Understand Use Knowledge in Practice, Practice: Social Work in Action, 22: 4, 245 -257 Gordon, J, Cooper, B. , & Dumbleton, S. (2009). How do social workers use evidence in practice? Milton Keynes: Open University. Gambrill, E. 2014 ‘Integrating research and practice: distractions, controversies and options for moving forward’, Research in social work practice, 1 -13 DOI: 10. 1177/1049731514544327 Gira, E. C. , Kessler, M. L. , Poetner, J. 2004 ‘Influencing Social Workersto Use Research Evidence in Practice: Lessons From Medicine and the Allied Health Professions, Research on Social Work Practice, Vol. 14 No. 2, March 2004 68 -79; DOI: 10. 1177/1049731503262128 Gray, M. , Joy, E. , Plath, D. and Webb, S. A. (2012) ‘Implementing evidence-based practice: a review of the empirical research literature’, Research on Social Work Practice. Gray, M. , Joy, E. , Plath, D. and Webb, S. A. (2013) ‘What supports and impedes evidence-based practice implementation? A survey of Australian Social Workers’, Research on Social Work Practice, 23 (2): 157– 66. Osmond, J. and O'Connor, I. (2006) Use of Theory and Research in Social Work Practice: Implications for Knowledge-Based Practice, Australian Social Work, 59: 1, 5 -19, Van der Zwet, R. J. M. , Beneken genaamd Kolmer, D. M. , Schalk, R. 2014 ‘Social Workers’ Orientation Toward the Evidence-Based Practice Process: A Dutch Survey’, Research on Social Work Practice, 1 -11, DOI: 10. 1177/1049731514540340 Webber, M. (ed) 2015 Applying research evidence in social work practice, Palgrave, UK