Evidence-based practice, shared decision making and performance in social services – A project at Leanlink, Advice and Support, for the municipality of Linköping
Since the late 1900s, evidence-based practice (EBP) has achieved major international impact. Both in health care and in education and social services, EBP is considered to lay the foundation for the best possible treatment, education and social services. EBP is described by the Swedish National Board of Health as "a deliberate and systematic use of the best available knowledge; the professional s expertise; the person s situation, experience and preferences."
This project focuses on the last component. One way in which to interpret how "the person s situation, experience and preferences" should be taken into account, is to formulate them in terms of shared decision making (SDM).
The aim of the project is to explore ideas concerning SDM and participation in relation to the performance of the social services. This means examining whether certain models or initiatives (for SDM and participation) more closely correspond to the values and considerations that the social services are obliged to adopt and safeguard, than others.
In order to achieve this, different tensions (between the user s service requests and services founded in EBP; between clients requests for participation and different ideas about SDM) will be analysed using moral theory and philosophical methods. The collection of data (consisting of documented initiatives) will link the project to the local providers of social services and the experiences they gain in practical social work.
This project focuses on the last component. One way in which to interpret how "the person s situation, experience and preferences" should be taken into account, is to formulate them in terms of shared decision making (SDM).
The aim of the project is to explore ideas concerning SDM and participation in relation to the performance of the social services. This means examining whether certain models or initiatives (for SDM and participation) more closely correspond to the values and considerations that the social services are obliged to adopt and safeguard, than others.
In order to achieve this, different tensions (between the user s service requests and services founded in EBP; between clients requests for participation and different ideas about SDM) will be analysed using moral theory and philosophical methods. The collection of data (consisting of documented initiatives) will link the project to the local providers of social services and the experiences they gain in practical social work.
Final report
Purpose of the project and how it has developed during the project period
The purpose was to explore ideas concerning shared decision-making (SDM) or participation as part of the evidence-based practice (EBP) in relation to the performance of the social services. The focus was on the component of EBP related to "the person’s situation, experience and preferences” and to examine whether some models for user participation more closely correspond to the values and considerations that the social services are obliged to adopt and safeguard.
Literature studies and the encounter with the practice have contributed to several insights that played a role in the project’s development. A first is that EBP in many cases is not "in place" within the social services. In addition, EBP and the promotion of it by Swedish authorities is questioned by a number of researchers in social work but also by some practitioners. Since the project had EBP as its starting point (where SDM was treated as a component of EBP), I considered it important to focus this tension between authorities, researchers and the profession. A first article was therefore written about a dilemma faced by the practitioner in social work regarding the introduction of EBP.
A second insight was that there is little empirical data to be found regarding different models for user participation. Many models have not been properly evaluated, so the question of on what grounds the social services should choose methods for participation became central and was addressed in a second article.
Several project questions became relevant for both decisions on intervention and decisions concerning performance and the difference between the decisional level and the executive level was therefore not decisive.
A short description of how it was implemented
Literature studies have been conducted of literature in the areas of EBP in social services, implementation, user participation in general and SDM in particular. Legislation and other governing and recommending documents have also been important.
The project plan included a possible collaboration with the organization’s “development unit” (where practitioners are part-time “co-researchers”) in that these co-researchers perhaps could be of help concerning collection of data. However, the project plan emphasized that the project was not dependent on such empirical data. The development unit was also less developed than I thought it would be, based on the documents I received before the Flexit project started. To gain more empirical knowledge, collaboration was initiated with prof. U-K Schön at Stockholm University who has extensive experience in research on SDM.
Articles have been written continually throughout the project and sent to peer-reviewed journals. Conference presentations have been held at national and international conferences.
How the project has contributed to increased collaboration between the university and organizations outside the academy
The project has contributed to increased collaboration primarily thanks to how the Flexit position is organized. Concretely, collaboration has taken place with regard to ethics, including 14 lectures on ethics, fundamental values (“värdegrund”) and user participation. Two lectures at the Social Services Department in Linköping as well, but also collaboration concerning the internal work at Råd & Stöd regarding the organization’s ethics and fundamental values (“värdegrund”).
I have participated in the development of the “development unit”, as well as being a participant in the unit’s steering committee and EBP-group. I have also supervised co-researchers working in this unit. In addition, I have attended two conferences hosted by the organization. I have also participated in the organization’s study visits to Angered and Helsingborg.
Together with co-workers at Råd & Stöd, I have conducted a survey of methods used within the organization. This was a jointly conducted survey sent to employees and the results were presented in a report for the organization. I have also contributed continuously with support regarding “external monitoring” (“omvärldsbevakning”) and content for the organization’s web page when it comes to research and development. The development officer and the coordinator for the development unit have also contributed with comments on the articles written during the time at the organization.
Thanks to a Flexit position, researchers also become more easily available for other parties outside the academia. Concretely, this has included invitations to be a speaker at events outside academia. This includes a conference organized by Linköping Municipality and Samordningsförbundet Östra Götaland and a Jubilee Conference held by SBU (The Swedish Agency for Health Technology Assessment and Assessment of Social Services, together with Prof. C. Munthe and Prof. L. Sandman). I have also taken part as an ethical expert concerning two evaluations of methods in social work, conducted by SBU. I also attended an expert meeting at the National Board of Health and Welfare, regarding interventions without consent. I have also received an assignment from Sveriges Stadsmissioner regarding the intervention Housing First,
The Flexit seminar, held by us three Flexit researchers (2016-2019) from the University of Gothenburg, was also an arrangement dedicated to collaboration. The seminar, which had collaboration and knowledge exchange as its theme, included participants from academia as well as the organizations.
The project’s three most important results and a discussion about this
One result has to do with the conditions for EBP and SDM. The organization of the social services provides a "decisional topography" that looks different from the one in medical practice (where SDM has its origin) and the social services is organized differently in different Swedish municipalities. The EBP work and the work with SDM thus have different conditions and can be very complex in a purchaser-provider model. Given the tension that exists between authorities, researchers and the practice regarding EBP and its implementation, it is proposed to organize the EBP work in units who have the desirable characteristics stability and continuity, sufficient proximity and multidisciplinarity.
A second result concerns methods for user participation. If there are few proper evaluations of such models, how should the social services choose between them? Here it is proposed that the choice should be made on the basis of how well a model “harmonizes” with the goals and values in the legislation, given that the legislation is morally sound. If it is not, the “fit” may be assessed between one’s professional-ethical code and the participatory method. We may also find preparatory work that can help us interpret a vague legislation. The case for SDM is strengthened by its having been evaluated in RCTs, and also because the SDM components harmonise with relevant components in the presented (Swedish) legislation.
A third result points out that ideological and organizational fit of SDM is important as well and that given the organization of the Swedish social services, several questions remain regarding the organizational fit. It needs to be clarified which decisions SDM should apply to and also what kind of SDM is desirable. Both attitudinal work and “habit-forming" work may also be relevant when it comes to implementation of SDM in the social services.
New research questions generated through the project
Several new research questions have emerged during the project. Normative questions regarding governance and implementation have become important thanks to the meeting with practice and research concerning the conditions for social work. This applies to both general implementation and implementation of EBP and various methods of user involvement, such as SDM. The key issue here is how authorities, but also regional and local actors should work to design, promote and implement different working methods. For example, when are recommendations and guidelines considered "top-down" by practitioners and when not? And what follows from this in terms of how recommendations and guidelines should be produced, communicated and implemented?
How the project team has disseminated the results and if and how collaboration has taken place
Research has been disseminated within the organization (as mentioned above), both continuously informal, but also through 14 lectures on ethics, values and user participation and at two conferences hosted by the organization. In addition, at a closing Flexit seminar in 2019 at Råd & Stöd in Linköping at the end of the project.
Research has also been presented as six conference presentations at five conferences: a national conference at Umeå University (2017) and four international conferences, three in South Africa (2017, 2018 and 2019) and one in Northern Ireland (2018, two different presentations).
Thanks to the conferences, I have also gained several new research contacts. In 2017-2019 I participated in the research network and/or research group KSSA at CKS (Centre for Local Government Studies) at Linköping University and presented the Flexit research.
I have also had a meeting (concerning EBP in social work) with researchers at SCORE (Stockholm Centre for Organizational Research) at Stockholm University. Since 2019, I have participated in the research group PROG (Social work in change. Organization, professionalization and knowledge) at the University of Gothenburg and have presented the Flexit research there. An article was also compiled with prof. U-K Schön and FD A. Björk at Stockholm University. A collaboration with researchers at four South African universities (and two Swedish) has been developed during the Flexit project, via SASUF (South Africa Sweden University Forum) and two conferences organized by SASUF. This collaboration has user participation within the social services as its theme, as well.
The purpose was to explore ideas concerning shared decision-making (SDM) or participation as part of the evidence-based practice (EBP) in relation to the performance of the social services. The focus was on the component of EBP related to "the person’s situation, experience and preferences” and to examine whether some models for user participation more closely correspond to the values and considerations that the social services are obliged to adopt and safeguard.
Literature studies and the encounter with the practice have contributed to several insights that played a role in the project’s development. A first is that EBP in many cases is not "in place" within the social services. In addition, EBP and the promotion of it by Swedish authorities is questioned by a number of researchers in social work but also by some practitioners. Since the project had EBP as its starting point (where SDM was treated as a component of EBP), I considered it important to focus this tension between authorities, researchers and the profession. A first article was therefore written about a dilemma faced by the practitioner in social work regarding the introduction of EBP.
A second insight was that there is little empirical data to be found regarding different models for user participation. Many models have not been properly evaluated, so the question of on what grounds the social services should choose methods for participation became central and was addressed in a second article.
Several project questions became relevant for both decisions on intervention and decisions concerning performance and the difference between the decisional level and the executive level was therefore not decisive.
A short description of how it was implemented
Literature studies have been conducted of literature in the areas of EBP in social services, implementation, user participation in general and SDM in particular. Legislation and other governing and recommending documents have also been important.
The project plan included a possible collaboration with the organization’s “development unit” (where practitioners are part-time “co-researchers”) in that these co-researchers perhaps could be of help concerning collection of data. However, the project plan emphasized that the project was not dependent on such empirical data. The development unit was also less developed than I thought it would be, based on the documents I received before the Flexit project started. To gain more empirical knowledge, collaboration was initiated with prof. U-K Schön at Stockholm University who has extensive experience in research on SDM.
Articles have been written continually throughout the project and sent to peer-reviewed journals. Conference presentations have been held at national and international conferences.
How the project has contributed to increased collaboration between the university and organizations outside the academy
The project has contributed to increased collaboration primarily thanks to how the Flexit position is organized. Concretely, collaboration has taken place with regard to ethics, including 14 lectures on ethics, fundamental values (“värdegrund”) and user participation. Two lectures at the Social Services Department in Linköping as well, but also collaboration concerning the internal work at Råd & Stöd regarding the organization’s ethics and fundamental values (“värdegrund”).
I have participated in the development of the “development unit”, as well as being a participant in the unit’s steering committee and EBP-group. I have also supervised co-researchers working in this unit. In addition, I have attended two conferences hosted by the organization. I have also participated in the organization’s study visits to Angered and Helsingborg.
Together with co-workers at Råd & Stöd, I have conducted a survey of methods used within the organization. This was a jointly conducted survey sent to employees and the results were presented in a report for the organization. I have also contributed continuously with support regarding “external monitoring” (“omvärldsbevakning”) and content for the organization’s web page when it comes to research and development. The development officer and the coordinator for the development unit have also contributed with comments on the articles written during the time at the organization.
Thanks to a Flexit position, researchers also become more easily available for other parties outside the academia. Concretely, this has included invitations to be a speaker at events outside academia. This includes a conference organized by Linköping Municipality and Samordningsförbundet Östra Götaland and a Jubilee Conference held by SBU (The Swedish Agency for Health Technology Assessment and Assessment of Social Services, together with Prof. C. Munthe and Prof. L. Sandman). I have also taken part as an ethical expert concerning two evaluations of methods in social work, conducted by SBU. I also attended an expert meeting at the National Board of Health and Welfare, regarding interventions without consent. I have also received an assignment from Sveriges Stadsmissioner regarding the intervention Housing First,
The Flexit seminar, held by us three Flexit researchers (2016-2019) from the University of Gothenburg, was also an arrangement dedicated to collaboration. The seminar, which had collaboration and knowledge exchange as its theme, included participants from academia as well as the organizations.
The project’s three most important results and a discussion about this
One result has to do with the conditions for EBP and SDM. The organization of the social services provides a "decisional topography" that looks different from the one in medical practice (where SDM has its origin) and the social services is organized differently in different Swedish municipalities. The EBP work and the work with SDM thus have different conditions and can be very complex in a purchaser-provider model. Given the tension that exists between authorities, researchers and the practice regarding EBP and its implementation, it is proposed to organize the EBP work in units who have the desirable characteristics stability and continuity, sufficient proximity and multidisciplinarity.
A second result concerns methods for user participation. If there are few proper evaluations of such models, how should the social services choose between them? Here it is proposed that the choice should be made on the basis of how well a model “harmonizes” with the goals and values in the legislation, given that the legislation is morally sound. If it is not, the “fit” may be assessed between one’s professional-ethical code and the participatory method. We may also find preparatory work that can help us interpret a vague legislation. The case for SDM is strengthened by its having been evaluated in RCTs, and also because the SDM components harmonise with relevant components in the presented (Swedish) legislation.
A third result points out that ideological and organizational fit of SDM is important as well and that given the organization of the Swedish social services, several questions remain regarding the organizational fit. It needs to be clarified which decisions SDM should apply to and also what kind of SDM is desirable. Both attitudinal work and “habit-forming" work may also be relevant when it comes to implementation of SDM in the social services.
New research questions generated through the project
Several new research questions have emerged during the project. Normative questions regarding governance and implementation have become important thanks to the meeting with practice and research concerning the conditions for social work. This applies to both general implementation and implementation of EBP and various methods of user involvement, such as SDM. The key issue here is how authorities, but also regional and local actors should work to design, promote and implement different working methods. For example, when are recommendations and guidelines considered "top-down" by practitioners and when not? And what follows from this in terms of how recommendations and guidelines should be produced, communicated and implemented?
How the project team has disseminated the results and if and how collaboration has taken place
Research has been disseminated within the organization (as mentioned above), both continuously informal, but also through 14 lectures on ethics, values and user participation and at two conferences hosted by the organization. In addition, at a closing Flexit seminar in 2019 at Råd & Stöd in Linköping at the end of the project.
Research has also been presented as six conference presentations at five conferences: a national conference at Umeå University (2017) and four international conferences, three in South Africa (2017, 2018 and 2019) and one in Northern Ireland (2018, two different presentations).
Thanks to the conferences, I have also gained several new research contacts. In 2017-2019 I participated in the research network and/or research group KSSA at CKS (Centre for Local Government Studies) at Linköping University and presented the Flexit research.
I have also had a meeting (concerning EBP in social work) with researchers at SCORE (Stockholm Centre for Organizational Research) at Stockholm University. Since 2019, I have participated in the research group PROG (Social work in change. Organization, professionalization and knowledge) at the University of Gothenburg and have presented the Flexit research there. An article was also compiled with prof. U-K Schön and FD A. Björk at Stockholm University. A collaboration with researchers at four South African universities (and two Swedish) has been developed during the Flexit project, via SASUF (South Africa Sweden University Forum) and two conferences organized by SASUF. This collaboration has user participation within the social services as its theme, as well.