10.1177/1049731504269581WORK RESEARCH ON SOCIAL PRACTICE Gilgun / FOUR CORNERSTONES OF EVIDENCE-BASED PRACTICE The Four Cornerstones of Evidence-Based Practice in Social Work Jane F. Gilgun University of Minnesota���Twin Cities The purpose of this article is to place evidence-based practice within its wider scholarly contexts and draw lessons from the experiences of other professions that are engaged in implementing it. The analysis is based primarily on evidence-based medicine, the parent discipline of evidence-based practice, but the author also draws on evidence- based nursing and evidence-based social work in the United Kingdom. It was found that the experiences of other practice professions have a great deal to offer social work practice. Similar to medicine, nursing, and our British col- leagues, U.S. social work practice will benefit from increased research activity, more widespread availability of reviews of research, on-line resources, and many more training opportunities. Similar to nursing administrators, social work administrators have the responsibility to allow social work practitioners the time and training to become familiar with research relevant to their practice. Keywords: evidence-based practice evidence-based medicine philosophies of science Evidence-based practice (EBP) is having a major impact in medicine, nursing, and other health care professions, both in the United States and internationally (Ciliska, DiCenso, & Cullum, 1999 Drake, 2003 Ferguson, 2003 Gambrill, 1999, 2001 Gray, 2002 Nathan & Gorman, 2002 Sheldon, 2001 Webb, 2001). Within social work, EBP is influential in some English-speaking countries, such as England and Australia. In the United States, EBP in social work is in its early stages. Some recent publica- tions describe its possibilities (Gambrill, 1999, 2001), advocate for standards (Rosen & Proctor, 2002), and sug- gest cautions (Witkin & Harrison, 2001). Though helpful, thesearticlesdo not placeEBP within itscontexts. In addi- tion, these authors do not draw lessons from the experi- ences of other professions with EBP. The purpose of this article is to present such an analysis and learn from the experiences of others. I based my analysis primarily on evidence-based medicine (EBM), the parent discipline of EBP, but I also draw on evidence-based nursing and evidence-based social work in the United Kingdom. From my analysis and reflections on the nature of social work practice, I conclude that EBP in social work rests on four cornerstones: (1) research and theory (2) practice wisdom, or what we and other professionals have learned from our clients, which also includes profes- sional values (3) the person of the practitioner, or our personal assumptions, values, biases, and world views and (4) what clients bring to practice situations. In addi- tion, based on my readings on the philosophy of science, I view evidence from any source as provisional, meaning understandings are open to modification as new evidence unfolds (Popper, 1969 Shaw & Shaw, 1997). Finally, I show that falsification���that is, a willingness to seek information that challenges our own understandings and an openness to contradictory evidence���is central to EBP in social work. Processes of falsification lead to inclusiveness and are a check on bias and blind spots, which is one of the main purposes of a scientific approach and a goal of EBP (Sheldon, 2001). EBM EBP originated within the medical school of McMaster University, Toronto, in the early 1990s (Evidence-Based Medicine Working Group [EBMWG], 1992). By definition, EBM involves the conscientious, explicit, and judicious application of best research evi- dence to a range of domains: clinical examinations, diag- nostic tests, prognostic markers, and the safety and effi- cacy of interventions whose purposes may be therapeutic, rehabilitative, or preventative, with thera- peutic interventions understandably getting most of the attention. 52 Author���s Note: Correspondence concerning this article should be addressed to Jane F. Gilgun, Ph.D., LICSW, School of Social Work, University of Minnesota, TwinCities,1404GortnerAve.,St.Paul,MN55108 e-mail:jgilgun@umn.edu. Research on Social Work Practice, Vol. 15 No. 1, January 2005 52-61 DOI: 10.1177/1049731504269581 �� 2005 Sage Publications

Besides best research evidence, EBM has two other elements: clinical expertise and patient values (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000 Straus & McAlister, 2000). Currently, EBM focuses primarily on locating and evaluating research evidence. In efforts to foster the application of best evidence to medical prac- tice, medical groups have developed journals and online resources that provide practice guidelines, reviews of research, and bibliographies (Bigby, 1998 Guyatt et al., 2000 McAlister, Straus, Guyatt, & Haynes, 2000 Sackett et al., 2000 Slawson, Shaughnessy, & Barry, 2001). Centers for EBM in a range of specialties exist throughout the world, most of which have Web sites. The EBMWG Web site (www.cebm.utoronto.ca) continually updates EBM (Sackett et al., 2000). EBM is laid out in a neat and orderly way, with a pains- takingly described set of five steps that compose its prac- tice, a list of questions to answer when following each of these steps, flow charts, a classification of evidence in terms of its relevance and value, and careful descriptions of blind, randomized clinical trials (RCTs) as the gold standard for deciding the efficacy of interventions (Guyatt etal., 2000 Sackettetal., 2000 Straus &Sackett, 1998). RCTs are called experimental designs in the social sciences. EBM relies heavily on quantitative indicators, such as confidence intervals, effect size, experimental event rate, control over event rate, and number needed to be treated to prevent one event. Guyatt et al. (2000) for the EBMWG recommended the quantification of both evidence and values, stating this is ���the most rigorous approach to mak- ing recommendations��� (p. 1839). Evidence about diag- nosis, prognosis, or harm can arise from other forms of research besides RCTs, including case studies and qualitative research (Berg, 2000 Glasziou, 1998 Godlee, 1998 Straus & McAlister, 2000). Evidence about the efficacy of interventions whose face validity is self-evident and whose withholding poses ethical issues do not require RCTs (Ellis, Mulligan, Rowe, & Sackett, 1995). Face validity means expert practitioners conclude that the intervention works and meets ethical standards. EBM requires giving up procedures and tests when evidence suggests that new approaches are safer, more efficacious, and accurate. For example, the cause of stom- ach ulcers was once thought to be stress or spicy foods, whereas today there is strong evidence that bacteria are the causative agents (Forman et al., 2001). As a result, treatment for stomach ulcers has changed. Research-based evidence informs but does not replace clinical expertise, which is the basis of judgments as to how research findings are used with individual clients (Guyatt et al., 2000 Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). Clinical expertise is the knowledge physicians have accumulated through their medical prac- tice in identification of patient���s state of health, in diagno- sis, and in the assessment of individual risk factors and potential benefits of possible interventions. In addition to clinical expertise, the application of research evidence to individuals requires knowledge of patients��� values (Guyatt et al., 2000). Patients��� values include the expectations, concerns, and preferences that patients bring with them. In using the term patient values, EBM has joined itself to person-centered medicine (PCM), where the term patient values is a core concept (Singer & Todkill, 2000). PCM is based on humanistic perspectives related to the work of Balint (1964), Rogers (1951), and nursing theorists Neuman and Young (1972), among others. A key aspect of PCM is the understanding and accommodation of patient values in clinical practice and the need for practitioners to be aware of their own val- ues (Singer & Todkill, 2000). Challenges Confronting EBM As this discussion suggests, contemporary EBM is a rational-technical model that also recognizes humanistic issues related to practice. Though clinical expertise and patient values are elements, the handbook on the practice of EBM (Sackett et al., 2000) and many other writings specific to EBM (cf., Browman, 2001 Friedland, 1998, Geyman, Deyo, & Ramsey, 2000 Guyat et al., 2000) focus attention on locating, evaluating, and applying research to clinical problems, with special emphasis on therapeutic interventions. Members of the EBMWG acknowledge that EBM has limitations (Guyatt et al., 2000 Sackett et al., 2000 Straus & McAlister, 2000). Limitations include not only underconceptualizations of patients���values and of physi- cians���clinical expertise, but also of how the personal per- spectives of physicians affect clinical practice. The chal- lenges that physicians confront in locating and using research evidence also limit the effectivenes of efforts to make medicine more evidence-based, meaning based on research. Finally, the effectiveness of EBM is difficult to document, though the importance of applying research evidence to practice is widely acknowledged as self- evident. Underconceptualization of patients��� values. At pres- ent, the EBMWG has expended little effort toward delin- eating the implications of what it means to incorporate Gilgun / FOUR CORNERSTONES OF EVIDENCE-BASED PRACTICE 53