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In This Article Expand or collapse the "in this article" section Social Intervention Research

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Social Intervention Research by Knut Sundell , Tina Olsson LAST REVIEWED: 26 July 2017 LAST MODIFIED: 26 July 2017 DOI: 10.1093/obo/9780195389678-0254

This article is about social intervention research. A general definition of intervention is any interference that would modify a process or situation. In social work, interventions are intentionally implemented change strategies which aim to impede or eradicate risk factors, activate and/or mobilize protective factors, reduce or eradicate harm, or introduce betterment beyond harm eradication; thus social work intervention encompasses a range of psychotherapies, treatments, and programs. Interventions may be simple or complex. Yet simple interventions may have multiple elements that contribute to their effectiveness. Although social intervention research is an essential aspect of social work as a profession and research discipline, it is clearly multidisciplinary in its nature. The current knowledge base of social intervention research draws on knowledge gained from a wide variety of behavioral, psychological, and health interventions as well as from disciplines as diverse as psychology, education, medicine, public health, social work and other caring sciences. Social intervention research is vital to social work practice as professional decisions should be informed by evidence of both the potential benefits and harms of alternative interventions. Social intervention research focuses on the effects of an intervention under study. Of primary importance is understanding changes in the health and well-being of a target population. Subsequent results are then, ideally, used for decisions on future service provision. The goal of social intervention research is to bring about change in individuals, groups, or entire communities, and requires research methods that are most appropriate for achieving this goal.

Intervention research has a long history dating back for more than a century. A brief history of intervention research can be found in Oakley 1998 . In the United States, the period from the early 1960s to the early 1980s was one in which there was a burst of activity in applying the randomized controlled trial in the evaluation of public policy. Introductory works for social intervention research include some of the early published studies of this type—for example, Institute for Research on Poverty & Mathematica, Inc. 1973 ; McCord 1978 ; Meyer, et al. 1965 ; and Mullen and Dumpson 1972 . In addition to these, the key publications Campbell and Stanley 1963 , Cook and Campbell 1979 , and Fisher 1966 have influenced the continuous development in the field and include description and guidance on the design of experiments for assessing the outcome of social interventions. Fisher 1970 , originally printed in 1925, describes the development of statistical methods for analysis of social intervention data as well as the application of these developments in the then real world of social intervention practice.

Campbell, D. T., and J. C. Stanley. 1963. Experimental and quasi-experimental designs for research . Boston: Houghton Mifflin.

This early work on experimental and quasi-experimental design draws from a broad range of social science research to form an all-encompassing and broadly applicable methodological presentation and provides recommendations for conducting social intervention research.

Cook, T. D., and D. T. Campbell. 1979. Quasi-experimentation: Design and analysis issues for field settings . Boston: Houghton Mifflin.

This early work considers the problems associated with answering, in real world settings, the question of whether treatment X causes the outcome of Y.

Fisher, R. A. 1966. The design of experiments . 8th ed. Edinburgh: Oliver and Boyd.

This early work presents an examination of widely successful experimental designs for valid inference. This book focuses on aspects of experimental design that impact unambiguous interpretation.

Fisher, R. A. 1970. Statistical methods for research workers . 14th ed. New York: Hafner.

This early work in mathematical statistics aimed to supply practical experimenters with a connected account of the application of statistics in conjunction with laboratory work. In addition, this work presents then recent advances in statistical theory and their relationship with the problems of experimental design. Originally printed in 1925 (Edinburgh: Oliver & Boyd).

Institute for Research on Poverty & Mathematica Inc. 1973. The New Jersey graduated work incentive experiment summary report . Washington, DC: Department of Health, Education and Welfare, Office of Economic Opportunity.

This report describes an early carefully controlled field test of a social intervention and compares the differential effects of eight different negative income tax or benefit formulas on changes in labor supply and other outcomes.

McCord, J. 1978. A thirty-year follow-up of treatment effects. American Psychologist 33.3: 284–289.

DOI: 10.1037/0003-066X.33.3.284

This article presents a thirty-year follow-up of the Cambridge-Sommerville Youth Study, an early experiment within social work where the outcomes of participants provided to a social worker were compared to the outcomes of participants that did not have a social worker assigned to their case. Results indicated that the participants who had regular contact with a social worker did worse than those who did not.

Meyer, H. J., E. F. Borgatta, and W. C. Jones. 1965. Girls at vocational high: An experiment in social work intervention . New York: Russell Sage Foundation.

This book describes an early experiment undertaken within social work in collaboration with a vocational high school in New York. It gives an initial experimental look into the lives of delinquent adolescent girls and raises questions on the effectiveness of case work in diverting deviant careers in this group.

Mullen, E. J., and J. R. Dumpson. 1972. Evaluation of social intervention . San Francisco: Jossey-Bass.

This early study reviews sixteen evaluation projects and concludes that social welfare programs have only limited success and often fail to achieve their goals. An in-depth review of the reasons for failure is given along with reform recommendations.

Oakley, A. 1998. Experimentation and social interventions: A forgotten but important history. British Medical Journal 317:1239–1242.

DOI: 10.1136/bmj.317.7167.1239

This piece presents a short history of social intervention research, from its start in the 1870s to the golden age of evaluation in the 1960s to early 1980s, when randomized experiments were considered the optimal design for evaluating public policy interventions in the United States.

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Article contents

Evidence-based practice.

Jeffrey M. Jenson Jeffrey M. Jenson University of Denver
and Matthew O. Howard Matthew O. Howard University of North Carolina at Chapel Hill
https://doi.org/10.1093/acrefore/9780199975839.013.137
Published online: 11 June 2013

Evidence-based practice (EBP) is an educational and practice paradigm that includes a series of predetermined steps aimed at helping practitioners and agency administrators identify, select, and implement efficacious interventions for clients. This entry identifies definitions of EBP and traces the evolution of EBP from its origins in the medical profession to its current application in social work. Essential steps in the process of EBP and challenges associated with applying EBP to social work practice, education, and research are noted.

evidence-based practice
social work education

Evidence-based practice (EBP) is a five-step process used to select, deliver, and evaluate individual and social interventions aimed at preventing or ameliorating client problems and social conditions. At its most basic level, EBP seeks to systematically integrate evidence about the efficacy of interventions in clinical decision-making. Adhering to EBP, however, is a complex process that requires practitioners to be skilled at posing practice-relevant questions and proficient at accessing evidence that answers these questions. Importantly, practitioners must have the requisite methodological skills to evaluate evidence about the efficacy of interventions from clinical trials, systematic reviews, and meta-analyses. Finally, to teach the process of EBP, social work educators must be competent in tasks associated with information retrieval and interpretation of evidence.

A recent surge of interest in EBP is raising awareness about the importance of considering empirical evidence in selecting interventions among practitioners who may not have considered such evidence in the past. At the same time, the sudden growth of EBP gives rise to a cautionary note about the many different ways that EBP is being defined in published works and taught in the classroom. A consistent definition of EBP and an educational commitment to the process steps required in EBP are critical at this juncture to prevent the misuse or misunderstanding of this new paradigm.

Definitions and Evolution of EBP

EBP appeared in the medical profession in the 1990s as a process to help physicians select effective treatments for their patients. The introduction of EBP in medicine was viewed by many scholars and practitioners as an effective way to bring research findings to medical practice decisions. The rapid diffusion of EBP since then has been attributed to advances in knowledge about the prevention and treatment of medial conditions and to economic forces that emphasize the selection of efficacious treatments as a strategy to reduce health care costs (Gray, 2001 ).

The growth of EBP in medicine has also been a product of an increasingly active and well-informed patient population. Unlike prior generations, a significant portion of today's patients are well educated about their medical problems and demand that they receive the most optimal treatments for their conditions. The sophistication of medical consumers has required physicians to become more skilled at evaluating and applying evidence to medical practice decisions (Gambrill, 2006 ; Gray, 2001 ; Wennberg, 2002 ).

Definitions and perceptions of what EBP is—and what it is not—vary widely. In what is arguably the most widely accepted definition of EBP, Sackett and colleagues (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000 ) state that EBP is “the integration of best research evidence with clinical expertise and [client] values” (p. 1). In this definition, EBP is implied to be a process characterized by specific steps and actions. In an earlier publication, Sackett, Richardson, Rosenberg, and Haynes ( 1997 ) had defined EBP as “the conscientious, explicit, judicious, use of current best evidence in making decisions about the care of individual [clients]” (p. 2).

The introduction of EBP in medicine has created considerable interest in the process of applying evidence to medical practice decision-making. Importantly, scholars also believe that EBP has moved the medical profession away from its long-standing reliance on authority-based decision-making processes that fail to adequately consider empirical evidence (Gambrill, 1999 , 2005 ).

Essential Steps of EBP

As the above definitions imply, EBP is both a philosophy of practice and a process that implies a series of structured steps. Sackett et al. ( 2000 ) have been credited with developing the five essential steps of EBP.

Step 1: Converting Practice Information Needs into Answerable Questions

An important first step in the process of EBP requires practitioners to define information needs about a particular client problem. Sackett et al. ( 2000 ) suggest that this information needs to be framed in the form of answerable questions. Further, they recommend that questions identify the client population, intervention type, and anticipated outcomes.

Several scholars have brought elements of this first step in the EBP process to social work. In an important book on the subject of EBP, Gibbs ( 2003 ) identified a framework for posing questions that emphasizes the need for practicality. According to Gibbs, questions must be client-oriented and they must be specific enough to guide a search for evidence using electronic resources. Gambrill ( 2005 ) summarized effectively the types of questions that are generally posed in EBP processes. Her synopsis includes the following question types: 1) effectiveness, 2) prevention, 3) assessment, 4) description, 5) prediction, 6) harm, and 7) cost-benefit.

Framing practice-relevant questions is the foundation of the EBP process. Questions must be specific and posed in terms that lead to a rational search for evidence. An illustration of an effectiveness question may be helpful in understanding the importance of this point. Suppose a practitioner in a substance abuse program is interested in knowing whether a cognitive-behavioral intervention is more effective than a 12-step treatment program for addressing alcohol abuse in adults. In this case, a logical practice question might be: Is a structured cognitive-behavioral intervention more effective than a self-help program in treating alcohol abuse in adults? In a second example, suppose practitioners and teachers in a local elementary school are concerned about the negative effects of bullying behaviors in the classroom. In this example, a school social worker might pose a question about the best way to address aggression. A typical question might be: Is a universal prevention approach aimed at changing social norms about aggression more effective than a skills training approach that seeks to reduce aggression by targeting only high-risk youth?

Posing answerable questions requires precision and practice. Students and practitioners must be trained to pose different types of practice-relevant questions and learn ways to retrieve evidence that is critical in answering such questions.

Step 2: Locating Evidence to Answer Questions

Step 2 requires practitioners to search for and locate evidence pertaining to the questions they pose. At least four sources are available currently to search for empirical evidence: 1) books and journals, 2) systematic reviews organized by client problem or treatment approach that detail the effects of interventions on specified outcomes, 3) published “lists” of effective programs by federal entities and research centers, and 4) practice guidelines that offer treatment protocols based on empirical evidence.

Books and Journals

Books and journals represent a traditional approach to answering practice-relevant questions identified in step 1. Printed books and journal articles are readily available and have traditionally been helpful information sources. However, practitioners must also be aware of the limitations inherent in books and journals. For example, there is often a significant time lag between the submission and subsequent publication of a book or journal article. Practitioners must also have the skills to identify and discern published findings that pertain to their questions. This requires knowing how to select and search appropriate databases for information. In addition, practitioners must be trained to recognize that findings reported in book chapters and other outlets are quite likely not subject to peer review processes.

A final limitation of books and journals as information sources relates to the types of articles commonly published in social work. For example, at least one investigation has revealed that relatively few intervention outcome studies are published in social work literature (Rosen, Proctor, & Staudt, 1999 ). The lack of outcome studies poses a limitation to practitioners searching for evidence pertaining to the efficacy of interventions.

Systematic Reviews

Systematic reviews are comprehensive evaluations that examine evidence about the effectiveness of interventions targeted to a range of client populations and problems. Leadership in disseminating knowledge of effective prevention and treatment approaches through the publication of systematic treatment outcome reviews has come from international interdisciplinary teams organized under the Campbell Collaboration ( 2007 , http://www.campbellcollaboration.org ) and the Cochrane Collaboration ( 2007 , http://www.cochrane.org ). Each of these groups disseminates the results of systematic reviews to inform practitioners about the effects of interventions in health, behavioral, and educational settings. Importantly, systematic reviews of treatment outcomes are also becoming more available in social science literature (Vaughn & Howard, 2004 ).

Lists of Efficacious Programs

A third dissemination approach has been organized by federal entities and independent research centers such as the Substance Abuse and Mental Health Services Administration ( SAMHSA ) and the Center for the Study and Prevention of Violence ( CSPV ) at the University of Colorado. For example, SAMHSA ( 2007 , http://www.modelprograms.samhsa.gov ) publishes a list of efficacious substance abuse prevention and treatment programs in the National Registry of Evidence-Based Programs and Practices . The agency identifies promising, effective, and model programs on the basis of methodological rigor and client outcomes. CSPV ( 2007 , http://www.colorado.edu/cspv/ ) identifies effective violence prevention programs as part of its Blueprints for Violence Prevention dissemination effort. At least one group concerned with the effects of school-based educational programs for high-risk youth has also published lists of effective interventions (Collaborative for Academic, Social, and Emotional Learning, 2003 ).

In psychology, concern about the failure of many therapists to use empirically supported treatments led to the establishment of the American Psychological Association ( APA ) Task Force on the Promotion and Dissemination of Psychological Procedures in 1993 (Barlow, Levitt, & Bufka, 1999 ). The Task Force was established by the APA Society of Clinical Psychology (Division 12) to identify efficacious treatments across a range of mental health disorders and problems. Task Force members with expertise in diverse therapeutic approaches and populations developed criteria for treatments deemed to be well established and empirically validated and for treatments considered to be probably efficacious. Well-established treatments were those therapies that evidenced efficacy in at least two independent and rigorous experimental studies. Probably efficacious treatments were therapies in which only one study supported a treatment's efficacy, or therapies that had been tested by a single investigator (Task Force on the Promotion and Dissemination of Psychological Procedures, 1995).

The Task Force recognized randomized clinical trials as the most rigorous and acceptable method of producing empirically supported treatments. In lieu of randomized trials, findings from a large series of single case design experiments were accepted as criteria. The Task Force initiated a search for efficacious and probably efficacious treatments in 1993 (Task Force on the Promotion and Dissemination of Psychological Procedures, 1995). The subsequent list of efficacious therapies has since been updated twice (Chambless et al., 1996 ; Chambless et al., 1998 ).

Compilations of effective programs allow practitioners to access considerable information about the efficacy of interventions targeted to a wide range of client groups and problems. Credible lists such as those identified above use rigorous selection criteria to identify effective programs. For example, to be included on the program list compiled by the CSPV at the University of Colorado, intervention studies must use strong research designs and demonstrate sustained effects. Replication of effects is also required to meet criteria for the highest level of evidence. Similarly, APA criteria clearly identify the levels of research rigor that are necessary to meet standards for efficacious or probably efficacious treatments.

Lists of EBPs lead practitioners to potentially effective interventions. However, such lists cannot simply be accepted uncritically. In all cases, practitioners should scrutinize the criteria used to identify effective programs and interventions when they consider selecting and implementing programs from lists of EBPs.

Practice Guidelines

Practice guidelines are a fourth method of disseminating knowledge of efficacious interventions to practitioners. Proctor and Rosen ( 2003 ) defined practice guidelines as “a set of systematically compiled and organized knowledge statements designed to enable practitioners to find, select, and use appropriately the interventions that are most effective for a given task” (p. 108). Guidelines offer specific treatment protocols for practitioners that, when followed, mirror the strategies used in efficacious interventions with similar types of clients. Clinical practice guidelines were introduced in medicine and have recently spread to psychology and social work. Guidelines in social work have been met with mixed reaction and their development and application have been limited to date (see Howard & Jenson, 1999a , 1999b , 2003 and Rosen & Proctor, 2003 for a discussion of practice guidelines in social work).

Sources of information and evidence have proliferated widely in recent years. Practitioners must possess a range of information retrieval skills to identify appropriate sources of credible evidence. The appraisal of such evidence, discussed next, is a critical next step in the EBP process.

Steps 3 & 4: Appraising and Applying Evidence to Practice and Policy Decisions

EBP requires practitioners to use their knowledge of research design and methodology to evaluate and apply evidence to practice situations. These steps require familiarity with research methodology and the ability to draw conclusions about the utility of information on the basis of levels of evidence. The scientific community recognizes findings produced by randomized controlled trials as the most rigorous and acceptable level of evidence. However, results from studies using correlation, single-subject, quasi-experimental, experimental, and meta-analytic designs must also be considered and evaluated in steps 3 and 4 (Thyer, 2004 ).

Evaluating the rigor of studies and selecting interventions that meet high research standards require advanced training in methodology and intervention research. Unfortunately, current standards for research training in most Master of Social Work programs fall short of assuring the advanced skills necessary to critically evaluate the validity and applicability of research reports. Additional course work in evaluating evidence should be included in the graduate social work curriculum.

A second concern in appraising and applying evidence to practice situations comes from studies suggesting that practitioners fail to routinely consult research evidence when selecting interventions. For example, several studies show that practitioners often choose interventions for reasons other than empirical evidence (Elliott & Mihalic, 2004 ; Rosen, Proctor, Morrow-Howell, & Staudt, 1995 ). In addition, agency and organizational policies that limit the choice of intervention approaches available to practitioners often constrain practitioners' ability to use EBP.

The flurry of activity associated with EBP is not confined to selecting and implementing well-tested programs. To develop new knowledge about the effects of interventions, a small but increasing number of social work researchers are testing the effects of interventions across different problem areas in controlled efficacy trials (Reid & Fortune, 2003 ). This is a promising development in view of findings suggesting there is a dearth of intervention studies in social work (Fraser, 2003 ; Jenson, 2005 ; Rosen et al., 1995 ). More intervention research by social work investigators is needed to contribute to the knowledge base of efficacious prevention and treatment approaches.

Step 5: Evaluating the Process

The steps in EBP appear deceptively simple at first glance. However, the process of EBP requires knowledge of current literature about the onset, prevention, and treatment of client or social problems, the ability to search for relevant information and data, and skills to evaluate and apply knowledge obtained in systematic searches. The complexity involved in steps one to four demands an ongoing evaluation of one's knowledge of current literature, familiarity with constantly changing electronic databases, and skills in drawing conclusions based on methodological rigor.

Gibbs ( 2003 ) summarizes effectively the process of EBP: “Placing the client's benefits first, evidence-based practitioners adopt a process of lifelong learning that involves continually posing specific questions of direct and practical importance to clients, searching effectively for the current best evidence to each question, and taking appropriate action guided by evidence” (p. 6). Most scholars would agree that the social work profession is in the beginning stage of implementing the process defined by Gibbs in practice, and education and research settings.

Challenges and Implications

The promotion of EBP in social work was attributed initially to individual scholars and small groups of researchers (e.g., Gambrill, 1999 , 2003 ; Howard & Jenson, 1999a ; Proctor & Rosen, 2003 ; Thyer, 2004 ). These early efforts were aimed largely at exposing social workers to definitions of EBP and to concurrent developments in evidence-based medicine. Discussion of the process of applying EBP principles to social work practice and policy soon followed (for example, Bilson, 2005 ; Gambrill, 2003 , 2006 ; Gibbs, 2003 ).

A significant number of social work researchers and educators have since acknowledged the importance of EBP. Support is evident in the exponential growth in the number of books and articles on EBP since 2003 (see Gambrill, 2005 , 2007 ; Howard, Himle, Jenson, & Vaughn, in press ; Rosenthal, 2004 for reviews). Sessions on EBP have increased significantly at recent national social work conferences sponsored by the Society for Social Work and Research and the Council on Social Work Education. Further, a 2006 University of Texas at Austin symposium on EBP signaled an increasing recognition of the importance of teaching EBP in the social work curriculum. The Austin conference led to the publication of a 2007 special issue of Research on Social Work Practice that summarized the viewpoints of presenters at the symposium. Transparency in the use of EBP in practice and education (Gambrill, in press ), steps required to teach EBP (Mullen, Bellamy, Bledsoe, & Francois, in press), and structural curricular reforms consistent with EBP (Howard & Allen-Meares, in press ; Jenson, in press) are among the topics discussed in that issue.

An increase in attention to EBP by social work educators is indisputable. However, EBP is not without its critics. There have been voices of skepticism (Taylor & White, 2002 ) and even rejection (Webb, 2001 ) characterized by claims that EBP offers nothing new to the field. Others point to the lack of an effective knowledge base for certain client problems and populations, which hinders the advancement of EBP in the field.

EBP is at an important turning point in social work. To some, it reflects a new and revolutionary practice approach that holds great promise for building stronger bridges between science and social work (Gambrill, 2007 ; Jenson, 2005 ). Others view EBP as a repackaged attempt to integrate research and practice that is fraught with educational and implementation problems (Webb, 2001 ). Regardless, the challenges of EBP to social work education, practice, and research are varied and complex.

EBP and Social Work Education

The challenge of educational reform.

Rubin and Parrish ( 2007 ) reported that more than 70% of respondents from a survey of social work educators were in favor of teaching EBP in the MSW curriculum. Rapp-Paglicci ( 2007 ) noted that as many as 40 social work programs have created classes that incorporate principles of EBP. At least one school of social work—the Brown School of Social Work at Washington University—has identified EBP as the organizational framework for its graduate curriculum (Edmond, Rochman, Megivern, Howard, & Williams, 2006 ; Howard, McMillen, & Pollio, 2003 ). Importantly, the Council on Social Work Education has identified EBP as an important principle in its educational policy and accreditation documents (Council on Social Work Education, 2004 ). These and other examples illustrate the increasing attention being paid to EBP in the social work curriculum.

It is also clear, however, that interest in EBP has not yet resulted in the adoption or implementation of significant curriculum reform. To illustrate, Woody, D'Souza, and Dartman ( 2006 ) reported less than encouraging findings from a survey of social work deans and directors examining whether and how their programs teach empirically supported interventions. Woody et al. ( 2006 ) noted that, “only 31 programs, less than half, had endorsed teaching specific ESI [Empirically Supported Interventions] content; still fewer, 26, had designated courses to teach specific ESI content; and of the 31 programs that had endorsed teaching ESI, very small numbers required ESI training materials designed for teaching students the skills and techniques for implementing the interventions” (p. 474).

Significant structural and pedagogical changes in social work education are necessary to teach EBP. For example, a new generation of students must be exposed to the complexities involved in posing relevant practice and policy questions. Students must become experts in information retrieval and possess the methodological skills necessary to evaluate and apply evidence. New and innovative teaching approaches will be required to systematically teach EBP. Faculty will need to be trained, and in some cases retrained, to teach EBP. Finally, the appropriate location for teaching the actual process of EBP must be determined in undergraduate and graduate curricula.

Teaching the Process of EBP

Above all, EBP is a process characterized by the five specific steps discussed above. Thus, a logical assumption is that educators should focus their efforts on teaching the actual process of conducting EBP. However, the degree to which faculty members in schools of social work are teaching the five-step process of EBP—or simply informing students of effective interventions—is unclear. Several scholars, most notably Gambrill ( 2007 ), caution that exposing students to only EBPs identified on compiled lists and national registries is inconsistent with the fundamental premise of EBP. She accurately notes that a singular focus on effective interventions, expressed through commonly used terms such as best practices , is taking focus away from teaching students the actual process of EBP. Gambrill ( 2007 ) further suggests that emphasizing EBPs at the cost of understanding the process of EBP is inconsistent with the original intent of EBP as an approach that fosters transparency and systematic decision-making with clients.

The importance of teaching students the actual process steps of EBP cannot be overstated. EBP is a philosophy and an approach to practice that requires students and practitioners to understand and apply its essential steps. Teaching students to identify and use lists of established EBPs to select interventions is but one small part of the EBP process. As Gambrill ( 2007 ) so eloquently states, the emphasis on EBPs “ignores the process of EBP that describes skills designed to help practitioners to integrate external findings with other vital information (e.g., concerning client characteristics and circumstances) such as posing well-structured questions, and ignores the importance of creating tools practitioners need such as access to high-speed computers with relevant databases” (p. 430).

Schools of social work must take bold steps to integrate EBP across the curriculum. Training in EBP occurs sporadically in most schools, with little consistent application across key parts of the curriculum. Therefore, discussions about the best place (e.g., practice or research courses) to teach the process of EBP in the curriculum are needed. In addition, new teaching techniques such as problem-based learning that are compatible with EBP should be examined for applicability in social work education (Gambrill, in press; Sackett et al., 2000 ). Finally, structural changes in long-held traditions such as advanced standing may need to be considered in the interest of increasing students' exposure to the complexities of EBP (Jenson, in press).

EBP and Social Work Practice

EBP is receiving considerable attention from local, state, and federal policy makers and funding sources. State and local systems of care, private foundations, and federal entities have entered the debate about the best ways to select and implement effective interventions for clients and client systems. Agency administrators and practitioners are working diligently to understand EBP in an effort to develop competitive research proposals and implement effective program components.

One significant practice challenge is how to teach principles of EBP to practitioners and agency administrators. Community agencies vary widely with respect to their awareness, understanding, and acceptance of EBP. Community partnerships and collaborative research projects such as those being developed at the University of Toronto (Regehr, Stern, & Shlonksy, 2007 ) are needed to help practitioners apply EBP principles in a wide variety of practice settings. At Toronto, the faculty of social work at the University of Toronto has created an institute for evidence-based social work that aims to develop and foster community collaborations (Regehr et al., 2007 ). This and similar models should be further developed and tested.

EBP and Research

EBP relies on the availability of accrued knowledge about a range of individual and social problems. Thus, it is imperative that new knowledge about the etiology, prevention, and treatment of problems be consistently developed. In this regard, rigorous research is needed across many or all substantive areas in social work. Intervention research to assess the efficacy and effectiveness of social interventions is particularly lacking. Such studies are necessary to advance the etiological and intervention knowledge bases available to practitioners who are interested in implementing EBP.

The translation of research evidence to practice and policy is a second important area of research. In many service sectors there is a considerable lag between the identification of efficacious treatments and the application of such treatments to practice and policy. Recently, entities such as the National Institute of Mental Health have emphasized the importance of translating research findings to the field (Brekke, Ell, & Palinkas, 2007 ). Models for translating research evidence to practice and policy in health care and adolescent service sectors have been offered by Gray ( 2001 ) and Jenson and Fraser ( 2006 ) respectively.

The careful translation of research into practice is particularly important in view of the rapid increase in practices and publications that are promoted as EBP but in reality fall short of the principles implied in EBP. For example, the sudden infusion and proliferation of terms that resemble EBP, but are not EBP, may have an adverse effect on the profession's interest in using EBP to enhance the connection between science and intervention. Phrases such as “best practices” and “exemplary programs” are frequently used for marketing clinical and community interventions. On closer examination, these terms may or may not reflect the underlying processes of EBP. In many cases, interventions packaged under such names are not based on empirical evidence and have not been subject to rigorous evaluation. Promoting untested interventions as evidence-based promotes a false sense of efficacy, erodes the basic principles of EBP, and dilutes commonly accepted definitions of EBP used in medicine and psychology.

Finally, research is needed to systematically assess the effects of implementing EBP with clients. Embedded in EBP is the notion that client outcomes will be improved significantly by using EBP. As EBP becomes more widely applied in practice, studies will be needed to assess the relationship between its use and client outcomes.

EPB offers the promise of a new approach to social work education and practice that will dramatically alter the profession for years to come. The move to EBP as a guiding educational framework will require schools of social work to include the essential elements of EBP training (e.g., posing practice-relevant questions, gaining sophisticated information retrieval skills, interpreting systematic reviews, applying clinical practice guidelines, etc.) in graduate courses. In addition, schools of social work must also assume leadership in assisting community-based and human service sectors to understand and apply EBP in practice and policy settings. The challenge and risk of such comprehensive change represents an exciting new opportunity in social work practice and education. The endorsement of EBP is a risk well worth taking.

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Exploring the Efficacy of Social Work Interventions in Hospital Settings: A Scoping Review

Affiliations.

1 Department of Social Work, Steve Hicks School of Social Work at the University of Texas at Austin, Austin, TX, USA.
2 College of Health Sciences, Department of Social Work, Rush University Medical Center, Chicago, Illinois, USA.
3 University of Texas at Arlington, Library Department.
PMID: 35895505
DOI: 10.1080/19371918.2022.2104415

Social workers play an integral role in hospitals, particularly as it relates to improving patient outcomes. This scoping review was conducted to explore the impact of social work interventions in hospital settings on healthcare utilization. Research literature was identified using the following search engines: PsycINFO, CINAHL Plus, SocINDEX & MEDLINE. The initial search was conducted in May 2019, and an updated search was conducted in April 2021. Search results identified 2633 references and 110 articles met criteria for full-text review. Eighteen articles were included in the final review. Social work interventions include transitional care (56%), care coordination (22%), behavioral health (17%) and case management (5%). Significant improvements to readmission, mortality and utilizations rates are reported in over 80% of the studies, however the vast majority are non-randomized quantitative studies. More rigorous studies are needed to expand the literature and further evaluate the effectiveness of social work interventions in hospital settings.

Keywords: Social work; healthcare utilization; mortality; patient readmission; social determinants of health.

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Social Work
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Intervention Research: Developing Social Programs

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1 What Is Intervention Research?

Published: April 2009
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At the core, making a difference is what social work practice is all about. Whether at the individual, organizational, state, or national level, making a difference usually involves developing and implementing some kind of action strategy. Often too, practice involves optimizing a strategy over time, that is, attempting to improve it.

In social work, public health, psychology, nursing, medicine, and other professions, we select strategies that are thought to be effective based on the best available evidence. These strategies range from clinical techniques, such as developing a new role-play to demonstrate a skill, to complex programs that have garnered support in a series of controlled studies, to policy-level initiatives that may be based on large case studies, expert opinion, or legislative reforms. To be sure, the evidence is often only a partial guide in developing new clinical techniques, programs, and policies. Indeed, strategies often must be adapted to meet the unique needs of the situation, including the social or demographic characteristics that condition problems. Thus, the hallmark of modern social work practice is this very process of identifying, adapting, and implementing what we understand to be the best available strategy for change.

However, suppose that you have an idea for how to develop a new service or revise an existing one. That is, through experience and research, you begin to devise a different practice strategy—an approach that perhaps has no clear evidence base, but one that may improve current services. When you attempt to develop new strategies or enhance existing strategies, you are ready to engage in intervention research.

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The Pursuit of Quality for Social Work Practice: Three Generations and Counting

Enola proctor.

Shanti K. Khinduka Distinguished Professor and director of the Center for Mental Health Services Research at Washington University in St. Louis

Social work addresses some of the most complex and intractable human and social problems: poverty, mental illness, addiction, homelessness, and child abuse. Our field may be distinct among professions for its efforts to ameliorate the toughest societal problems, experienced by society’s most vulnerable, while working from under-resourced institutions and settings. Members of our profession are underpaid, and most of our agencies lack the data infrastructure required for rigorous assessment and evaluation.

Moreover, social work confronts these challenges as it is ethically bound to deliver high-quality services. Policy and regulatory requirements increasingly demand that social work deliver and document the effectiveness of highest quality interventions and restrict reimbursement to those services that are documented as evidence based. Social work’s future, its very survival, depends on our ability to deliver services with a solid base of evidence and to document their effectiveness. In the words of the American Academy of Social Work and Social Welfare (AASWSW; n.d.) , social work seeks to “champion social progress powered by science.” The research community needs to support practice through innovative and rigorous science that advances the evidence for interventions to address social work’s grand challenges.

My work seeks to improve the quality of social work practice by pursuing answers to three questions:

What interventions and services are most effective and thus should be delivered in social work practice?
How do we measure the impact of those interventions and services? (That is, what outcomes do our interventions achieve?)
How do we implement the highest quality interventions?

This paper describes this work, demonstrates the substantive and methodological progression across the three questions, assesses what we have learned, and forecasts a research agenda for what we still need to learn. Given Aaron Rosen’s role as my PhD mentor and our many years of collaboration, the paper also addresses the role of research mentoring in advancing our profession’s knowledge base.

What Interventions and Services Are Most Effective?

Answering the question “What services are effective?” requires rigorous testing of clearly specified interventions. The first paper I coauthored with Aaron Rosen—“Specifying the Treatment Process: The Basis for Effectiveness Research” ( Rosen & Proctor, 1978 )—provided a framework for evaluating intervention effectiveness. At that time, process and outcomes were jumbled and intertwined concepts. Social work interventions were rarely specified beyond theoretical orientation or level of focus: casework (or direct practice); group work; and macro practice, which included community, agency-level, and policy-focused practice. Moreover, interventions were not named, nor were their components clearly identified. We recognized that gross descriptions of interventions obstruct professional training, preclude fidelity assessment, and prevent accurate tests of effectiveness. Thus, in a series of papers, Rosen and I advocated that social work interventions be specified, clearly labeled, and operationally defined, measured, and tested.

Specifying Interventions

Such specification of interventions is essential to two professional responsibilities: professional education and demonstrating the effectiveness of the field’s interventions. Without specification, interventions cannot be taught. Social work education is all about equipping students with skills to deliver interventions, programs, services, administrative practices, and policies. Teaching interventions requires an ability to name, define, see them in action, measure their presence (or absence), assess the fidelity with which they are delivered, and give feedback to students on how to increase or refine the associated skills.

To advance testing the effectiveness of social work interventions, we drew distinctions between interventions and outcomes and proposed these two constructs as the foci for effectiveness research. We defined interventions as practitioner behaviors that can be volitionally manipulated by practitioners (used or not, varied in intensity and timing), that are defined in detail, can be reliably measured, and can be linked to specific identified outcomes ( Rosen & Proctor, 1978 ; Rosen & Proctor, 1981 ). This definition foreshadowed the development of treatment manuals, lists of specific evidence-based practices, and calls for monitoring intervention fidelity. Recognizing the variety of intervention types, and to advance their more precise definition and measurement, we proposed that interventions be distinguished in terms of their complexity. Interventive responses comprise discrete or single responses, such as affirmation, expression of empathy, or positive reinforcement. Interventive strategies comprise several different actions that are, together, linked to a designated outcome, such as motivational interviewing. Most complex are interventive programs , which are a variety of intervention actions organized and integrated as a total treatment package; collaborative care for depression or community assertive treatment are examples. To strengthen the professional knowledge base, we also called for social work effectiveness research to begin testing the optimal dose and sequencing of intervention components in relation to attainment of desired outcomes.

Advancing Intervention Effectiveness Research

Our “specifying paper” also was motivated by the paucity of literature at that time on actual social work interventions. Our literature review of 13 major social work journals over 5 years of published research revealed that only 15% of published social work research addressed interventions. About a third of studies described social problems, and about half explored factors associated with the problem ( Rosen, Proctor, & Staudt, 2003 ). Most troubling was our finding that only 3% of articles described the intervention or its components in sufficient detail for replication in either research or practice. Later, Fraser (2004) found intervention research to comprise only about one fourth of empirical studies in social work. Fortunately, our situation has improved. Intervention research is more frequent in social work publications, thanks largely to the publication policies of the Journal of the Society for Social Work and Research and Research on Social Work Practice .

Research Priorities

Social work faces important and formidable challenges as it advances research on intervention effectiveness. The practitioner who searches the literature or various intervention lists can find more than 500 practices that are named or that are shown to have evidence from rigorous trials that passes a bar to qualify as evidence-based practices. However, our profession still lacks any organized compendium or taxonomy of interventions that are employed in or found to be effective for social work practice. Existing lists of evidence-based practices, although necessary, are insufficient for social work for several reasons. First, as a 2015 National Academies Institute of Medicine (IOM) report—“Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards” ( IOM, 2015 )—concluded, too few evidence-based practices have been found to be appropriate for low-resource settings or acceptable to minority groups. Second, existing interventions do not adequately reflect the breadth of social work practice. We have too few evidence-based interventions that can inform effective community organization, case management, referral practice, resource development, administrative practice, or policy. Noting that there is far less literature on evidence-based practices relevant to organizational, community, and policy practice, a social work task force responding to the 2015 IOM report recommended that this gap be a target of our educational and research efforts ( National Task Force on Evidence-Based Practice in Social Work, 2016 ). And finally, our field—along with other professions that deliver psychosocial interventions—lacks the kinds of procedure codes that can identify the specific interventions we deliver. Documenting social work activities in agency records is increasingly essential for quality assurance and third-party reimbursement.

Future Directions: Research to Advance Evidence on Interventions

Social work has critically important research needs. Our field needs to advance the evidence base on what interventions work for social work populations, practices, and settings. Responding to the 2015 IOM report, the National Task Force on Evidence-Based Practice in Social Work (2016) identified as a social work priority the development and testing of evidence-based practices relevant to organizational, community, and policy practice. As we advance our intervention effectiveness research, we must respond to the challenge of determining the key mechanisms of change ( National Institute of Mental Health, 2016 ) and identify key modifiable components of packaged interventions ( Rosen & Proctor, 1978 ). We need to explore the optimal dosage, ordering, or adapted bundling of intervention elements and advance robust, feasible ways to measure and increase fidelity ( Jaccard, 2016 ). We also need to conduct research on which interventions are most appropriate, acceptable, and effective with various client groups ( Zayas, 2003 ; Videka, 2003 ).

Documenting the Impact of Interventions: Specifying and Measuring Outcomes

Outcomes are key to documenting the impact of social work interventions. My 1978 “specifying” paper with Rosen emphasized that the effectiveness of social work practice could not be adequately evaluated without clear specification and measurement of various types of outcomes. In that paper, we argued that the profession cannot rely only on an assertion of effectiveness. The field must also calibrate, calculate, and communicate its impact.

The nursing profession’s highly successful campaign, based on outcomes research, positioned that field to claim that “nurses save lives.” Nurse staffing ratios were associated with in-hospital and 30-day mortality, independent of patient characteristics, hospital characteristics, or medical treatment ( Person et al., 2004 ). In contrast, social work has often described—sometimes advertised—itself as the low-cost profession. The claim of “cheapest service” may have some strategic advantage in turf competition with other professions. But social work can do better. Our research base can and should demonstrate the value of our work by naming and quantifying the outcomes—the added value of social work interventions.

As a start to this work—a beginning step in compiling evidence about the impact of social work interventions—our team set out to identify the outcomes associated with social work practice. We felt that identifying and naming outcomes is essential for conveying what social work is about. Moreover, outcomes should serve as the focus for evaluating the effectiveness of social work interventions.

We produced two taxonomies of outcomes reflected in published evaluations of social work interventions ( Proctor, Rosen, & Rhee, 2002 ; Rosen, Proctor, & Staudt, 2003 ). They included such outcomes as change in clients’ social functioning, resource procurement, problem or symptom reduction, and safety. They exemplify the importance of naming and measuring what our profession can contribute to society. Although social work’s growing body of effectiveness research typically reports outcomes of the interventions being tested, the literature has not, in the intervening 20 years, addressed the collective set of outcomes for our field.

Fortunately, the Grand Challenges for Social Work (AASWSW, n.d.) now provide a framework for communicating social work’s goals. They reflect social work’s added value: improving individual and family well-being, strengthening social fabric, and helping to create a more just society. The Grand Challenges for Social Work include ensuring healthy development for all youth, closing the health gap, stopping family violence, advancing long and productive lives, eradicating social isolation, ending homelessness, creating social responses to a changing environment, harnessing technology for social good, promoting smart decarceration, reducing extreme economic inequality, building financial capability for all, and achieving equal opportunity and justice ( AASWSW, n.d. ).

These important goals appropriately reflect much of what we are all about in social work, and our entire field has been galvanized—energized by the power of these grand challenges. However, the grand challenges require setting specific benchmarks—targets that reflect how far our professional actions can expect to take us, or in some areas, how far we have come in meeting the challenge.

For the past decade, care delivery systems and payment reforms have required measures for tracking performance. Quality measures have become critical tools for all service providers and organizations ( IOM, 2015 ). The IOM defines quality of care as “the degree to which … services for individuals and populations increase the likelihood of desired … outcomes and are consistent with current professional knowledge” ( Lohr, 1990 , p. 21). Quality measures are important at multiple levels of service delivery: at the client level, at the practitioner level, at the organization level, and at the policy level. The National Quality Forum has established five criteria for quality measures: They should address (a) the most important, (b) the most scientifically valid, (c) the most feasible or least burdensome, (d) the most usable, and (e) the most harmonious set of measures ( IOM, 2015 .) Quality measures have been advanced by accrediting groups (e.g., the Joint Commission of the National Committee for Quality Assurance), professional societies, and federal agencies, including the U.S. Department of Health and Human Services. However, quality measures are lacking for key areas of social work practice, including mental health and substance-use treatment. And of the 55 nationally endorsed measures related to mental health and substance use, only two address a psychosocial intervention. Measures used for accreditation and certification purposes often reflect structural capabilities of organizations and their resource use, not the infrastructure required to deliver high-quality services ( IOM, 2015 ). I am not aware of any quality measure developed by our own professional societies or agreed upon across our field.

Future Directions: Research on Quality Monitoring and Measure Development

Although social work as a field lacks a strong tradition of measuring and assessing quality ( Megivern et al., 2007 ; McMillen et al., 2005 ; Proctor, Powell, & McMillen, 2012 ), social work’s role in the quality workforce is becoming better understood ( McMillen & Raffol, 2016 ). The small number of established and endorsed quality measures reflects both limitations in the evidence for effective interventions and challenges in obtaining the detailed information necessary to support quality measurement ( IOM, 2015 ). According to the National Task Force on Evidence-Based Practice in Social Work (2016) , developing quality measures to capture use of evidence-based interventions is essential for the survival of social work practice in many settings. The task force recommends that social work organizations develop relevant and viable quality measures and that social workers actively influence the implementation of quality measures in their practice settings.

How to Implement Evidence-Based Care

A third and more recent focus of my work addresses this question: How do we implement evidence-based care in agencies and communities? Despite our progress in developing proven interventions, most clients—whether served by social workers or other providers—do not receive evidence-based care. A growing number of studies are assessing the extent to which clients—in specific settings or communities—receive evidence-based interventions. Kohl, Schurer, and Bellamy (2009) examined quality in a core area of social work: training for parents at risk for child maltreatment. The team examined the parent services and their level of empirical support in community agencies, staffed largely by master’s-level social workers. Of 35 identified treatment programs offered to families, only 11% were “well-established empirically supported interventions,” with another 20% containing some hallmarks of empirically supported interventions ( Kohl et al., 2009 ). This study reveals a sizable implementation gap, with most of the programs delivered lacking scientific validation.

Similar quality gaps are apparent in other settings where social workers deliver services. Studies show that only 19.3% of school mental health professionals and 36.8% of community mental health professionals working in Virginia’s schools and community mental health centers report using any evidence-based substance-abuse prevention programs ( Evans, Koch, Brady, Meszaros, & Sadler, 2013 ). In mental health, where social workers have long delivered the bulk of services, only 40% to 50% of people with mental disorders receive any treatment ( Kessler, Chiu, Demler, Merikangas, & Walters, 2005 ; Merikangas et al., 2011 ), and of those receiving treatment, a fraction receive what could be considered “quality” treatment ( Wang, Demler, & Kessler, 2002 ; Wang et al., 2005 ). These and other studies indicate that, despite progress in developing proven interventions, most clients do not receive evidence-based care. In light of the growth of evidence-based practice, this fact is troubling evidence that testing interventions and publishing the findings is not sufficient to improve quality.

So, how do we get these interventions in place? What is needed to enable social workers to deliver, and clients to receive, high-quality care? In addition to developing and testing evidence-based interventions, what else is needed to improve the quality of social work practice? My work has focused on advancing quality of services through two paths.

Making Effective Interventions Accessible to Providers: Intervention Reviews and Taxonomies

First, we have advocated that research evidence be synthesized and made available to front-line practitioners. In a research-active field where new knowledge is constantly produced, practitioners should not be expected to rely on journal publications alone for information about effective approaches to achieve desired outcomes. Mastering a rapidly expanding professional evidence base has been characterized as a nearly unachievable challenge for practitioners ( Greenfield, 2017 ). Reviews should critique and clarify the intervention’s effectiveness as tested in specific settings, populations, and contexts, answering the question, “What works where, and with whom?” Even more valuable are studies of comparative effectiveness—those that answer, “Which intervention approach works better, where, and when?”

Taxonomies of clearly and consistently labeled interventions will enhance their accessibility and the usefulness of research reports and systematic reviews. A pre-requisite is the consistent naming of interventions. A persistent challenge is the wide variation in names or labels for interventive procedures and programs. Our professional activities are the basis for our societal sanction, and they must be capable of being accurately labeled and documented if we are to describe what our profession “does” to advance social welfare. Increasingly, and in short order, that documentation will be in electronic records that are scrutinized by third parties for purposes of reimbursement and assessment of value toward outcome attainment.

How should intervention research and reviews be organized? Currently, several websites provide lists of evidence-based practices, some with links, citations, or information about dissemination and implementation organizations that provide training and facilitation to adopters. Practitioners and administrators find such lists helpful but often note the challenge in determining which are most appropriate for their needs. In the words of one agency leader, “The drug companies are great at presenting [intervention information] in a very easy form to use. We don’t have people coming and saying, ‘Ah, let me tell you about the best evidence-based practice for cognitive behavioral therapy for depression,’” ( Proctor et al., 2007 , p. 483). We have called for the field to devise decision aids for practitioners to enhance access to the best available empirical knowledge about interventions ( Proctor et al., 2002 ; Proctor & Rosen, 2008 ; Rosen et al., 2003 ). We proposed that intervention taxonomies be organized around outcomes pursued in social work practice, and we developed such a taxonomy based on eight domains of outcomes—those most frequently tested in social work journals. Given the field’s progress in identifying its grand challenges, its associated outcomes could well serve as the organizing focus, with research-tested interventions listed for each challenge. Compiling the interventions, programs, and services that are shown—through research—to help achieve one of the challenges would surely advance our field.

We further urged profession-wide efforts to develop social work practice guidelines from intervention taxonomies ( Rosen et al., 2003 ). Practice guidelines are systematically compiled, critiqued, and organized statements about the effectiveness of interventions that are organized in a way to help practitioners select and use the most effective and appropriate approaches for addressing client problems and pursuing desired outcomes.

At that time, we proposed that our published taxonomy of social work interventions could provide a beginning architecture for social work guidelines ( Rosen et al., 2003 ). In 2000, we organized a conference for thought leaders in social work practice. This talented group wrestled with and formulated recommendations for tackling the professional, research, and training requisites to developing social work practice guidelines to enable researchers to access and apply the best available knowledge about interventions ( Rosen et al., 2003 ). Fifteen years later, however, the need remains for social work to synthesize its intervention research. Psychology and psychiatry, along with most fields of medical practice, have developed practice guidelines. Although their acceptance and adherence is fraught with challenges, guidelines make evidence more accessible and enable quality monitoring. Yet, guidelines still do not exist for social work.

The 2015 IOM report, “Psychosocial Interventions for Mental and Substance Use Disorders: A Framework for Establishing Evidence-Based Standards,” includes a conclusion that information on the effectiveness of psychosocial interventions is not routinely available to service consumers, providers, and payers, nor is it synthesized. That 2015 IOM report called for systematic reviews to inform clinical guidelines for psychosocial interventions. This report defined psychosocial interventions broadly, encompassing “interpersonal or informational activities, techniques, or strategies that target biological, behavioral, cognitive, emotional, interpersonal, social, or environmental factors with the aim of reducing symptoms and improving functioning or well-being” ( IOM, 2015 , p. 5). These interventions are social work’s domain; they are delivered in the very settings where social workers dominate (behavioral health, schools, criminal justice, child welfare, and immigrant services); and they encompass populations across the entire lifespan within all sociodemographic groups and vulnerable populations. Accordingly, the National Task Force on Evidence Based Practice in Social Work (2016) has recommended the conduct of more systematic reviews of the evidence supporting social work interventions.

If systematic reviews are to lead to guidelines for evidence-based psychosocial interventions, social work needs to be at the table, and social work research must provide the foundation. Whether social work develops its own guidelines or helps lead the development of profession-independent guidelines as recommended by the IOM committee, guidelines need to be detailed enough to guide practice. That is, they need to be accompanied by treatment manuals and informed by research that details the effect of moderator variables and contextual factors reflecting diverse clientele, social determinants of health, and setting resource challenges. The IOM report “Clinical Practice Guidelines We Can Trust” sets criteria for guideline development processes ( IOM, 2011 ). Moreover, social work systematic reviews of research and any associated evidence-based guidelines need to be organized around meaningful taxonomies.

Advancing the Science of Implementation

As a second path to ensuring the delivery of high-quality care, my research has focused on advancing the science of implementation. Implementation research seeks to inform how to deliver evidence-based interventions, programs, and policies into real-world settings so their benefits can be realized and sustained. The ultimate aim of implementation research is building a base of evidence about the most effective processes and strategies for improving service delivery. Implementation research builds upon effectiveness research then seeks to discover how to use specific implementation strategies and move those interventions into specific settings, extending their availability, reach, and benefits to clients and communities. Accordingly, implementation strategies must address the challenges of the service system (e.g., specialty mental health, schools, criminal justice system, health settings) and practice settings (e.g., community agency, national employee assistance programs, office-based practice), and the human capital challenge of staff training and support.

In an approach that echoes themes in an early paper, “Specifying the Treatment Process—The Basis for Effectiveness Research” ( Rosen & Proctor, 1978 ), my work once again tackled the challenge of specifying a heretofore vague process—this time, not the intervention process, but the implementation process. As a first step, our team developed a taxonomy of implementation outcomes ( Proctor et al., 2011 ), which enable a direct test of whether or not a given intervention is adopted and delivered. Although it is overlooked in other types of research, implementation science focuses on this distinct type of outcome. Explicit examination of implementation outcomes is key to an important research distinction. Often, evaluations yield disappointing results about an intervention, showing that the expected and desired outcomes are not attained. This might mean that the intervention was not effective. However, just as likely, it could mean that the intervention was not actually delivered, or it was not delivered with fidelity. Implementation outcomes help identify the roadblocks on the way to intervention adoption and delivery.

Our 2011 taxonomy of implementation outcomes ( Proctor et al., 2011 ), became the framework for two national repositories of measures for implementation research: the Seattle Implementation Research Collaborative ( Lewis et al., 2015 ) and the National Institutes of Health GEM measures database ( Rabin et al., 2012 ). These repositories of implementation outcomes seek to harmonize and increase the rigor of measurement in implementation science.

We also have developed taxonomies of implementation strategies ( Powell et al., 2012 ; Powell et al., 2015 ; Waltz et al., 2014 , 2015) . Implementation strategies are interventions for system change—how organizations, communities, and providers can learn to deliver new and more effective practices ( Powell et al., 2012 ).

A conversation with a key practice leader stimulated my interest in implementation strategies. Shortly after our school endorsed an MSW curriculum emphasizing evidence-based practices, a pioneering CEO of a major social service agency in St. Louis met with me and asked,

Enola Proctor, I get the importance of delivering evidence based practices. My organization delivers over 20 programs and interventions, and I believe only a handful of them are really evidence based. I want to decrease our provision of ineffective care, and increase our delivery of evidence-based practices. But how? What are the evidence-based ways I, as an agency director, can transform my agency so that we can deliver evidence-based practices?

That agency director was asking a question of how . He was asking for evidence-based implementation strategies. Moving effective programs and practices into routine care settings requires the skillful use of implementation strategies, defined as systematic “methods or techniques used to enhance the adoption, implementation, and sustainability of a clinical program or practice into routine service” ( Proctor et al., 2013 , p. 2).

This question has shaped my work for the past 15 years, as well as the research priorities of several funding agencies, including the National Institutes of Health, the Agency for Healthcare Research and Quality, the Patient-Centered Outcomes Research Institute, and the World Health Organization. Indeed, a National Institutes of Health program announcement—Dissemination and Implementation Research in Health ( National Institutes of Health, 2016 )—identified the discovery of effective implementation strategies as a primary purpose of implementation science. To date, the implementation science literature cannot yet answer that important question, but we are making progress.

To identify implementation strategies, our teams first turned to the literature—a literature that we found to be scattered across a wide range of journals and disciplines. Most articles were not empirical, and most articles used widely differing terms to characterize implementation strategies. We conducted a structured literature review to generate common nomenclature and a taxonomy of implementation strategies. That review yielded 63 distinct implementation strategies, which fell into six groupings: planning, educating, financing, restructuring, managing quality, and attending to policy context ( Powell et al., 2012 ).

Our team refined that compilation, using Delphi techniques and concept mapping to develop conceptually distinct categories of implementation strategies ( Powell et al., 2015 ; Waltz et al., 2014 ). The refined compilation of 73 discrete implementation strategies was then further organized into nine clusters:

changing agency infrastructure,
using financial strategies,
supporting clinicians,
providing interactive assistance,
training and educating stakeholders,
adapting and tailoring interventions to context,
developing stakeholder relationships,
using evaluative and iterative strategies, and
engaging consumers.

These taxonomies of implementation strategies position the field for more robust research on implementation processes. The language used to describe implementation strategies has not yet “gelled” and has been described as a “Tower of Babel” ( McKibbon et al., 2010 ). Therefore, we also developed guidelines for reporting the components of strategies ( Proctor et al., 2013 ) so researchers and implementers would have more behaviorally specific information about what a strategy is, who does it, when, and for how long. The value of such reporting guidelines is illustrated in the work of Gold and colleagues (2016) .

What have we learned, through our own program of research on implementation strategies—the “how to” of improving practice? First, we have been able to identify from practice-based evidence the implementation strategies used most often. Using novel activity logs to track implementation strategies, Bunger and colleagues (2017) found that strategies such as quality improvement tools, using data experts, providing supervision, and sending clinical reminders were frequently used to facilitate delivery of behavioral health interventions within a child-welfare setting and were perceived by agency leadership as contributing to project success.

Second, reflecting the complexity of quality improvement processes, we have learned that there is no magic bullet ( Powell, Proctor, & Glass, 2013 ). Our study of U.S. Department of Veterans Affairs clinics working to implement evidence-based HIV treatment found that implementers used an average of 25 (plus or minus 14) different implementation strategies ( Rogal, et al., 2017 ). Moreover, the number of implementation strategies used was positively associated with the number of new treatment starts. These findings suggest that implementing new interventions requires considerable effort and resources.

To advance our understanding of the effectiveness of implementation strategies, our teams have conducted a systematic review ( Powell et al., 2013 ), tested specific strategies, and captured practice-based evidence from on-the-ground implementers. Testing the effectiveness of implementation strategies has been identified as a top research priority by the IOM (2009) . In work with Charles Glisson in St. Louis, our 15-agency-based randomized clinical trial found that an organizational-focused intervention—the attachment, regulatory, and competency model—improved agency culture and climate, stimulated more clinicians to enroll in evidence-based-practice training, and boosted clinical effect sizes of various evidence-based practices ( Glisson, Williams, Hemmelgarn, Proctor, & Green, 2016a , 2016b ). And in a hospital critical care unit, the implementation strategies of developing a team, selecting and using champions, provider education sessions, and audit and feedback helped increase team adherence to phlebotomy guidelines ( Steffen et al., in press ).

We are also learning about the value of different strategies. Experts in implementation science and implementation practice identified as most important the strategies of “use evaluate and iterative approaches” and “train and educate stakeholders.” Reported as less helpful were such strategies as “access new funding streams” and “remind clinicians of practices to use” ( Waltz et al., 2015 ). Successful implementers in Veterans Affairs clinics relied more heavily on such strategies as “change physical structures and equipment” and “facilitate relay of clinical data to providers” than did less successful implementers ( Rogal et al., 2017 ).

Many strategies have yet to be investigated empirically, as has the role of dissemination and implementation organizations—organizations that function to promote, provide information about, provide training in, and scale up specific treatments. Most evidence-based practices used in behavioral health, including most listed on the Substance Abuse and Mental Health Services Administration National Registry of Promising and Effective Practices, are disseminated and distributed by dissemination and implementation organizations. Unlike drugs and devices, psychosocial interventions have no Federal Drug Administration-like delivery system. Kreuter and Casey (2012) urge better understanding and use of the intervention “delivery system,” or mechanisms to bring treatment discoveries to the attention of practitioners and into use in practice settings.

Implementation strategies have been shown to boost clinical effectiveness ( Glisson et al., 2010 ), reduce staff turnover ( Aarons, Sommerfield, Hect, Silvosky, & Chaffin, 2009 ) and help reduce disparities in care ( Balicer et al., 2015 ).

Future directions: Research on implementation strategies

My work in implementation science has helped build intellectual capital for the rapidly growing field of dissemination and implementation science, leading teams to distinguish, clearly define, develop taxonomies, and stimulate more systematic work to advance the conceptual, linguistic, and methodological clarity in the field. Yet, we continue to lack understanding of many issues. What strategies are used in usual implementation practice, by whom, for which empirically supported interventions? What strategies are effective in which organizational and policy contexts? Which strategies are effective in attaining which specific implementation outcomes? For example, are the strategies that are effective for initial adoption also effective for scale up, spread, and sustained use of interventions? Social workers have the skill set for roles as implementation facilitators, and refining packages of implementation strategies that are effective in social service and behavioral health settings could boost the visibility, scale, and impact of our work.

The Third Generation and Counting

Social work faces grand, often daunting challenges. We need to develop a more robust base of evidence about the effectiveness of interventions and make that evidence more relevant, accessible, and applicable to social work practitioners, whether they work in communities, agencies, policy arenas, or a host of novel settings. We need to advance measurement-based care so our value as a field is recognized. We need to know how to bring proven interventions to scale for population-level impact. We need to discover ways to build capacity of social service agencies and the communities in which they reside. And we need to learn how to sustain advances in care once we achieve them ( Proctor et al., 2015 ). Our challenges are indeed grand, far outstripping our resources.

So how dare we speak of a quality quest? Does it not seem audacious to seek the highest standards in caring for the most vulnerable, especially in an era when we face a new political climate that threatens vulnerable groups and promises to strip resources from health and social services? Members of our profession are underpaid, and most of our agencies lack the data infrastructure required for assessment and evaluation. Quality may be an audacious goal, but as social workers we can pursue no less. By virtue of our code of ethics, our commitment to equity, and our skills in intervening on multiple levels of systems and communities, social workers are ideally suited for advancing quality.

Who will conduct the needed research? Who will pioneer its translation to improving practice? Social work practice can be only as strong as its research base; the responsibility for developing that base, and hence improve practice, is lodged within social work research.

If my greatest challenge is pursuing this quest, my greatest joy is in mentoring the next generation for this work. My research mentoring has always been guided by the view that the ultimate purpose of research in the helping professions is the production and systemization of knowledge for use by practitioners ( Rosen & Proctor, 1978 ). For 27 years, the National Institute of Mental Health has supported training in mental health services research based in the Center for Mental Health Services Research ( Hasche, Perron, & Proctor, 2009 ; Proctor & McMillen, 2008 ). And, with colleague John Landsverk, we are launching my sixth year leading the Implementation Research Institute, a training program for implementation science supported by the National Institute of Mental Health ( Proctor et al., 2013 ). We have trained more than 50 social work, psychology, anthropology, and physician researchers in implementation science for mental health. With three more cohorts to go, we are working to assess what works in research training for implementation science. Using bibliometric analysis, we have learned that intensive training and mentoring increases research productivity in the form of published papers and grants that address how to implement evidence-based care in mental health and addictions. And, through use of social network analysis, we have learned that every “dose” of mentoring increases scholarly collaboration when measured two years later ( Luke, Baumann, Carothers, Landsverk, & Proctor, 2016 ).

As his student, I was privileged to learn lessons in mentoring from Aaron Rosen. He treated his students as colleagues, he invited them in to work on the most challenging of questions, and he pursued his work with joy. When he treated me as a colleague, I felt empowered. When he invited me to work with him on the field’s most vexing challenges, I felt inspired. And as he worked with joy, I learned that work pursued with joy doesn’t feel like work at all. And now the third, fourth, and fifth generations of social work researchers are pursuing tough challenges and the quality quest for social work practice. May seasoned and junior researchers work collegially and with joy, tackling the profession’s toughest research challenges, including the quest for high-quality social work services.

Acknowledgments

Preparation of this paper was supported by IRI (5R25MH0809160), Washington University ICTS (2UL1 TR000448-08), Center for Mental Health Services Research, Washington University in St. Louis, and the Center for Dissemination and Implementation, Institute for Public Health, Washington University in St. Louis.

This invited article is based on the 2017 Aaron Rosen Lecture presented by Enola Proctor at the Society for Social Work and Research 21st Annual Conference—“Ensure Healthy Development for All Youth”—held January 11–15, 2017, in New Orleans, LA. The annual Aaron Rosen Lecture features distinguished scholars who have accumulated a body of significant and innovative scholarship relevant to practice, the research base for practice, or effective utilization of research in practice.

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Module 3 Chapter 1: Overview of Intervention/Evaluation Research Approaches

In our prior course, you learned how the nature of an investigator’s research question dictates the type of study approach and design that might be applied to achieve the study aims. Intervention research typically asks questions related to the outcomes of an intervention effort or approach. However, questions also arise concerning implementation of interventions, separate from understanding their outcomes. Practical, philosophical, and scientific factors contribute to investigators’ intervention study approach and design decisions.

In this chapter you learn:

how content from our earlier course about study approaches and designs relate to intervention research;
additional approaches to intervention research (participatory research; formative, process, outcome, and cost-related evaluation research)
intervention research strategies for addressing intervention fidelity and internal validity concerns.

Review and Expansion: Study Approaches

In our earlier course you became familiar with the ways that research questions lead to research approach and methods. Intervention and evaluation research are not different: the question dictates the approach. In the earlier course, you also became familiar with the philosophical, conceptual and practical aspects of different approaches to social work research: qualitative, quantitative, and mixed methods. These methods are used in research for evaluating practice and understanding interventions, as well. The primary emphasis in this module revolves around quantitative research designs for practice evaluation and understanding interventions. However, taking a few moments to examine qualitative and mixed methods in these applications is worthwhile. Additionally, we introduce forms of participatory research—something we did not discuss regarding efforts to understand social work problems and diverse populations. Participatory research is an approach rich in social work tradition.

Qualitative methods in intervention & evaluation research.

The research questions asked by social workers about interventions often lend themselves to qualitative study approaches. Here are 5 examples.

Early in the process of developing an intervention, social workers might simply wish to create a rich description of the intervention, the contexts in which it is being delivered, or the clients’ experience with the intervention. This type of information is going to be critically important in developing a standardized protocol which others can use in delivering the intervention, too. Remember that qualitative methods are ideally suited for answering exploratory and descriptive questions.
Qualitative methods are well-suited to exploring different experiences related to diversity—the results retain individuality arising from heterogeneity rather than homogenizing across individuals to achieve a “normative” picture.
Qualitative methods are often used to assess the degree to which the delivery of an intervention adheres to the procedures and protocol originally designed and empirically tested. This is known as an intervention fidelity issue (see the section below on the topic of process evaluation).
Intervention outcomes are sometimes evaluated using qualitative approaches. For example, investigators wanted to learn from adult day service participants what they viewed as the impact of the program on their own lives (Dabelko-Schoeny & King, 2010). The value of such information is not limited to evaluating this one program. Evaluators are informed about important evaluation variables to consider in their own efforts to study interventions delivered to older adults—variables beyond the typical administrative criteria of concern. The study participants identified social connections, empowering relationships with staff, and enjoyment of activities as important evaluation criteria.
Assessing the need for intervention (needs assessment) is often performed with qualitative approaches, especially focus groups, open-ended surveys, and GIS mapping.
Qualitative approaches are an integral aspect of mixed-methods approaches.

Qualitative approaches often involve in-depth data from relatively few individuals, seeking to understand their individual experiences with an intervention. As such, these study approaches are relatively sensitive to nuanced individual differences—differences in experience that might be attributed to cultural, clinical, or other demographic diversity. This is true, however, only to the extent that diversity is represented among study participants, and individuals cannot be presumed to represent groups or populations.

Sketch of silhouettes of different people in a variety of colors

Quantitative methods in intervention & evaluation research.

Many intervention and evaluation research questions are quantitative in nature, leading investigators to adopt quantitative approaches or to integrate quantitative approaches in mixed methods research. In these instances, “how much” or “how many” questions are being asked, questions such as:

how much change was associated with intervention;
how many individuals experienced change/achieved change goals;
how much change was achieved in relation to the resources applied;
what trends in numbers were observed.

Many study designs detailed in Chapter 2 reflect the philosophical roots of quantitative research, particularly those designed to zero in on causal inferences about intervention—the explanatory research designs. Quantitative approaches are also used in descriptive and exploratory intervention and evaluation studies. By nature, quantitative studies tend to aggregate data provided by individuals, and in this way are very different from qualitative studies. Quantitative studies seek to describe what happens “on average” rather than describing individual experiences with the intervention—you learned about central tendency and variation in our earlier course (Module 4). Differences in experience related to demographic, cultural, or clinical diversity might be quantitatively assessed by comparing how the intervention was experienced by different groups (e.g., those who differ on certain demographic or clinical variables). However, data for the groups are treated in the aggregate (across individuals) with quantitative approaches.

Mixed methods in intervention & evaluation research.

Qualitative and quantitative approaches are very helpful in evaluation and intervention research as part of a mixed-methods strategy for investigating the research questions. In addition to the examples previously discussed, integrating qualitative and quantitative approaches in intervention and evaluation research is often done as means of enriching the results derived from one or the other approach. Here are 3 scenarios to consider.

Investigators wish to use a two-phase approach in studying or evaluating an intervention. First, they adopt a qualitative approach to inform the design of a quantitative study, then they implement the quantitative study as a second phase. The qualitative phase might help inform any aspect of the quantitative study design, including participant recruitment and retention, measurement and data collection, and presenting study results.
Investigators use a two-phase approach in studying or evaluating an intervention. First, they implement a quantitative study. Then, they use a qualitative approach to explore the appropriateness and adequacy of how they interpret their quantitative study results.
Investigators combine qualitative and quantitative approaches in a single intervention or evaluation study, allowing them to answer different kinds of questions about the intervention.

For example, a team of investigators applied a mixed methods approach in evaluating outcomes of an intensive experiential learning experience designed to prepare BSW and MSW students to engage effectively in clinical supervision (Fisher, Simmons, & Allen, 2016). BSW students provided quantitative data in response to an online survey, and MSW students provided qualitative self-assessment data. The quantitative data answered a research question about how students felt about supervision, whereas the qualitative data were analyzed for demonstrated development in critical thinking about clinical issues. The investigators concluded that their experiential learning intervention contributed to the outcomes of forming stronger supervisory alliance, BSW student satisfaction with their supervisor, and MSW students thinking about supervision as being more than an administrative task.

Cross-Sectional & Longitudinal Study Designs.

You are familiar with the distinction between cross-sectional and longitudinal study designs from our earlier course. In that course, we looked at these designs in terms of understanding diverse populations, social work problems, and social phenomena. Here we address how the distinction relates to the conduct of research to understand social work interventions.

A cross-sectional study involves data collection at just one point in time. In a program evaluation, for example, the agency might look at some outcome variable at the point when participants complete an intervention or program. Or, perhaps an agency surveys all clients at a single point in time to assess their level of need for a potential new service the agency might offer. Because the data are collected from each person at only one point in time, these are both cross-sectional studies. In terms of intervention studies, one measurement point obviously needs to be after the intervention for investigators to draw inferences about the intervention. As you will see in the discussion of intervention study designs, there exist considerable limitations to using only one single measurement to evaluate an intervention (see post-only designs in Chapter 2).
A longitudinal study involves data collection at two or more points in time. A great deal of intervention and evaluation research is conducted using longitudinal designs—answering questions about what changes might be associated with the intervention being delivered. For example, in program evaluation, an agency might compare how clients were functioning on certain variables at the time of discharge compared to their level of functioning at intake to the program. Because the same information is collected from each individual at two points in time (pre-intervention and post-intervention), this is a longitudinal design.
Distinguishing cross-section and longitudinal in studies of systems beyond the individual person can become confusing. When social workers intervene with individuals or families or small groups, that longitudinal study involves the same individuals or members at different points in time is evident—perhaps measuring individuals before, immediately after, and months after intervention (this is called follow-up ). However, if an intervention is conducted in a community, a state, or across the nation, the data might not be collected from the same individual persons at each point in time—the unit of analysis is what matters here. For example, if the longitudinal study’s unit of analysis is the 50 states, District of Columbia, and 5 inhabited territories of the United States, data are repeatedly collected at that level (states, DC, and territories), perhaps not from the same individual persons in each of those communities.

an oragne cut in two different ways to illustrate different cross sections

Formative, Process, and Outcome Evaluation

Practice and program evaluation are important aspects of social work practice. It would be nice if we could simply rely on our own sense of what works and what does not. However, social workers are only human and, as we learned in our earlier course, human memory and decisions are vulnerable to bias. Sources of bias include recency, confirmation, and social desirability biases.

Recency bias occurs when we place higher emphasis on what has just happened (recently) than on what might have happened in the more distant past. In other words, a social worker might make a casual practice evaluation based on one or two exceptionally good or exceptionally bad recent outcomes rather than a longer, larger history of outcomes and systematic evidence.
Confirmation bias occurs when we focus on outcomes that reinforce what we believed, feared, or hoped would happen and de-emphasize alternative events or interpretations that might contradict those beliefs, fears, or hopes.
Social desirability bias by practitioners occurs when practice decisions are influenced by a desire to be viewed favorably by others—that could be clients, colleagues, supervisors, or others. In other words, a practice decision might be based on “popular” rather than “best” practices, and casual evaluation of those practices might be skewed to create a favorable impression.

In all three of these forms of bias, the problem is not necessarily intentional, but does result in a lack of sufficient attention to evidence in monitoring one’s practices. For example, relying solely on qualitative comments volunteered by consumers (anecdotal evidence) is subject to a selection bias —individuals with strong opinions or a desire to support the social workers who helped them are more likely to volunteer than the general population of those served.

Thus, it is incumbent on social work professionals to engage in practice evaluation that is as free of bias as possible. The choice of systematic evaluation approach is dictated by the evaluation research question being asked. According to the Centers for Disease Control and Prevention (CDC), there are four most common types of intervention or program evaluation: formative, process, outcome, and impact evaluation ( https://www.cdc.gov/std/Program/pupestd/Types%20of%20Evaluation.pdf ). Here, we consider these as three types, combining impact and outcome evaluation into a single category, and we consider an additional category, as well: cost evaluation.

Formative Evaluation.

Formative evaluation is emphasized during the early stages of developing or implementing a social work intervention, as well as following process or outcome evaluation as changes to a program or intervention strategy are considered. The aim of formative evaluation is to understand the context of an intervention, define the intervention, and evaluate feasibility of adopting a proposed intervention or change in the intervention (Trochim & Donnelly, 2007). For example, a needs assessment might be conducted to determine whether the intervention or program is needed, calculate how large the unmet need is, and/or specify where/for whom the unmet need exists. Needs assessment might also include conducting an inventory of services that exist to meet the identified need and where/why a gap exists (Engel & Schutt, 2013). Formative evaluation is used to help shape an intervention, program, or policy.

Process Evaluation.

Investigating how an intervention is delivered or a program operates is the purpose behind process evaluation (Engel & Schutt, 2013). The concept of intervention fidelity was previously introduced. Fidelity is a major point of process evaluation but is not the only point. We know that the greater the degree of fidelity in delivery of an intervention, the more applicable the previous evidence about that intervention becomes in reliably predicting intervention outcomes. As fidelity in the intervention’s delivery drifts or wanes, previous evidence becomes less reliable and less useful in making practice decisions. Addressing this important issue is why many interventions with an evidence base supporting their adoption are manualized , providing detailed manuals for how to implement the intervention with fidelity and integrity. For example, the Parent-Child Interaction Therapy for Traumatized Children (PCIT-TC) treatment protocol is manualized and training certification is available for practitioners to learn the evidence-based skills involved ( https://pcit.ucdavis.edu/ ). This strategy increases practitioners’ adherence to the protocol.

Process evaluation, sometimes called implementation evaluation and sometimes referred to as program monitoring, helps investigators determine the extent to which fidelity has been preserved. But, process evaluation serves other purposes, as well. For example, according to King, Morris and Fitz-Gibbon (1987), process evaluation helps:

document details about the intervention that might help explain outcome evaluation results,
keep programs accountable (delivering what they claim to deliver),
inform planned modifications and changes to the intervention based on evidence.

Process evaluation also helps investigators determine where the facilitators and barriers to implementing an intervention might operate and can help interpret outcomes/results from the intervention, as well. Process evaluation efforts addresses the following:

Who delivered the intervention
Who received the intervention
What was (or was not) done during the intervention
When intervention activities occurred
Where intervention activities occurred
How the intervention was delivered
What facilitated implementation with fidelity/integrity
What presented as barriers to implementation with fidelity/integrity

For these reasons, many authors consider process evaluation to be a type of formative evaluation.

Outcome and Impact Evaluation.

The aim of outcome or impact evaluation is to determine effects of the intervention. Many authors refer to this as a type of summative evaluation , distinguishing it from formative evaluation: its purpose is to understand the effects of an intervention once it has been delivered. The effects of interest usually include the extent to which intervention goals or objectives were achieved. An important factor to evaluate concerns positive and negative “side effects”—those unintended outcomes associated with the intervention. These might include unintended impact of the intervention participants or impacts on significant others, those delivering the intervention, the program/agency/institutions involved, and others. While impact evaluation, as described by the CDC, is about policy and funding decisions and longer-term changes, we can include it as a form of outcome evaluation since the questions answered are about achieving intervention objectives. Outcome evaluation is based on the elements presented in the logic model created at the outset of intervention planning.

Process evaluation sequence including early planning intervention planning and conclusion processes

Cost-Related Evaluation.

Social workers are frequently faced with efficiency questions related to the interventions we deliver—thus, cost-related evaluation is part of our professional accountability responsibilities. For example, once an agency has applied the evidence-based practice (EBP) process to select the best-fitting program options for addressing an identified practice concern, program planning is enhanced by information concerning which of the options is most cost-effective. Here are some types of questions addressed in cost-related evaluation.

cost analysis: How much does it cost to deliver/implement the intervention with fidelity and integrity? This type of analysis typically analyzes monetary costs, converting inputs into their financial impact (e.g., space resources would be converted into cost per square foot, staffing costs would include salary, training, and benefits costs, materials and technology costs might include depreciation).

cost-benefit: What are the inputs and outputs associated with the intervention? This type of analysis involves placing a monetary value on each element of input (resources) and each of the outputs. For example, preventing incarceration would be converted to the dollars saved on jail/prison costs; and, perhaps, including the individuals’ ability to keep their jobs and homes which could be lost with incarceration, as well as preventing family members needing public assistance and/or children being placed in foster care if their family member is incarcerated.
cost-effectiveness: What is the ratio of cost units (numerator) to outcome units (denominator) associated with delivering an intervention. Outcomes are tied to the intervention goals rather than monetary units. For example, medical interventions are often analyzed in terms of DALYs (disability-adjusted life years)—units designed to indicate “disease burden,” calculated to represent the number of years lost to illness, disability, or premature death (morbidity and mortality). Outcomes might also be numbers of “cases,” such as deaths or hospitalizations related to suicide attempts, drug overdose events, students dropping out from high school, children reunited with their families (family reunification), reports of child maltreatment, persons un- or under-employed, and many more examples. Costs are typically presented as monetary units estimated from a costs analysis. (See http://www.who.int/heli/economics/costeffanalysis/en/ ).
cost-utility: A comparison of cost-effectiveness for two or more intervention options, designed to help decision-makers make informed choices between the options.

Two of the greatest challenges with these kinds of evaluation are (1) ensuring that all relevant inputs and outputs are included in the analysis, and (2) realistically converting non-monetary costs and benefits into monetary units to standardize comparisons. An additional challenge has to do with budget structures: the gains might be realized in a different budget than where the costs are borne. For example, implementing a mental health or substance misuse treatment program in jails and prisons costs those facilities; the benefits are realized in budgets outside those facilities—schools, workplaces, medical facilities, family services, and mental health programs in the community. Thus, it is challenging to make decisions based on these analyses when constituents are situated in different systems operating with “siloed” budgets where there is little or no sharing across systems.

An Additional Point.

An intervention or evaluation effort does not necessarily need to be limited to one types. As in the case of mixed-methods approaches, it is sometimes helpful to engage in multiple evaluation efforts with a single intervention or program. A team of investigators described how they used formative, process, and outcome evaluation all in the pursuit of understanding a single preventive public health intervention called VERB, designed to increase physical activity among youth (Berkowitz et al., 2008). Their formative evaluation efforts allowed the team to assess the intervention’s appropriateness for the target audience and to test different messages. The process evaluation addressed fidelity of the intervention during implementation. And, the outcome evaluation led the team to draw conclusions concerning the intervention’s effects on the target audience. The various forms of evaluation utilized qualitative and quantitative approaches.

Participatory Research Approaches

One contrasts previously noted between qualitative and quantitative research is the nature of the investigator’s role. Every effort is made to minimize investigator influence on the data collection and analysis processes in quantitative research. Qualitative research, on the other hand, recognizes the investigator as an integral part of the research process. Participatory research fits into this latter category.

“Participant observation is a method in which natural social processes are studied as they happen (in the field, rather than in the laboratory) and left relatively undisturbed. It is a means of seeing the social world as the research subjects see it, in its totality, and of understanding subjects’ interpretations of that world” (Engel & Schutt, 2013, p. 276).

This quote describes naturalistic observation very well. The difference with participatory observation is that the investigator is embedded in the group, neighborhood, community, institution, or other entity under study. Participatory observation is one approach used by anthropologists to understand cultures from an embedded rather than outsider perspective. For example, this is how Jane Goodall learned about chimpanzee culture in Tanzania: she became accepted as part of the group she observed, allowing her to describe the members’ behaviors and social relationships, her own experiences as a member of the group, and the theories she derived from 55 years of this work. In social work, the participant approach may be used to answer the research questions of the type we explored in our earlier course: understanding diverse populations, social work problems, or social phenomena. The investigator might be a natural member of the group, where the role as group member precedes the role as observer. This is where the term indigenous membership applies: naturally belonging to the group. (The term “indigenous people” describes the native, naturally occurring inhabitants of a place or region.) It is sometimes difficult to determine how the indigenous member’s observations and conclusions might be influenced by his or her position within the group—for example, the experience might be different for men and women, members of different ages, or leaders. Thus, the conclusions need to be confirmed by a diverse membership.

Participant observers are sometimes “adopted” members of the group, where the role of observer precedes their role as group member. It is somewhat more difficult to determine if evidence collected under these circumstances reflects a fully accurate description of the members’ experience unless the evidence and conclusions have been cross-checked by the group’s indigenous members. Turning back to our example with Jane Goodall, she was accepted into the chimpanzee troop in many ways, but not in others—she could not experience being a birth mother to members of the group, for example.

Sometimes investigators are more actively engaged in the life of the group being observed. As previously noted, participant observation is about the processes being left relatively undisturbed (Engel & Schutt, 2013, p. 276). However, participant observers might be more actively engaged in change efforts, documenting the change process from “inside” the group promoting change. These instances are called participatory action research (PAR) , where the investigator is an embedded member of the group, joining them in making a concerted effort to influence change. PAR involves three intersecting roles: participation in the group, engaging with the action process (planning and implementing interventions), and conducting research about the group’s action process (see Figure 2-1, adapted from Chevalier & Buckles, 2013, p. 10).

Figure 2-1. Venn diagram of participatory action research roles.

For example, Pyles (2015) described the experience of engaging in participatory action research with rural organizations and rural disaster survivors in Haiti following the January 12, 2010 earthquake. The PAR aimed to promote local organizations’ capacity to engage in education and advocacy and to secure much-needed resources for their rural communities (Pyles, 2015, p. 630). According to the author, rural Haitian communities have a history of experience with exploitative research where outsiders conduct investigations without the input or participation of community members, and where little or no capacity-building action occurs based on study results and recommendations. Pyles also raised the point that, “there are multiple barriers impeding the participation of marginalized people” in community building efforts, making PAR approaches even more important for these groups (2015, p. 634).

The term community-based participatory research (CBPR) refers to collaborative partnerships between members of a community (e.g., a group, neighborhood, or organization) and researchers throughout the entire research process. CBPR partners (internal and external members) all contribute their expertise to the process, throughout the process, and share in all steps of decision-making. Stakeholder members of the community (or organization) are involved as active, equal partners in the research process, co-learning by all members of the collaboration is emphasized, and it represents a strengths-focused approach (Harris, 2010; Holkup, Tripp-Reier, Salois, & Weinert, 2004). CBPR is relevant in our efforts to understand social work interventions since the process can result in interventions that are culturally appropriate, feasible, acceptable, and applicable for the community since they emerged from within that community. Furthermore, it is a community empowerment approach whereby self-determination plays a key role and the community is left with new skills for self-study, evaluation, and understanding the change process (Harris, 2010). These characteristics of CBPR help define the approach.

(a) recognizing the community as a unit of identity,

(b) building on the strengths and resources of the community,

(d) achieving a balance between research and action that mutually benefits both science and the community,

(e) emphasizing the relevance of community-defined problems,

(f) employing a cyclical and iterative process to develop and maintain community/ research partnerships,

(g) disseminating knowledge gained from the CBPR project to and by all involved partners, and

(h) requiring long-term commitment on the part of all partners ( Holkup, Tripp-Reier, Salois, & Weinert, 2004, p. 2).

Quinn et al (2017) published a case study of CBPR practices being employed with youth at risk of homelessness and exposure to violence. The authors cited a “paucity of evidence-based, developmentally appropriate interventions” to address the mental health needs of youth exposed to violence (p. 3). The CBPR process helped determine the acceptability of a person-centered trauma therapy approach called narrative exposure therapy (NET). The results of three pilot projects combined to inform the design of a randomized controlled trial (RCT) to study the impact of the NET intervention. The three pilot projects engaged researchers and members of the population to be served (youth at risk of homelessness and exposure to violence). The authors of the case study article discussed some of the challenges of working with youth in the CBPR process and research process. Adapted from Quinn et al (2017), these included:

Compliance with federal regulations for research involving minors (defined as “children” in the policies). Compounding this challenge was the vulnerable status of the youth due to their homeless status, and the frequency with which many of the youth were not engaged with any adults who had legal authority to provide consent for them to participate.
The team was interdisciplinary, which brings many advantages. However, it also presented challenges regarding different perspectives about how to engage in the varied research processes of participant recruitment and retention, measurement, and intervention.
Logistics of conducting focus groups with this vulnerable population. Youth encounter difficulties with participating predictably, and for this vulnerable population the practical difficulties are compounded. They experience complex and often competing demands on their schedules, “including school obligations, court, group or other agency appointments, or childcare,” as well as managing public transportation schedules and other barriers (p. 11). Furthermore, members of the group may have pre-existing relationships and social network ties that can impinge on their comfort with openly sharing their experiences or perspectives in the group setting. They may also have skepticism and reservations about sharing with the adults leading the focus group sessions.

Awareness of these challenges can help CBPR teams develop solutions to overcome the barriers. The CBPR process, while time and resource intensive, can result in appropriate intervention designs for under-served populations where existing evidence is not available to guide intervention planning.

A somewhat different approach engages members of the community as consultants regarding interventions with which they may be engaged, rather than a fully CBPR approach. This adapted consultation approach presents an important option for ensuring that interventions are appropriate and acceptable for serving the community. However, community members are less integrally involved in the action-related aspects of defining and implementing the intervention, or in the conduct of the implementation research. An example of this important community-as-consultant approach involved a series of six focus group sessions conducted with parents, teachers, and school stakeholders discussing teen pregnancy prevention among high-school aged Latino youth (Johnson-Motoyama et al., 2016). The investigating team reported recommendations and requests from these community members concerning the important role played by parents and potential impact of parent education efforts in preventing teen pregnancy within this population. The community members also identified the importance of comprehensive, empowering, tailored programming that addresses self-respect, responsibility, and “realities,” and incorporates peer role models. They concluded that local school communities have an important role to play in planning for interventions that are “responsive to the community’s cultural values, beliefs, and preferences, as well as the school’s capacity and teacher preferences” (p. 513). Thus, the constituencies involved in this project served as consultants rather than CBPR collaborators. However, the resulting intervention plans could be more culturally appropriate and relevant than intervention plans developed by “outsiders” alone.

interconnected hands with overlayed wordcloud about connection and unity

One main limitation to conducting CBPR work is the immense amount of time and effort involved in developing strong working collaborative relationships—relationships that can stand the test of time. Collaborative relationships are often built from a series of “quick wins” or small successes over time, where the partners learn about each other, learn to trust each other, and learn to work together effectively.

Chapter Summary

This chapter began with a review of concepts from our earlier course: qualitative, quantitative, mixed-methods, cross-sectional and longitudinal approaches. Expanded content about approach came next: formative, process, outcome, and cost evaluation approaches were connected to the kinds of intervention questions social workers might ask, and participatory research approaches were introduced. Issues of cultural relevance were explored, as well. This discussion of approach leads to an expanded discussion of quantitative study design strategies, which is the topic of our next chapter.

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Published: 26 April 2024

Contextual barriers and enablers to establishing an addiction-focused consultation team for hospitalized adults with opioid use disorder

Sandra K. Evans ORCID: orcid.org/0000-0001-5218-2190 1 ,
Allison J. Ober 1 ,
Ariella R. Korn 1 ,
Alex Peltz 1 ,
Peter D. Friedmann 4 ,
Kimberly Page 3 ,
Cristina Murray-Krezan 5 ,
Sergio Huerta 3 ,
Stephen J. Ryzewicz 4 ,
Lina Tarhuni 3 ,
Teryl K. Nuckols 1 , 2 ,
Katherine E. Watkins 1 &
Itai Danovitch 2

Addiction Science & Clinical Practice volume 19 , Article number: 31 ( 2024 ) Cite this article

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Metrics details

Hospitalization presents an opportunity to begin people with opioid use disorder (OUD) on medications for opioid use disorder (MOUD) and link them to care after discharge; regrettably, people admitted to the hospital with an underlying OUD typically do not receive MOUD and are not connected with subsequent treatment for their condition. To address this gap, we launched a multi-site randomized controlled trial to test the effectiveness of a hospital-based addiction consultation team (the Substance Use Treatment and Recovery Team (START)) consisting of an addiction medicine specialist and care manager team that provide collaborative care and a specified intervention to people with OUD during the inpatient stay. Successful implementation of new practices can be impacted by organizational context, though no previous studies have examined context prior to implementation of addiction consultation services (ACS). This study assessed pre-implementation context for implementing a specialized ACS and tailoring it accordingly.

We conducted semi-structured interviews with hospital administrators, physicians, physician assistants, nurses, and social workers at the three study sites between April and August 2021 before the launch of the pragmatic trial. Using an analytical framework based on the Consolidated Framework for Implementation Research, we completed a thematic analysis of interview data to understand potential barriers or enablers and perceptions about acceptability and feasibility.

We interviewed 28 participants across three sites. The following themes emerged across sites: (1) START is an urgently needed model for people with OUD; (2) Intervention adaptations are recommended to meet local and cultural needs; (3) Linking people with OUD to community clinicians is a highly needed component of START; (4) It is important to engage stakeholders across departments and roles throughout implementation. Across sites, participants generally saw a need for change from usual care to support people with OUD, and thought the START was acceptable and feasible to implement. Differences among sites included tailoring the START to support the needs of varying patient populations and different perceptions of the prevalence of OUD.

Conclusions

Hospitals planning to implement an ACS in the inpatient setting may wish to engage in a systematic pre-implementation contextual assessment using a similar framework to understand and address potential barriers and contextual factors that may impact implementation. Pre-implementation work can help ensure the ACS and other new practices fit within each unique hospital context.

The inpatient hospitalization is an opportune moment to reach people with an opioid use disorder (OUD) because they may be willing to engage with treatment, including initiating MOUD, if barriers can be reduced [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 ]. However, people with OUD do not typically initiate MOUD while in the hospital or get linked with subsequent treatment for their OUD after discharge [ 12 , 13 , 14 ]. A growing body of research shows that addiction consultation services (ACS), which typically consist of an addiction specialist, a care manager with expertise in addiction, and sometimes other members, such as peer navigators —are an important strategy for increasing the delivery and initiation of MOUD to people with OUD during their hospitalization and linkage to outpatient care once they leave [ 10 , 15 , 16 ]. Some prior work suggests that hospital-based ACS are feasible and cost-effective to implement, considered acceptable to both patients and clinicians [ 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ], may contribute to lower readmission rates for people with OUD [ 25 ], and increase the likelihood that patients continue MOUD post-discharge [ 26 ]. However, this prior work did not use an implementation framework or systematic process aimed at ensuring the fit of the consult team with the context-specific needs of the hospital. Additionally, few studies have used an ACS-specific intervention or used a systematic approach to identifying contextual factors that affect successful implementation, and no other studies have assessed organizational context prior to the implementation of an ACS in order to improve implementation success.

To evaluate the effectiveness of an ACS that uses a specialized intervention for improving MOUD initiation and linkage to care in hospital settings, we planned a multi-site, open label, pragmatic randomized controlled trial of an ACS with a tailored intervention called the Substance Use Treatment and Recovery Team (START) at three diverse academic hospitals in different states (California, New Mexico, Massachusetts) [ 27 ]. The primary outcomes were initiation of MOUD and linkage to OUD-focused follow-up care [ 27 ].

The START is an ACS comprised of an addiction medicine specialist (AMS) and care manager (CM) who deliver a tailored intervention based on motivational interviewing (MI) [ 28 ] and focused discharge planning [ 29 , 30 ]. The START provides diagnostic assessments, makes appropriate treatment recommendations, assists with implementation of treatment plans, establishes OUD-focused discharge plans, facilitates linkage to treatment after discharge, and provides follow-up telephone calls for one month. In this pragmatic trials, each hospital’s AMS and CM were hospital staff members, and the START was integrated into the hospital workflow, relying on acceptance from the medical team for successful implementation. Further detail about the START and the study can be found in our protocol paper [ 27 ].

Understanding organizational context—particularly the perspectives of key stakeholders including clinician administrators, clinicians and patients—is an important first step for successful implementation of new practices [ 31 ]. Guided by the Consolidated Framework for Implementation Research (CFIR) [ 32 , 33 ], we collected pre-implementation contextual data from key stakeholders, including hospital administrators, physicians, physician assistants, nurses, and social workers to better understand the context for implementing an addiction-focused consultation service within three diverse hospitals and to inform implementation. CFIR is an implementation determinant framework comprised of five domains that characterize the innovation or intervention, outer setting, inner setting, individuals involved, and the implementation process. Each domain contains a menu of constructs thought to affect implementation of new practices. The CFIR domains and constructs can be used to assess key determinants relevant to a given innovation. Pre-implementation contextual assessments can guide the development and tailoring of new practices and inform strategies for successful implementation. (Of note, we did not collect pre-implementation data from patients as part of this inquiry because we obtained patient input in a separate pilot study [ 24 ].)

The objective of this pre-implementation research was primarily to understand contextual factors that could affect implementation of the START for our trial, as it was directly integrated into the hospital workflow, and if successful, after the trial; we also aimed to advance the literature on contextual factors affecting hospital-based ACS more broadly. We sought to examine hospital administrator and clinician perspectives on contextual factors that could act as barriers or enablers to implementing a hospital-based ACS; assess acceptability and feasibility of an ACS team in comparison to usual care practices for people with OUD; and understand perceptions about people with OUD and the use of MOUD more generally. In this article we describe our findings and discuss how this exploration can facilitate broader implementation of hospital-based ACS for treating OUD.

To examine potential determinants of implementation in the pre-implementation phase of the START, we conducted semi-structured interviews with hospital administrators and clinicians at each START site between April and August 2021 prior to the launch of the pragmatic trial [ 34 ]. Footnote 1 Details about the START intervention itself are described elsewhere [ 27 ]. Using a qualitative research approach, we gathered in-depth views about contextual determinants that could affect START from a range of hospital staff, including administrators, who had a unique perspective about feasibility, clinicians (doctors and nurses) who might encounter or refer patients to the START, and social workers, who might coordinate with START for discharge planning.

Hospital sites were Baystate Medical Center (BMC) in Springfield, MA, Cedars-Sinai Medical Center (CSMC) in Los Angeles, CA, and University of New Mexico Hospital (UNMH) in Albuquerque, NM. BMC, CSMC, and UNMH are each teaching hospitals. BMC is the flagship hospital of Baystate Health, a nonprofit integrated healthcare system serving over 800,000 people in Western New England and providing care for approximately 45,000 inpatients, 197,000 emergency care patients, and 1.8 million outpatient visits annually [ 35 ]. CSMC is a nonprofit academic healthcare organization serving more than 1 million people each year in the diverse Los Angeles community and beyond [ 36 ]. UNMH is part of the UNM Medical Group that includes 30 clinics and six hospitals and medical centers across the state, collectively providing care for 900,000 outpatient visits, 22,000 surgical cases, and 100,000 emergency room visits annually [ 37 ].

In both Los Angeles County, CA and Bernalillo County, NM (home to CSMC and UNMH, respectively) approximately half of the population is Hispanic or Latino, whereas about a quarter of residents in Hampden County, MA (home to BMC) have a Hispanic or Latino background. Bernalillo County has the greatest proportion of American Indian and Alaska Native residents (4.9% vs. <1.0% in Los Angeles and Hampden counties). Los Angeles County has the greatest proportion of Asian residents (14.8% vs. approximately 2.6% in Bernalillo and Hampden counties), foreign-born residents (33.5% vs. 9.2–10.2%), and those who speak a language other than English at home (55.8% vs. 26.2–27.5%) [ 38 , 39 , 40 ].

Data collection processes

Sampling and recruitment.

We used a mix of purposive and snowball sampling to develop a sample of interviewees at each hospital. Hundreds of employees work at each participating hospital and potentially eligible patients for the START intervention could be admitted to the hospital in any unit. Therefore, we could not simply select a sample of clinicians from particular hospital units. Instead, we asked START researchers who were also clinicians and addiction medicine specialists at the participating hospitals to provide a list of possible interviewees representing different roles, including administrative leadership, attending physicians, nurses, and social workers. Our sampling approach prioritized staff members who were most likely to interact with potential START participants. The START clinicians sent an email to potential participants to say that START research personnel would be reaching out to request their participation in an interview. START researchers then emailed each potential participant (up to three times) to request and schedule interviews.

We did not have a target number of interviewees, particularly since we were seeking additional interviews via snowball sampling. Lists of possible interviewees ranged from 12 to 20 individuals. After each interview, we asked participants to recommend key individuals to interview whose insights could assist with the implementation of the START.

Recruitment

The protocol was reviewed and approved by the Cedars Sinai Medical Center Institutional Review Board (IRB). Cedars Sinai served as the IRB of record. BMC and UNM ceded IRB review to Cedars-Sinai via a SMART IRB agreement; the respective IRBs at BMC and UNM reviewed for local context only. Approval included a waiver of written informed consent for participants, given low risk. While the identities of interviewees were visible to the researchers who conducted interviews, all potentially identifying information has been kept confidential in the reporting of results.

Data collection

Three team members with experience in semi-structured interviewing and qualitative analysis conducted the semi-structured interviews via the Microsoft Teams videoconferencing platform. Each interview took approximately 30–45 min to complete. The interview guide consisted of open-ended questions to engage participants in discussion about their professional views and experiences. The interview guide was informed by CFIR categories and related materials including the CFIR qualitative interview guide tool [ 41 ]. We used these resources to develop interview questions that both addressed the context of the START and the most relevant components of the CFIR. The resulting interview guide addressed the following domains (see Additional File 1 ):

Acceptability of addressing OUD during the inpatient stay and MOUD (focus on usual care).

Perceptions about the START.

CFIR constructs addressed : Relative Advantage and Tension for Change; Compatibility; Clinician/Hospital Needs and Resources; Linking.

Patient and organizational needs.

CFIR constructs addressed : Patient Needs and Resources; Adaptability and Culture.

Enabling factors.

CFIR constructs addressed : Stakeholders and Opinion Leaders; Communication.

Possible additional barriers.

We pilot-tested the interview guide with members of the START steering committee who were knowledgeable about both the START and the sites that were involved. These pilot interviews allowed us to refine question wording and order, as well as content.

Because interviews were conducted in the pre-implementation phase, the guide featured prospectively framed questions, for example, about whether participants could foresee any barriers or challenges related to how the START would fit into their workflow. Interviews were recorded and transcribed with participants’ verbal consent. As an incentive, each interviewee was offered a $50 gift card for their participation.

Qualitative analysis

We conducted thematic analysis to examine themes that cut across the interviews [ 42 , 43 ]. Taking a primarily deductive approach, we developed a codebook structured around the topics from the interview guide and related CFIR constructs [ 32 ]. In addition to referencing the 2009 CFIR constructs that informed the interview guide, we referred to CFIR resources including the CFIR codebook to inform our analysis [ 44 ]. Through extensive discussions among our interview team and with input from the broader research team involved with the START, we narrowed down, and in some cases tailored or combined, the CFIR constructs that were most relevant to the context of our data and research objectives to include: (1) Outer Setting constructs, Patient Needs and Resources, Linking (adapted from Cosmopolitanism); (2) Combined Intervention and Inner Setting constructs, Relative Advantage and Tension for change, and Adaptability and Culture; (3) Inner Setting constructs, Clinician/Hospital Needs and Resources (adapted from Implementation Climate), Communication (adapted from Networks and Communications), and Compatibility; and (4) a combined Process construct, Key Stakeholders (adapted from Opinion Leaders and Formally Appointed Internal Implementation Leaders) (see Table 1 ).

We then adapted these categories and their definitions through further discussion and practice application to our interview data. We also included three additional codes to help us sort the data based on reported barriers, recommendations or ideas for the START intervention, and impacts of the COVID-19 pandemic (e.g., the study was launching relatively early in the pandemic when normal hospital protocols were set aside to cope with the influx of COVID patients and to mitigate risks related to potential COVID exposure). These sorting codes helped us more easily examine combinations of codes such as barriers related to the CFIR-derived code, Adaptability and Culture. More than one code could be applied to any given excerpt (codes were not mutually exclusive). A summary of our codebook is provided in Table 1 .

Three members of the research team coded interview data in Dedoose [ 45 ]. We took several iterative steps to train the coders and assess intercoder reliability. First, we practice-coded two to three transcripts and updated the codebook by refining codes, their descriptions, and examples where necessary. We then triple-coded the same sample of five transcripts to measure intercoder reliability. This sample included transcripts from each site. Each member of the coding team coded the same excerpts from the five sample interviews independently. We calculated Krippendorff’s Alpha to evaluate the consistency of code application by the three coders [ 46 ]. For the codes that scored lower than 0.70, the coders discussed discrepancies at length in order to further refine the codebook and to make sure coders were consistent in how we were interpreting and applying codes. We then divided up the transcripts among the three coders and coded these samples in Dedoose.

We interviewed 28 staff members from the three hospitals participating in the START study. Table 2 reports the number of participants by site and role, in addition to the response rates for each site and overall (52.8%). Across sites, the most common interviewee role was attending physician ( n = 10), followed by social worker ( n = 7), administrative leader ( n = 6), and nurse ( n = 5). Table 2 lists participants by site (we combined administrative leaders and attending physicians in Table 2 to ensure confidentiality for participants; at least one administrator and one attending were interviewed at each site).

In the following section we summarize the overarching themes from the analysis of the interview data. We also describe examples of practical advice provided to research team to help address potential barriers in the pre-implementation period. We grouped the overarching themes into four categories:

Urgency for Change : There is a sense of urgency for change as well as perceived advantages and compatibility with current practices of an ACS. This included results from the Outer Setting code “Relative Advantage/Tension for Change” and Inner Setting codes “Compatibility” and “Clinician/Hospital Needs and Resources”.

Culturally Appropriate Adaptations : Intervention adaptations are necessary to meet local and cultural needs. This included results from the Intervention code “Adaptability/Culture”.

Post-discharge Linkage : Linking to other clinicians and organizations is needed to support OUD care. This included results from the Outer Setting codes “Linking” and “Patient Needs and Resources.”

Opinion Leader Engagement : It is important to engage key stakeholders across departments and roles. This included results from the Inner Setting code “Communication” and the Process code “Opinion Leader/Stakeholder Engagement.”

Because codes used in the qualitative analysis process were not considered to be mutually exclusive, we found thematic overlap across certain CFIR-based codes. We therefore grouped findings under similar overarching themes. We also examined code co-occurrence data within Dedoose to check the extent to which codes were double-coded as an additional step to validate the extent to which findings in certain categories tended to overlap.

Urgency for Change. There is a sense of urgency for change as well as perceived advantages and compatibility with current practices of an ACS.

An innovation is unlikely to succeed unless those involved see a need for it and perceive it as fitting with existing norms, values, and workflows [ 47 ]. Most interviewees across sites agreed that there was a need for change from usual care to meet the needs of people with OUD, and the START seemed to offer an advantage. For example, an administrative leader from CSMC noted a critical gap in care that an ACS team could help fill:

“ I think there’s a lot of frustration for our social work team and for our clinicians. You get this person out of an and the resulting actions taken in response’s a cry for help. You get them stabilized and then to throw them out the door and not give them any support, it feels wrong. It feels like we’re abandoning them. ” (Administrator, CSMC).

Some interviewees also discussed how the teaching hospital culture and focus on education aligns with openness to adopt new programs like addiction-focused consult liaison services. A social worker from UNMH noted:

“ I feel like we’re actually fairly open to new programs, new ideas, because a lot of what we, there’s a lot of research going on at UNM, a lot of new trials for, not just this, but lots of different areas and I feel like, because we’re a teaching institution, it’s pretty common for new practices to come up. I think, especially in an area like this that is so needed, I think people will be open to some of these changes, whatever they end up being, so I don’t think it’s uncommon for us to go through new policies or practices like this, if it’s going to, in the long run, benefit our patients and the hospital and New Mexico. ” (Social worker, UNMH).

At BMC, interviewees discussed how aspects of usual care fell short in comparison to what the START proposed. During the previous year, BMC initiated an ACS to address infrequent initiation of MOUD. The ACS consisted of an addiction medicine specialist, but it did not have a care manager or pre-specified intervention. Although the ACS was an improvement over their earlier usual care approach in that it started to improve MOUD initiation, it still faced limitations. The new ACS was composed of a single addiction medicine specialist with no care manager or post-discharge planning intervention. Further, even with the new ACS, there was still no opportunity to actively link patients to OUD treatment or support them after discharge. The ACS offered through START augmented existing services by adding a discharge planning intervention and a care manager to implement it and provide active post-discharge linkage and support.

A CSMC social worker noted that addiction medicine is its own specialty and not their area so this type of team would be welcome:

“ I would be a fan of the resource because… some of the patient population that are falling under the OUD -- they may have mental health illness in addition to some of their other medical conditions, and so it is really, really difficult when you have those other issues as well. The more specialized resources that we have to better care for our patients, it’s advantageous for us. I think there’s going to be lots of advantages that can really maybe open some doors for some people that we didn’t know existed. ” (Social worker, CSMC).

Some CSMC interviewees also discussed how certain concerns among people with OUD, such as willingness to go to treatment and challenges with pain management, such as the perception among clinicians and patients that treatment with MOUD may conflict with the need for pain management, may deter the perceived advantages and compatibility of an ACS offered through the START. A CSMC interviewee also noted the challenge of selecting people with OUD that would qualify for the intervention, including the concern that some individuals may not be in the hospital long enough to be identified and referred to the START.

There were some differences between the hospitals with regard to Tension for Change and Relative Advantage of the START over existing programs. As noted above, BMC had already started a consultation service to address the high need for OUD treatment, but the existing service was perceived as “stretched thin” and in need of a care manager. Perception of need at UNMH also was high, with many clinicians noting the need for trained social workers to facilitate linkage to community programs. UNMH personnel also discussed that while there was not an existing ACS, the idea had been discussed among leadership and clinicians and there was general agreement about the strong need, but the hospital had not yet implemented one. As this UNMH nurse noted to emphasize the need,

I would say [OUD care] is very important. In New Mexico, we have a long-standing issue with multi-substance abuse, opioid abuse…We’re the academic medical center, but we’re also the public hospital for Bernalillo County and the City of Albuquerque, which is the largest metropolitan Center in New Mexico so we see many patients with substance abuse disorders. (Nurse, UNMH)

At CSMC, based on comments made during the interviews indicating lack of certainty about the number of people with OUD passing through the hospital, the perception of need for START did not seem to be as strong as at BMC or UNMH, where participants saw OUD as more prevalent. However, CSMC clinicians did see a need for START because of lack of expertise to prescribe MOUD on the medical team and to support patients after discharge.

Culturally Appropriate Adaptations. Intervention adaptations are necessary to meet local and cultural needs.

Interviewees across sites discussed the extent to which the START intervention should be tailored for various groups of people with OUD based on economic stability factors, culture, and language. For example, a social worker at BMC noted:

“ I think just that so many of our patients here are extremely limited, like, socio-economically, so there are going to be tons of patients who just truly can’t get anywhere where they would need to go for treatment. Or just so many constraints like that or no supports once they leave here. ” (Social worker, BMC).

Similarly, as discussed by an attending physician at CSMS, low-income populations may have trouble linking to follow-up care:

“ We take care of often uninsured, underinsured, unrepresented, undocumented patients and there are, just as many issues with opioid disorder in that population of patients, if not more, but they have very little to no follow up at all on discharge. ” (Attending physician, CSMC).

Interviewees across sites emphasized the desire for linguistic and cultural patient-clinician concordance to improve patients’ access to services and heighten the intervention’s impact among diverse patient populations. Having team members who share or are familiar with patients’ cultural backgrounds would help develop trusting relationships with patients.

Because the sites are located in dissimilar locations, there was some nuance in how participants suggested how adaptability could be valuable to the START. For example, participants from BMC focused primarily on the need to support low socioeconomic status patients in addition to patients with different cultural and linguistic backgrounds. CSMC’s population was unique in its wide range of patients across the socioeconomic spectrum from the unhoused to the very wealthy, in addition to patients with different cultural and linguistic backgrounds. UNMH participants emphasized the importance of working with members of Native American populations and underserved populations, including patients who had to travel very long distances to access care at the hospital. As one participant noted, “We [have] a large Native American population state and that’s a core part of our identity as a hospital…And a lot of our patients don’t have very many resources at all [so] understanding that is part of what we do” (Administrator, UNMH).

Post-discharge Linkage. Linking to other clinicians and organizations is needed to support OUD care.

At all three sites, participants noted the challenge of referring people with OUD to acute care facilities after they start taking MOUD. Post-discharge linkage was seen as an essential component of patient care—dependent not only on logistics connecting with outpatient facilities that offer medication therapies for OUD, but also on the support that can begin in the hospital.

The lack of a systematic way of transitioning patients to outpatient care was seen as a major barrier and not a standard practice. A CSMC physician noted that “ there is not a robust outpatient pain management network of physicians ” and an administrator at UNMH similarly perceived limited access to outpatient specialty treatment for people with OUD:

“ We have very little access for the patients that come into the hospital or come into the emergency department to establish them with follow up to continue treatment should we initiate it in the, in either the inpatient or emergency department setting. So, it’s a tremendous problem. We see it all the time and it’s hard to know what to do with it. Because when people leave the hospital, there are so few ways in which, we can ensure a transition of care. ” (Administrator, UNMH).

Interviewees also discussed that fact that few acute-care rehabilitation programs would accept patients who have already started MOUD. This issue was particularly prevalent at UNMH, with almost all interviewees noting linkage barriers due to regulations preventing skilled nursing facilities (SNFs) from administering or treating patients who are on MOUD. Clinicians described how treatment planning for people with OUD often depends on where they need to receive care after discharge. This can be a conundrum, because people with OUD, who likely cannot be released home with peripherally inserted central catheter (PICC) line and intravenous (IV) antibiotics, generally are the ones who need to go to a SNF. For example, a nurse at UNMH noted:

“ Our patients with opioid use disorders oftentimes, how we address it and treat it often depends on what we think their discharge plan is going to be. So, a very common scenario is that we have a person with opioid use disorder, IV drug use in particular, who comes in for things like endocarditis and bacteremia, and has to complete long-term antibiotics. In New Mexico or in Albuquerque there’s basically maybe two skilled nursing facilities that will take somebody on say, methadone or buprenorphine .” (Nurse, UNMH).

Clinicians at BMC similarly described how resources for mental health services are limited in the Springfield, MA area when compared to the eastern part of the state toward Boston.

Additionally, building relationships with people with OUD and meeting them where they are was seen as critical in shepherding individuals from the inpatient to outpatient setting. Participants noted that linkage can vary in terms of providing resources versus connecting patients with an external facility, and that more substantial linkage efforts prior to discharge reduces the burden on the patient for seeking and obtaining necessary care.

Lastly, given the context of COVID-19 or future public health emergency, linking to outpatient care could prove to be more difficult. A social worker at UNMH described such difficulties for patients experiencing homelessness:

“ I know we had more post-discharge issues during COVID, just even a harder time linking people to community clinics for medication assisted treatment, just because…a lot of places closed down significantly for a lot of homeless patients. They were staying at, you know, city funded motels and trying to get their medications delivered there, especially for patients on methadone every day was a significant barrier to discharging people…We were talking to most patients over the phone in a room, so that was really difficult just from a communication perspective. ” (Social worker, UNMH).

A distinct difference between sites regarding linkage is that clinicians at BMC were very concerned about lack of available community treatment and social services for patients, while at CSMC the concern was less around community availability of services and more about ensuring patients get linked to them. One clinician at CMSC discussed the need for a “warm handoff” to follow-up clinicians or treatment programs, while another suggested the need for telehealth for follow-up because of the size of the county and services being located far from where patients live.

Stakeholder Engagement. It is important to engage key stakeholders across departments and roles.

Interviewees across sites discussed the diversity of actors involved in care for people with OUD that would be critical for the success of the ACS team intervention, including but not limited to hospital administrators; department leaders; social workers; case managers; physicians (e.g., psychiatrists and internal medicine specialists); and nurses. Interviewees discussed how key stakeholders span disciplines and teams. One interviewee from CSMC noted that key stakeholders would include the:

“…Pain management team, definitely psychiatry team and I think social services because resources are necessary to sustain any kind of a program. We need social services to find the right resource for them, when they are no longer in our supervision .” (Nurse, CSMC).

Similarly, an interviewee noted that:

“… for champions, I actually think the unit nursing staff can be really helpful, right, beyond leadership, because I think they’re there all the time, right and can really influence whether or not, at least in my experience, whether or not this program will float or not. ” (Attending physician, UNMH).

Interviewees also discussed that, not only will stakeholder involvement aid in the implementation of the intervention, but having important members of the hospital involved and supportive of the intervention will be essential in funding these types of programs following the study. An attending physician at BMC noted:

“The big thing for making sure that the program is adequately funded and staffed. I think they need to have a lot of support from our patient safety and quality department…I think the high-level c-suite people do believe that it’s important. I think it’s just a matter of justifying the cost to compared to all the other things we have to pay for. ” (Attending physician, BMC).

Receiving support from specific programs such as pain management, psychiatry, and other social services was also thought to be necessary to sustain this type of intervention in the long term. There were very few differences among the sites with regard to this theme. Overall, participants emphasized the need to engage with different types of department leaders and to spread awareness to stakeholders, including physicians, through effective communication.

Implications for research study implementation

Because this pre-implementation research also had practical, near-term implications for the research study, we discussed preliminary findings and their implications with the research team in August of 2021 prior to the fall launch of the START, and developed actions to address implementation issues. Table 3 summarizes those recommendations and the resulting actions taken in response.

Many action items for sites related to communication among hospital providers and staff, for example, to leverage CSMC Grand Rounds as a venue to educate medical teams about OUD prevalence and the START intervention. Interviewees across all sites recommended actions to reduce barriers to linking hospitalized patients with OUD to post-discharge care. Care managers at UNMH, for example, could help facilitate the linking process by updating referral resources with tips specific to the local context. We also produced an FAQs document about the START that could be used or adapted at each site to help support hospital-wide communication about the START. The FAQ document was based on common questions from interviewees, such as how to contact representatives from the START or how the START was designed to not impact patient length of stay.

This qualitative study explored perspectives on contextual barriers and enablers to implementation of an ACS and tailored intervention called the START to improve MOUD initiation and linkage to services for hospitalized people with OUD. Our thematic analysis pointed to several common findings across the three disparate sites. Overall, participants saw a strong need for change from usual care to provide care for people with OUD and comments tended toward viewing the START as an acceptable and feasible option. Additionally, the START was considered likely to be compatible with current practices in that it could easily fit into medical team workflows. Shared concerns across sites included the need to adapt the START to meet local, cultural and linguistic needs such as the ability to meet the needs of very low-income individuals as well as those from diverse racial and ethnic groups and the need for hospital-wide information about the need for START and how it would fit into the workflow. Linking patients to community clinicians for post-discharge care was also described as a potential impediment to the success of the ACS.

While there were relatively few differences in perspectives among the three sites, some of these differences were notable. Most differences had to do with how the START should be tailored to meet the needs of specific patient populations. Additionally, perceptions about OUD prevalence varied in that at one site in particular (CSMC), where several interviewees recommended greater educational opportunities for medical teams to learn about the prevalence and treatment of OUD. Further, there were perceived differences in current gaps in care, such as the need for a care manager to complement an existing addiction medicine specialist to support linkage to community clinicians, versus concerns about availability of community clinicians and limitations of SNFs for people on MOUD. These types of differences about tailoring, perceptions about the degree to which OUD is prevalent in the patient population, and differences in gaps in care are likely to be relevant to other sites attempting an intervention.

Strengths of this study included the diversity of perspectives gathered across three different geographic areas (CA, MA, NM) and roles within participating hospital sites, including clinicians (social workers, physicians, nurses) and administrative leadership. Additionally, the CFIR was used to analyze contextual factors in a way that could help inform the implementation of similar ACS in other hospital settings. For example, other sites may consider engaging with stakeholders via interviews or other stakeholder discussion forums using CFIR categories like those used in this study to help introduce or preview the implementation of a given initiative and to tailor the ACS to meet identified barriers. By understanding contextual factors such as perceptions about compatibility and feasibility, adaptability, and stakeholder views, an innovation may be more likely to avoid at least some barriers in implementation. Finally, collecting and sharing pre-implementation feedback allowed the START implementation team to adapt the intervention accordingly.

Several limitations should be considered. First, interviews were conducted in Spring and Summer of 2021 during the COVID-19 pandemic, which may have impacted participation in the study. At UNMH in particular, staff shortages were a widespread concern which could have limited participation. Second, there is the potential for selection bias; that is, that the sample is biased toward staff and clinicians at the forefront of OUD care because they were referred by study team members at each hospital. To try to avoid this possibility, we let the study team members who recommended participants know that we were hoping to hear a range of views, even from those who might not encounter or support the START. Third, because patients can enter a hospital in multiple ways and see many clinicians, it would have been impossible to speak with every clinician that could come in contact with a potential START patient at each site. Knowing this limitation, we considered interviewing a purposively selected sample to be the most practical method to gather in-depth data in the timeframe available for this project.

Future research could examine post-implementation interviews with hospital staff and clinicians that came into contact with the START during the study period to compare differences in perspectives and perceptions of needs. This approach would provide an opportunity to compare pre- and post-implementation perceptions about the START. It would also provide a way to examine the START as a program that was implemented during the COVID-19 pandemic and that continued into the post-pandemic period (i.e., when COVID was still present but no longer considered a government emergency in the U.S.). Additionally, researchers could explore how the CFIR constructs explored in this research relate to START implementation outcomes with the goal of identifying drivers that impact implementation. Further, additional, qualitative data collection from patient participants in the START study could be useful for understanding patient experiences with the intervention as well as with their experiences linking to post-discharge follow-up care.

In sum, this qualitative pre-implementation work is an approach other studies can use to preview potential barriers and contextual factors that may impact the implementation of ACS and has broader implications for implementing and sustaining ACS and other new practices within the inpatient setting.

Data availability

The deidentified qualitative data generated and analyzed during this study can be made available from the corresponding author on reasonable request and with execution of appropriate Data Use Agreements.

Implementation is typically broken out into phases including pre-, during, and post- because these time periods require different steps for a given intervention. In this research we refer to the pre-implementation phase as the time period prior to the launch of the START in which researchers were planning and working with participating hospitals to lay the foundation for the intervention.

Abbreviations

addiction consultation services

Baystate Medical Center

Consolidated Framework for Implementation Research

Cedars-Sinai Medical Center

medications for opioid use disorder

opioid use disorder

skilled nursing facilities

Substance Use Treatment and Recovery Team

University of New Mexico Hospital

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Acknowledgements

We would like to acknowledge the interview participants whose input was central to this manuscript, and the START study team for their assistance with data collection and feedback on this manuscript.

Grant Number: 1U01TR002756-01A1: National Center for Advancing Translational Sciences, National Institute on Drug Abuse.

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SKE, AJO, ARK, and AP contributed to data collection, analysis, and manuscript writing. PF, SH, and ID assisted with data collection steps including initial outreach to potential interviewees. The remaining authors provided extensive, valuable feedback and manuscript revisions throughout the data analysis and writing process. All authors read and approved the final manuscript.

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Evans, S.K., Ober, A.J., Korn, A.R. et al. Contextual barriers and enablers to establishing an addiction-focused consultation team for hospitalized adults with opioid use disorder. Addict Sci Clin Pract 19 , 31 (2024). https://doi.org/10.1186/s13722-024-00461-x

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Register Here Professor Maria Lohan is Chair in Social Sciences and Health, UNESCO Chair in Gender Equality and is a consultant to the WHO Department of Sexual and Reproductive Health and Research. Professor Lohan’s interdisciplinary team is dedicated to improving a/ the sexual and reproductive health and rights of women and girls through men’s engagement and support for gender equality and b/ meeting men’s own sexual and reproductive health needs. She leads a program of research undertaking systematic reviews and developing, evaluating, and implementing evidence-based educational and health care interventions, such as comprehensive sexuality education in schools and prisons to engage men and boys. The objective of this research is to generate new thinking of men’s roles in sexual health, reproduction, and parenting and in promoting gender equality.

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Nurses are inventors and mentors, scientists and lifesavers, trailblazers and groundbreakers. They embody the humanity of healthcare as they provide hands on patient care and create the future as they pioneer new technology and care models. And they see beyond the limitations of today, breaking down barriers for patients and populations to build a healthier world.

Johnson & Johnson has proudly championed the nursing profession for over 125 years because we know the irreplaceable role they have played in so many scientific breakthroughs, difficult surgeries and challenging recoveries, and major medical moments of the last century and beyond. They do it by thinking holistically, connecting directly with people to understand their challenges, and developing strategic, human-centered solutions.

This National Nurses Month, join us in celebrating nurses and their tremendous impact. We invite you to meet, celebrate and share the stories of inspiring nurses dedicated to transforming the health of their communities, underscoring the innovation and leadership of the nursing profession.

Nurses & Community-Inspired Research

The nurse scientist designing culturally sensitive interventions to advance health equity..

Timiya S. Nolan, PhD, APRN-CNP, ANP-BC was hooked on nursing from the moment she stepped into her first clinical rotation. “I will never forget that moment,” says Nolan, a three-time graduate of the University of Alabama at Birmingham (UAB) School of Nursing, where she earned her bachelor’s, master’s, and PhD degrees. “I immediately saw it was the nurse, not the doctor, at the bedside doing the work and watching out for the patient. From that point on, I was all in.”

After joining Ohio State University as an Assistant Professor in 2018, Nolan is now back at her alma mater as an Associate Professor in the Heersink School of Medicine at UAB.

There, she studies ways to reduce health disparities in breast cancer and cardiovascular disease among medically underserved communities in Alabama by better understanding underrepresented minorities with chronic conditions and developing culturally sensitive interventions.

Nolan sees herself as a convener – “My style is to bring people together,” she said. “The best teams are ones that don't just encompass academics, but also include community members and government officials and industry partners, all working together toward a common and shared goal, which for me is to find ways that we can reduce health disparities and really move toward health equity.”

Timiya Nolan spearheads the Uplift Her wellness event in Columbus, Ohio

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Inspired by a mother who encouraged her child to “huff and puff” like the “big bad wolf” before being fitted with an anesthesia mask, Hess had an idea. Could she create a breathing-controlled video game, where kids practice using an anesthesia mask and “puff” to blow bubbles or inflate balloons in the game?

She created a prototype and, encouraged by her research mentor, began to seek grant funding to develop a functional version. Hess admits, it was challenging at first: “Intellectual property, FDA classification, commercialization partners — they don’t teach any of that in nursing school! But collaborating with different disciplines and learning new skills and technologies is something that we do constantly as nurses.”

It took several years from receiving the grant to creating a licensed product, Hess says, as COVID and other factors created roadblocks. But she persevered, and in 2023, Cincinnati Children’s officially secured a licensing agreement with LittleSeed Calming Technologies LLC of Columbus, Ohio to distribute the patented product nationwide.

As an “intrapreneur,” Hess has developed her innovative idea while continuing to work clinically at Cincinnati Children’s. She received $200,000 in internal innovation grant funding, as well as $50,000 through the 2019 Johnson & Johnson QuickFire Challenge and additional funding through the state of Ohio’s Technology Validation and Start-up Fund . Today, she works in both a clinical role and an innovation role within the health system. She is also collaboratively developing a program to support front-line clinical innovation.

“There are so many different things that you can do in nursing, and you can work to shape your career to be what you're most passionate about and what you love,” Hess said. “When I was in nursing school, I never considered or even heard of being a nurse innovator, but now it’s become my passion, and what I’m super excited to do every day.”

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The nurse scientist working at the intersection of climate change and health equity..

Roxana Chicas, PhD, RN, is an assistant professor in the tenure track at Emory’s School of Nursing, where she conducted the first field-based intervention study examining methods to reduce core body temperature and improve health among farmworkers in the U.S. using real-time biomonitoring equipment.

Chicas is a bilingual, bicultural investigator – and her path to nursing wasn’t a straight one. She immigrated to the United States from El Salvador as a child, where she was undocumented before receiving temporary protected status that allowed her to work in the U.S., which she did in lieu of graduating high school.

She began working in a pediatric office as a billing administrator, and became an unofficial interpreter for patients and families, which gave her an initial taste of working in the healthcare field. One of the doctors with whom she worked helped her pursue nursing, and today, she brings important perspective to solving public health challenges exacerbated by climate change.

In the last year, Chicas and her team have been working on developing a biomedical patch to be worn on the chest and monitor the physiological response of heat exposure.

“The idea is that eventually, this patch will be able to predict when someone is heading into heat exhaustion and set off an alarm, so that farmworkers – or any outdoor worker – can take a break and cool down before going back to work,” she said.

They currently have data on 50 construction workers and are planning to collect data with 100 farmworkers in Florida this summer.

“Nurses and future nurses who want to conduct research and improve community health should know that they are needed. I don't want anyone to feel intimidated by research,” she says. “I see the energy, the motivation, and the commitment of nursing students to achieve health, equity, and be visionary nurse leaders and scholars. They will guide our country and the world to a more equitable society.”

Nurses & Groundbreaking Startups

The nurse entrepreneur making social services accessible for families..

As a hospital-based nurse, Kwamane Liddell, JD, MHA, BSN, saw how important social services are for patients to remain healthy. From access to food, to housing or transportation support and beyond, Liddell saw firsthand the gaps that existed when patients and communities didn’t have access to the resources they needed.

image of Nurse Entrepreneur Kwamane Liddell

Liddell also saw the potential of technology to solve accessibility gaps. This insight led him first to create Nutrible, a technology platform that helps healthcare providers connect patients with healthy food aligned with their medical and cultural needs. Today, Nutrible has evolved into ThriveLink, an AI-powered startup empowering families to sign up for programs like health insurance, food stamps and utility assistance by verbalizing their answers to application questions.

Rather than filling out forms – which present challenges for those with language barriers, literacy challenges, or conditions that make reading or writing difficult, individuals can hear and respond to application questions verbally, expanding access to needed services.

“To me, being a nurse means changing the lives of people who need it most,” Liddell said. “We can make an impact in so many ways, whether it be at the bedside, or in policy and technology, we have the ability and the knowledge to change the world.”

His advice for nurses interested in entrepreneurship, innovation and community health: “Think big but take small steps. I learned things at every step of my journey, and the steps built on each other. That’s enabled me to make a big impact.”

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This special issue is in keeping with the mission of intervention research in social work; "to generate high-quality evidence on the effects of social work interventions" (Soyden, 2010, p. 457). This issue is the result of that special call. To be selected for the special issue, manuscripts were subjected to the usual peer-review process ...
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Research on Social Work Practice (RSWP), peer-reviewed and published eight times per year, is a disciplinary journal devoted to the publication of empirical research concerning the assessment methods and outcomes of social work practice. Intervention programs covered include behavior analysis and therapy; psychotherapy or counseling with individuals; case management; and education.
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The purpose of this article is to review substantive and methodological advances in interventive research. Three substantive advances are discussed: (a) the growing use of a risk factor perspective, (b) the emergence of practice-relevant micro social theories, and (c) the increased acceptance of structured treatment protocols and manual.
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Abstract This article traces themes over time for conducting social work research to improve social work practice. The discussion considers 3 core themes: (a) the scientific practitioner, including different models for applying this perspective to research and practice; (b) intervention research; and (c) implementation science. While not intended to be a comprehensive review of these themes ...
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Practice researchers need to develop expertise in multiple methods to respond flexibly to the demands of intervention development and evaluation in social work practice research. 社会工作实践研究需要多元主义方法论, 使研究者能够回应不同实践为本的问题, 特别有助于开发和评估让社会工作者在多种 ...
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The purpose of this article is to review substantive and methodological advances in interventive research. Three substantive advances are discussed: (a) the growing use of a risk factor perspective, (b) the emergence of practice-relevant micro social theories, and (c) the increased acceptance of structured treatment protocols and manual. In addition, three methodological developments are ...
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When social workers draw on experience, theory, or data in order to develop new strategies or enhance existing ones, they are conducting intervention research. This relatively new field involves program design, implementation, and evaluation and requires a theory-based, systematic approach. Intervention Research presents such a framework.
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Effectiveness of social work intervention research: Internal versus
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This is a promising development in view of findings suggesting there is a dearth of intervention studies in social work (Fraser, 2003; Jenson, 2005; Rosen et al., 1995). More intervention research by social work investigators is needed to contribute to the knowledge base of efficacious prevention and treatment approaches.
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Intervention Research in Social Work Haluk Soydan1 Research on social work practice is a complex enterprise. It may involve studies of value systems, human relations, ethical issues, legislation, organizational structures, and clinical experiences. The core of social work practice is change. Social workers aim to change life parameters and ...
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The standard review-of-outcome research (Eysenck, 1952, 1961, 1965) has tended to approach the literature methodologically—i.e., by considering various studies in terms of the validity of inferences that might be drawn on the basis of the results they present.Methodologically speaking, two points are pertinent to therapeutic interventions in social work (more specifically, with respect to ...
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During 2015-2017, we conducted three pilot studies of the intervention groups to research how participating social workers reflected upon and utilized theories when reviewing qualitative research (Muurinen & Kääriäinen, Citation 2020). The first group was in a social work agency serving adults where Heidi Muurinen worked as a team manager.
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Contextual barriers and enablers to establishing an addiction-focused
We interviewed 28 staff members from the three hospitals participating in the START study. Table 2 reports the number of participants by site and role, in addition to the response rates for each site and overall (52.8%). Across sites, the most common interviewee role was attending physician (n = 10), followed by social worker (n = 7), administrative leader (n = 6), and nurse (n = 5).
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Professor Maria Lohan is Chair in Social Sciences and Health, UNESCO Chair in Gender Equality and is a consultant to the WHO Department of Sexual and Reproductive Health and Research. ... and implementing evidence-based educational and health care interventions, such as comprehensive sexuality education in schools and prisons to engage men and ...
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Johnson & Johnson has proudly championed the nursing profession for over 125 years because we know that for healthcare to work, it takes nurses. This National Nurses Month, we celebrate the innovation, expertise and tremendous impact of more than 4 million nurses across the U.S. Below, meet four inspiring nurses dedicated to transforming the health of their patients and communities ...
A systematic review of parenting interventions used by social workers
The search was limited to literature written in English and based on research undertaken in the area of social work in the United Kingdom. Searches started from January 2009. The rationale for starting in 2009 is that our principal research focal point is on the contemporary research evidence available on social work and parenting interventions.