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Evidensbaserat Socialt Arbete: Från Idé Till Praktik Evidensbaserat socialt arbete: Från idé till praktik Kajsa Svanevie Umeå universitet/Umeå University Institutionen för socialt arbete/Department of Social Work Umeå 2011 This work is protected by the Swedish Copyright Legislation (Act 1960:729) ISBN: 978-91-7459-319-8 ISSN: 0283-300-67 Omslag: Pär Andersson Omslagsbild: Kajsa Svanevie Elektronisk version tillgänglig på http://umu.diva-portal.org/ Tryck/Printed by: Print & Media Umeå, Sverige 2011 Historien erbjuder såvitt jag vet aldrig någon väg tillbaka. Det finns inga pendelrörelser som innebär att utvecklingen rör sig fram och åter. Utvecklingen rör sig alltid framåt, även om detta naturligtvis inte alltid, eller långt ifrån alltid, innebär framsteg. (Bengt Börjeson) i Svanevie, Kajsa, 2011: Evidensbaserat socialt arbete: Från idé till praktik. (Evidence-based social work: From idea to practice). Monograph. Language: Swedish, with a summary in Eng- lish. Umeå University, Department of Social Work, SE-901 87 Umeå, Sweden. Doctoral Dissertation at the Faculty of Social Sciences. ISBN: 978-91-7459-319-8 ISSN: 0283-300-67 Abstract As an innovation Evidence-Based Practice (EBP) is designed as a tool for clinical problem solving. According to its theory of use EBP will bring a difference for policy makers, for professionals, for researchers and for service users. One question to be asked is whether EBP actually leads to the radical social change it is designed to accomplish. The aim of the study is to describe and analyse the outcome of the effort to establish EBP, with a focus on the case of social work in Sweden. The research questions are: What is EBP? Why are efforts made to establish EBP? What is the outcome of the EBP project? How can the outcome of the EBP project be explained? The case study was conducted on a critical realistic meta-theoretical ground with a focus on explanation of social change with an explicit actor-structure perspective. Methodologically, a narrative synthesis of studies was made. As a complement primary data were collected to fill empirical gaps. The state of things was described before and after the EBP-initiatives. Several helping theories – Kuhn’s theory of paradigm, program theory, neo-institutional theory and theory of diffusion – were used to analyse the empirically mapped outcome of the EBP project. The results show that the import of the original model of Evidence-Based Medicine (EBM) to social work is a part of a wider social movement in the helping and educational professions. The new model has influenced social work as a discipline, as a field of practice and as a field of policy. There are examples of full-scale implementations of EBP, although EBP has not reached a general status as daily practice. Some obstacles remain. The gradual adaption of EBP corresponds to criteria hold by Kuhn for a paradigm shift. Acceptance of the model has contributed to change the structure and function of social systems. At an organizational level, this change means on-going institutionalization. The innovation is influencing the way institutional actors conduct their work. Although the structural conditions have been optimal, the EBP-model has been debated with heat. The EBP-debate and policy- driven infrastructural efforts have brought a more in-depth examination of the model. So-called coercive, normative, and regulative isomorphisms were used to change organizations. The degree of institutionalization depended on the individual’s and the organization’s willingness and preparedness to change, to understand, and to put the model into practice. When actors used a less strict version of the original EBP model, the pace of cultural and institutional change slowed down. Keywords: Evidence-based practice, social work, critical realism, narrative synthesis, actor- structure perspective, contextual model, paradigm shift, program theory, neo-institutional theory, isomorphism, diffusion, innovation, social change, social mechanisms, learning organization. ii iii Använda förkortningar AASW: The Australian Association of Social Workers, Australien. ANSWER: The Action Network for Social Work Education and Research, USA. ART: Aggression Replacement Training. ASI: Addiction Severity Index, system för bedömning och uppföljning inom området vuxna missbrukare. BBIC: Barns Behov i Centrum, system för bedömning och uppföljning inom området barn och unga. CEBSS: Centre for Evidence-based Social Services, England. CSWE: The Council of Social Work Education, USA. EPPI-Centre: Evidence for Policy and Practice Information and Co-ordinat- ion Centre, England. FinSoc: Utvärdering av Social Service, under STAKES, Finland. FoU-enheter: Forsknings- och Utvecklingsenheter. HO: Handikappomsorgen. IFO: Individ- och familjeomsorgen. IMS: Institutet för utveckling av Metoder i Socialt arbete (eng. The Institute for Evidence based Social Work), under Socialstyrelsen, Sverige. KUBAS: Kunskapsbaserad Socialtjänst, projekt Sverige 2003-2005. LVM: Lag om vård av missbrukare. LPT: Lag om psykiatrisk tvångsvård. LVU: Lag om vård av unga. MST: Multi Systemisk Terapi. NHS: National Health Service, motsvarande svenska Socialstyrelsen, Eng- land. NICE: National Institute for Health and Clinical Excellence, England. NISW: National Institute for Social Work. PALS: Phonological Awareness Literacy Screening. PMTO: Parent Management Training. RiP: Research in Practice. SBU: Statens Beredning för medicinsk Utvärdering, Sverige. SCIE: The Social Care Institute for Excellence, England. SoS: Socialstyrelsen, Sverige. SOU: Statens Offentliga Utredningar. SSWR: the Society for Social Work and Research, USA. STAKES: National Research and Development Centre for Welfare and He- alth, motsvarande svenska Socialstyrelsen, Finland. TFSW: Task Force on Social Work Research. WHO: Världshälsoorganisationen. ÄO: Äldreomsog. iv v Innehåll Abstract ii Använda förkortningar iv Innehåll vi Förord x 1. Inledning 1 1.1 Syfte och frågeställningar 1 1.2 Disposition 2 2. Metateoretiska utgångspunkter 4 2.1 Grundantaganden om verklighet och kunskap 4 2.2 EBP i ett aktör-struktur-perspektiv 5 2.3 Sammanfattning 7 3. Metodologi 8 3.1 Sammanfattning 10 4. Metod 11 4.1 Narrativ syntes 11 4.1.1 Datainsamling 12 4.1.2 Abduktion 13 4.1.3 Retroduktion 16 4.2 Metodologiska reflektioner 17 4.3 Sammanfattning 18 5. Teori 19 5.1 Paradigm och programteori 19 5.2 Institutionalisering: Isomorfism 21 5.3 Diffusion 22 5.3.1 Översättningar och paketeringar 24 5.4 Sammanfattning 24 6. Evidensbaserad medicin 25 6.1 Cochrane 25 6.1.1 Genomslaget av Cochranes idéer 26 6.2 Chalmers 28 6.3 The Evidence-based Medicine Group 29 6.3.1 Lanseringen av EBM 30 6.4 Sackett och programskriften för EBM 31 6.4.1 Utbildning för EBM 33 6.4.2 Forskning för EBM 34 6.4.3 EBM-modellens idéelement 35 6.5 Implementering – exemplet Storbritannien 35 6.6 Debatt och kritik 37 6.7 Några nedslag i utfall av EBM-etableringen 38 6.8 Sammanfattande kommentar 41 vi 7. Idéöverföringen från medicin till andra fält 42 7.1 Smith och The Royal Statistical Society 42 7.2 Chalmers och Peckham 43 7.2.1 Inledande workshops 43 7.3 Campbell Collaboration: Uppbyggnad och sammansättning 44 7.3.1 Sponsorer, volontärer och partnerskap 45 7.3.2 Soydan 47 7.4 Sammanfattande kommentar 48 8. Evidensbaserad policy 49 8.1 Campbell 49 8.2 Några ord om metaanalys 50 8.2.1 Pawsons metodinlägg 51 8.3 Exempel på idégenomslag 52 8.4 Sammanfattande kommentar 54 9. Om EBP-etableringen inom olika fält 55 9.1 Utvecklingen i korthet 55 9.2 Sammanfattande kommentar 59 10. Förklaringar till EBP-etableringen 60 10.1 EBP som en produkt av sin tid 60 10.1.1 Behov av politisk legitimitet 62 10.1.2 Behov av professionellt kunnande 63 10.1.3 Behov av vetenskaplig legitimitet 64 10.2 Sammanfattning 65 11. Om socialt arbete 66 11.1 Definition 66 11.2 Socialt arbete som görande 67 11.2.1 Kontextens betydelse 69 11.3 Socionomprofessionen och yrken i socialt arbete 69 11.3.1 En internationell utblick 69 11.3.2 Sverige 69 11.4 Socialt arbete som ämnesområde 72 11.4.1 En internationell utblick 72 11.4.2 Sverige 73 11.5 Om professionell osäkerhet 75 11.6 Sammanfattande kommentar 76 12. EBP-etableringen i socialt arbete 77 12.1 USA 77 12.1.1 Gambrill och Gibbs 78 12.1.2 Amerikanska forskare för EBP – Några exempel 80 12.1.3 Partnerskap universitet-socialtjänstpraktik 84 12.1.4 Fokus på den lärande organisationen 86 12.1.5 Framväxande utfall 87 12.2 Storbritannien 89 vii 12.2.1 Macdonald och Sheldon 89 12.2.2 Uppbyggnad av infrastruktur 90 12.2.3 Brittiska forskare om EBP – Några exempel 93 12.2.4 Framväxande utfall 97 12.3 Australien 98 12.4 Kina och Japan 100 12.5 Ytterligare nedslag i Europa 101 12.5.1 Tyskland 101 12.5.2 Schweiz 102 12.5.3 Nederländerna 103 12.6 De nordiska länderna 104 12.6.1 Norge 104 12.6.2 Danmark 106 12.6.3 Finland 108 12.6.4 Island 109 12.7 Sammanfattande kommentar 110 13. Sverige 112 13.1 CUS 1993-2004 112 13.1.1 Tengvald 114 13.2 Ett nationellt program 2000-2005 116 13.2.1 Wigzell och Pettersson 118 13.2.2 Inför programgenomförandet 120 13.2.3 Perspektiv på EBP-satsningen 120 13.2.4 Fullskaleförsök 130 13.3 IMS 2004-2008 134 13.3.1 Sundell 136 13.3.2 Om verksamheten 138 13.4 Utredning om EBP inom socialtjänsten 2008 141 13.4.1 Wigzells pressmeddelande och Soydans kommentar 143 13.5 EBP i daglig praktik – Ett försök 2008-2009 144 13.6 Oscarssons skrift om EBP 2009 146 13.7 IMS 2009-2010: Startpaket och avslut 148 13.7.1 Professorsinlägg 2010 150 13.8 Plattformsarbete för EBP 2009-2010 152 13.8.1 FoU-nätverk och myndighetsnätverk 154 13.8.2 På väg mot EBP 2011 155 13.9 Diskussioner och kontroverser om EBP 157 13.9.1 Debattinlägg om EBP-satsningen 157 13.9.2 Inlägg om RCT 161 13.9.3 Debatt om riktlinjer 163 13.9.4 Om effektstudier i socialt arbete 166 13.10 Framväxande utfall 167 13.11 Sammanfattande kommentar 175 viii 14.
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