LITERATURE REVIEW : TRAINING AND ASSESSMENT 4.1 INTRODUCTION
4.3 OUTCOME BASED EDUCATION (OBE) PROBLEM BASED LEARNING (PBL) AND EVIDENCE BASED LEARNING (EBL)
4.3.3 Evidence Based Learning
Evidence based learning synthesizes problem-based learning with critical appraisal of concepts to be learned and with quality management of learning projects (Eitel &
Steiner 1999).
Social work has in recent years undergone a move from opinion-based to evidence- based practice (EBP). Where opinion based work is being perceived as authoritive, the process in EBP is a bottom- up process of engaging with the client to encompass their unique experience with their presenting problem (Shlonsky & Gibbs 2004)
The diagram shows the evidence based practice as a result of a careful integration of the practitioner‟s individual expertise, best evidence and the client values and expectations.
Figure 4:1. Evidence based practice EBP Model. Shlonsky & Gibbs (2004).
Evidence practice originated in Health Care. Decision making about clinical choices needed to be based on evidence and not on intuition and unsystematic clinical expertise. At the same time the “value laden nature” of clinical decisions required contextual understanding of the patient, belonging to a patient group and community. A systemic approach included sensitive listening skills, compassion and added perspectives from humanities and social sciences (Guyatt & Rennie 2002 in Gambrill 2003).
The components of evidence-based practice are the evidence from research findings, systemic reviews of randomized clinical trials (RCTs) as well as descriptive and qualitative studies, opinion leaders and evidence based theories, the evidence from what the client presents and availability of care resources, personal professional experience and information about client preferences, values and concerns.
Steps involved in Evidence Based Practice (EBP) are:
1. Formulating an answerable question regarding information needs related to
practice decisions. The health care profession mentions the PICO format (population, intervention of interest, comparison intervention or status and
outcome). The social work profession uses the COPES format (client oriented, practical evidence search) (Gibbs 2003).
2. Tracking down, with maximum efficiency, the best evidence with which to answer them. Search for systematic reviews and evidence-based family therapy or pastoral counseling practice guidelines e.g. the Dulwich centre, narrative therapy website.
3. Critically appraise the collected evidence by asking for its validity, relevance, impact and applicability.
4. Integrate the appraisal with one‟s professional expertise, client‟s circumstances values and preferences, available referral resources and then applying it to a practice decision or change.
5. Evaluate effectiveness and efficiency of the evidence-based intervention.
(Melnyk & Fineout-Overholt 2005).
The researcher can see value in the evidence based approach to practice for the training programme. The above mentioned points provide for an enhanced knowledge and practice base. According to the diagram, the research based evidence doesn‟t take the place of clinical expertise and incorporates the client‟s expectations and values. In the design for the training programme, the five steps are followed to derive at training material related to the problems presenting and are given as a task to the participants when they design their case studies. Particular attention will be given to aspects of culture and spirituality as these are not measurable in similar ways as other behavioral changes.
Rubin and Parrish (2007), discussed the above mentioned five points and commented that EBP is client empowering, as the evidence regarding the plausible effects of a particular intervention is shared with the clients, who become involved in the process of the selection of interventions. Other advantages of EBP, as mentioned by Hhlonsky and Gibbs (2004) are the extensive initial knowledge base about the clients, the search for, evaluation and practice of effective interventions, and the emphasis on interdisciplinary understanding and teamwork. The researcher believes that all these points have value and relevance for the training programme as participants are indeed her co-researchers and their empowerment is crucial for best practice to prevail.
Rubin and Parrish (2007) expressed a concern with evidence based work, that practitioners may not always find evidence, and may have to provide interventions without an evidence base. They gave the example of clients with multiple problems, who may not carry a formal diagnosis validity of randomized clinical trials (RCT).
Clients with co-morbid diagnosis (e.g. depression, anxiety, substance abuse and personality disorders) were excluded when treating clients for post traumatic stress disorder. Also clients with severe multiple trauma might need longer-term treatment.
Empirically supported interventions, e.g. cognitive therapy and exposure therapy are examples of brief therapy.
EBP is also restricted to practitioners who have access to electronic databases.
Advances in information technology have increased the speed of access to and the
spread of continually updated systematic reviews of practice information. Many church leaders and lay counsellors come from underprivileged communities and do not have access to a computer. When there is access, time spent on internet may be too costly and computer skills need to be acquired. Hence, the concern raised by Rubin and Parrish (2007) applies to participants in the training programme.
Organisations such as the Campbell Collaboration and the Cochrane Library identify which interventions have the best empirical support.
The client-orientated practical evidence search “COPES” (Gibbs 2003) requires separation of the question in four distinct elements : client type and problem, what might be done, alternative course of action, outcome desired. The questions are then categorized into five domains: effectiveness, prevention, risk/prognosis, assessment, and description (Shlonsky & Gibbs 2004). After finding the evidence, the practitioner would still need to critically evaluate these reviews about the quality of the research and idiosyncratic client needs. When practitioners were trained in other approaches, which may not be appraised as best evidence, they may be overwhelmed by the evidence and fail to appraise it or rigidly adhere to new treatment manuals without adhering to therapeutic alliance with the client and their experience as a practitioner. Another risk is if practitioners selectively find evidence that would support their existing practice base and not necessarily be the best evidence (Rubin & Parrish 2007).
The researcher would agree that it takes practice to arrive at the required results. Then the practitioner needs to carefully consider the match between the client‟s situation and the available practice model. The whole process needs a practitioner who is committed to evidence based work and preferably works in a team where modalities are discussed and shared with other team professionals and participants who as co-researchers, are partners in the forward planning of the model. When practiced well, the method would create a wider ranch of treatment option and skill development.
The EBP process accepts alternative sources, e.g. case reports, clinical descriptions, qualitative studies, correlational studies, uncontrolled pre and posttest trials. Thyer (according to Rubin & Parrish, 2007) argues that if these are the best sources available, then they are acceptable for professionally guiding the practitioner. It seems
important to find the right balance of the best evidence of certain studies and studies with lower internal validity, that may better fit clients‟ unique attributes, circumstances, values and preferences. “Qualitaitve studies might generate deeper tentative understandings of client perspectives” (Rubin & Parrish 2004: 419).
To evaluate their application of the intervention, practitioners are advised to use a single-case design. The concern here is the time constraint and therefore the lack of evaluative information of effectiveness and efficiency. “Practitioners would need to adopt a process of lifelong learning that involves continually posing specific questions of direct practical importance to clients, searching objectively and efficiently for the current best evidence relative to each question, and taking appropriate action guided by evidence‟‟ (Gibbs 2003:6). Constant reflection for best practice to prevail is necessary although it is time consuming but important for adoption in the training programme.
Sexton argues that accountability is mostly important in evidence based counseling practice and that „best practice‟ is concerned with the service costs, knowledge base and competence of the counselor, which is supported through outcome based research.
He mentions the “art versus science” and “research verses practice” debate as irrelevant, as counselors become highly efficient and skilled in their practice and informed by evidence based research. Sexton promotes the practice of empirically supported treatments (EST), which are evidence-based systematic counselling intervention protocols. Lambert (according to Sexton 1999) states that while theoretical orientation or model only accounts for 15 % of the effective outcome of counselling, these protocols would also attribute to common factors of successful counselling as to a collaborative counselling relationship, the value of experiential learning and acquired and experienced action.
The researcher would be concerned if the EST‟s for personal and familial problems would become part of the training curriculum for pastoral counsellors, that the complex social processes might be minimized. Church leaders may be tempted to a literal application of knowledge and counselling skill and procedure, which might take away their warmth, empathy and natural ability to take the role of the spiritual counsellor. In
the training model, the EST‟s would need to be contextualized and appraised by the church leaders.