Making evidence-based practice actionable in the social service context: experiences and implications of workplace education

Creating double-loop learning related to organizational evidence-based practice development

To achieve DLL in the workplace, the underlying governing variables (i.e. norms and values) driving actions must be exposed, visualized and reflected on by the individual actors involved. That is because “governing variables are the preferred states that individuals strive to ‘satisfice’ when they are acting” (Argyris, 1999, p. 9). So, to challenge the underlying governing variables in the studied context, the staff’s and managers’ assumptions regarding work content and their professional roles merit study in relation to EBP outcomes.

Creating effective double loops entails “teaching people how to reason about their behaviour in new and more effective ways [which] breaks down the defences that block learning” (Argyris, 1991, p. 5). Reasoning enhances processes of reflexivity, including examining personal assumptions, decisions, actions and interactions, and the assumptions underpinning organizational policies and practices (Cunliffe, 2016). This involves analyzing the consequences of own actions and criticizing unquestioned routines (Hallensleben et al., 2015).

To facilitate OL and change of action in workplace practice, explicit knowledge can be codified and recorded in manuals, procedures and documents (Prencipe and Tell, 2001; Basten and Haamann, 2018), like instructions for carrying out a task (Zander and Kogut, 1995). In our context, making knowledge actionable includes codification of the aims and knowledge of the EBP model (Figure 1) in the social service housing context. The generalization of knowledge in the EBP model is actionable only “if it informs the user how to create it in settings beyond those in which it was first created” (Argyris, 1999, p. 299). We will discuss how guided reflection, reasoning, new knowledge and codification of the EBP model during and after EBP workplace education helped create ongoing transformative reflexive processes and socialization, creating DLL and new knowledge-based EBP actions.

Analysis of empirical data

As one of the authors (Karina Tilling) has been professionally involved as manager of regional EBP development projects and in the design of interventions used as empirical material for this study, some reflection on the method and our roles as authors is required. In analyzing the material, the author Birgitta Schwartz acted as an outside interviewer not involved in collecting the empirical material in 2014–2016 and was not previously familiar with EBP development or the social service context. Karina Tilling informed Birgitta Schwartz about the EBP model and the social service sector, whereafter the authors jointly explored the empirical material from 2014 to 2016. This entailed constantly and collaboratively posing new questions about the material to extract key elements of the experience of learning about EBP model implementation in social services. As the insider responsible for collecting the empirical data, Karina Tilling conducted a first-order review of the data, while Birgitta Schwartz and Karina Tilling jointly conducted a second-order review based on a theoretical perspective on the raw data and first-order findings (Gioia and Chittipeddi, 1991). Karina Tilling engaged in participant observations and was able to provide first-hand accounts of her own sensemaking and that observed in others (Maitlis and Christianson, 2014). As a result of this joint sensemaking and analytical process, we conducted additional interviews in 2018 to understand how social service workers’ EBP learning process and workplace practice had evolved posteducation.

Example 1: Guided reflection reveals single-loop learning

A participant described a situation that arose each Tuesday morning at the group home. One care recipient woke up very early and immediately wanted help with breakfast. This created a dilemma as this person had very little time awareness, and serving breakfast right away would leave a long stretch of time until the next activity (leaving for work). However, the alternative of waiting for another hour to eat proved equally frustrating and anxiety-inducing. Both alternatives had been tried repeatedly, always resulting in stressful mornings.

In guided reflection, the strong governing variables of actions in practice (Argyris, 1999) – i.e. aiming to best meet needs – were exposed in dialogue as being obviously in conflict with the actions taken. New insights arose when staff were asked to take the service users’ perspective, and realized the consequences of differing and, therefore, unpredictable actions each morning, which in itself probably caused anxiety. Existing SLL actions (see Figure 3) were framed as part of the problem (Argyris, 1991). The new insights, gained through individual reflexivity, as in Example 1, furthered constructive group discussions focusing on how to better support independence and meet the service user’s needs. Core EBP model content and aims were directly related to the staff’s own empirical examples, jointly reflected on during the educational sessions and over time and at the group level developed into DLL processes. Also, new knowledge-based actions were suggested and discussed based on the outcomes of the dialogues on governing variables, relevant knowledge sources and the professional roles at the workplace. Related to Example 1, actions taken by the participants included trying out time awareness support for the service user and developing common work routines.

Example 2: “Experts at being close” – recognizing own professional value

Defining work content and professional roles among staff turned out to be key in developing an EBP approach at the workplace. In an early discussion, the participants were asked to reflect on and describe their own roles in the support and service given to service users. The staff viewed their roles as performing different tasks in assisting the residents. Getting through the day’s tasks, and not doing anything wrong was highlighted as important.

Staff described themselves as having inferior professional status; for instance, they related that they did not want to approach the service user’s doctor to discuss observations related to new medications/dosages. This professional interaction was “not an option” because they had inferior academic education and lower work status. They devalued the relevance of their own observations. In guided reflection during the education sessions, they realized that different professions contribute different knowledge, experiences and perspectives, and jointly support the service user. Also, the important features of their own profession in relation to the EBP model were explored and gained prominence over time. The DLL processes on coding EBP content started evolving during education (Figure 4), leading to a redefinition of work content and the development of professional self-confidence. One staff member said, “We’re the experts at being close!” (Education session, 2015-04-29). Hence, redefining the governing variables (Argyris, 1999) of the professional role was key in opening up for new EBP-based actions in workplace practice.

Example 3: “Connecting the dots” – codifying the evidence-based practice model

Example 3 relates to the codification of the EBP model. An EBP form designed by the local management for disability care, codifying the EBP model and guiding knowledge-based actions related to a service user’s needs and desires, had already been available for some time before the education started. The form included: guiding questions on/instructions for defining specific needs/desires, collecting and analyzing relevant information and describing a suggested intervention; a strategy for implementing the suggested intervention; and an evaluation of intervention experiences to improve the outcome. Despite its practical aspects, the form was not extensively used by staff in their daily work. Moreover, regularly updating the mandatory individual implementation plan on care and support (National Board of Health and Welfare, 2014; SOSFS, 2014, p. 5) for each service user was described by participants as a time-consuming, solitary and tricky work task that had to be performed every year. When discovering the usefulness of the EBP form in mapping and identifying specific individual challenges to explore and try out relevant knowledge-based interventions, one participant said:

Oh, now I see how this could make my work on the individual plan update a routine matter – and not add to my workload every year! (Education session, 2015-06-10).

The participant connected the “dot” of the mandatory individual plan to the “dot” of the EBP form, which is based on the EBP model, creating a meaningful whole of new professional, knowledge-based planning and evaluation action. Thus, the DLL process evolved as the defences blocking learning were broken (Argyris, 1991). The connections between the two documents on meeting service users’ needs/desires suddenly became obvious, contributing to DLL. The governing variables (Figure 5) of work content and aims became objects of reflection and reconstruction, contributing to a game-changing shift in professional self-definition, going from correctly performing given tasks to creating knowledge-based individual support, using EBP-based content to initiate and guide new actions.

Results of education in practice: evidence-based practice as a guide for actionable knowledge

The joint efforts of staff and managers, in approaching service user challenges during the education, contributed to a common and socialized view of EBP content and the professional role at the workplace. A changed mindset and a more exploratory way of thinking and working as a team in supporting the service user were frequently mentioned as gains (Oral/written evaluations, 2015-09-16, 2016-06-08). The guided discussions contributed new insights, as participants acknowledged their own professional roles, focused on the service users’ perspectives and explored relevant knowledge sources. Also, new practical skills in evaluating individual interventions using a simple table (including date/time, result of intervention and service user’s reaction) were created together with participants during the education. The table functioned as a codification of EBP knowledge and was tested in workplace practice. It was well-accepted as a tool, and in course evaluations, the participants related that they frequently used it in their daily work. Knowing how and why to work in a certain way and keeping up with new knowledge and insights was likewise seen as a crucial gain from education:

Very large gains: you can now get results that can be measured, follow-ups are performed as decided, the service users can more easily achieve their goals, staff see positive results, which is very encouraging, and you are able to switch focus if something doesn’t work – this generates results. (Written evaluation, 2016-06-08)

The following global positioning system (GPS) metaphor illustrates how one first-line manager’s new cognitive map was communicated to staff (Crossan et al., 1999; Maitlis and Christianson, 2014) after the education:

EBP is our GPS, our way of working that takes us from point A […], which is the service user’s needs and desires, to point B, which is goal completion and the wellbeing of the service user. On this journey, we should use knowledge and, together with the service user, find the most effective ways to reach goals. EBP is an approach that creates our professionalism. (Written evaluation, 2016-06-08)

The manager’s codification and shared understanding of EBP as a GPS stimulated further organizational DLL (Argyris, 1977, 1991; Avby, 2018) by illustrating a new outline of work based on the governing variables (Argyris, 1999) of the EBP model. The process contributed to the socialization of new professional staff and manager roles, enabling the institutionalization (Crossan et al., 1999) of EBP at the workplace. Three years after the first education, one first-line manager described an integrated approach to EBP implementation using quality meeting time to discuss and complete the EBP form jointly as a team, with the form functioning as a common structuring device for meetings:

The EBP form is important – without a tool you tend to rely on your personal values, which is devastating. (Interview, 2018-06-11)

Staff from both workplaces described being able to identify and understand individual service users’ desires. They saw this as a new skill they had gained from participating in the education. Both the EBP form and the simple evaluation table were described as useful in developing and socializing knowledge-based practice. Overall, the education was described as an eye-opener, helping participants observe and be alert to individual service users’ needs. “Maybe we should do an EBP on this” became a common expression at the workplace when experiencing uncertainty about how to meet a service user’s needs (Interview, 2018-06-11). The EBP form provided guidelines for repetitive actions (Prencipe and Tell, 2001).

Important features of the DLL learning transfer processes, making EBP actionable in workplace practice, are illustrated in Figure 6. New governing variables of EBP work and professional roles were developed in DLL processes at both individual (staff, manager) and group levels (staff-manager teams). This process was facilitated by supervision during education sessions, connecting individual experiences with group reflection. Both coding of EBP knowledge (e.g. EBP form, structured dialogue at meetings) and socialization (use of EBP form/table during meetings; collegial support/exchange of experiences) were crucially important in developing individual and group DLL and knowledge-based actions. In turn, this had positive effects on workplace practice (design and content of support, increased transparency and consistency with law), benefiting the service user.

In sum, the long-term effects of education are the establishment of a socialized EBP platform, including a common understanding and language (Crossan et al., 1999) and ongoing joint learning processes at work.

Professionalization processes making way for novel approaches

Knowledge-based inquiries, based on service users’ needs/desires, were developed in the educational sessions with the reflective support of the educators and staff themselves. During these learning processes, new cognitive “master programs” (Argyris, 1991) for the own profession and work emerged, governing new and knowledge-based behavior at the individual level. From an organizational perspective, these results indicate a paradigm shift from caregiving to a professional supportive paradigm. The new paradigm, based on new individual cognitive master programs, focused on the needs/desires of the service user and was guided by the knowledge-based inquiry approach taught and practiced. By contrast, the caregiving paradigm had come with a limiting SLL approach focused on performing given tasks and correcting performance errors. With the reframing of the work content to a professional supportive paradigm, reflecting on, trying out and analyzing the results of knowledge-based interventions (jointly with the service user and as a team) developed into DLL and gradually became the new work logic.

Becoming a professional

In this study, the underlying idea of the EBP model (Figure 1) has proven difficult to relate to in social service practice. However, a crucial finding is the importance of learning to recognize the own professionalism, including the professional expertise of being close to the service user. This finding has implications for the content and design of future EBP education initiatives. Also, basic research skills taught in higher education, including methodological awareness, critical thinking and formal writing, are often lacking in social services, yet are both assumed and useful in EBP practice. Based on our findings, we advocate embracing the professional role and expertise of social workers, in parallel with practical training in knowledge-based ways of working when implementing EBP in practice.

Building a new frame of reference for work content

Staff and managers participating in the educational sessions and working jointly on a case between sessions created a common base for questioning existing socialized actions (Argyris, 1991), enabling a new shared EBP frame of reference for their own practice. An important outcome of these DLL processes (Argyris, 1991; Argyris and Schön, 1978) was a new framing of the work content, including recognition of the need to collect and use knowledge about the individual service user’s situation. This developed as a result of actively exposing the underlying governing variables (Argyris, 1991) guiding existing actions, and then reflecting on, questioning and redefining them collectively in a secure training environment, where participants’ own examples of difficult situations were shared and explored in guided discussions, promoting evidence-enriched practice (Andrews et al., 2020).

These guided reflections on current ways of working and discussions of alternative approaches became game changers. Generating personal experience of knowledge-based inquiries, starting by defining the needs/desires of individual service users and systematically using dialogue, reflection and evaluation as tools, made the EBP model actionable. In tandem with the participants redefining their own professional roles, the experience enabled new DLL in the team on how to meet service users’ needs/desires.

After the education, some DLL processes were continued during regular meetings at work. These meetings constituted important arenas for further facilitating team thinking, reflection and action, in turn building a new frame of reference for knowledge-based work over time. Some supportive organizational features (“infrastructural devices”) proved crucial. The EBP form and the customizable table for both systematically mapping individual service user information and evaluating results are two tools frequently described as useful in translating the EBP model into practice. Using these tools after the education also helped staff engaging in more autonomous decision-making and practice to step back from their own personal values (Plath, 2014; Prencipe and Tell, 2001; Zander and Kogut, 1995). As a result, new, bottom-up, ideas for designing and providing individual support have been put into practice. Besides resulting in knowledge-based interventions for individual support, ongoing DLL processes are also stimulated in work practice, creating a new institution (Lawrence and Suddaby, 2006) where EBP becomes more habituated (Reay et al., 2013) at the workplace.

Organizational support in establishing evidence-based practice

In the studied organizations, implementation of the EBP model and the workplace education were mandatory top-down initiatives; and higher-management support signaled their importance. Research has demonstrated that such top-down implementation can be detrimental to practical results deriving from EBP education (Mullen et al., 2008); however, once initiated, the new way of conducting work, along with the achieved DLL, required continuous management support and guidance to be sustainable and develop further over time. The first-line managers’ use of the EBP form at meetings and in daily work outlined the managers’ new supervisory role in EBP processes and highlighted daily obstacles that required guidance. Introducing a new idea (the EBP model) entailed replacing old meanings (Pratt, 2000) to change practice, connecting organizational-level ideas and microlevel practices (Reay et al., 2013).

Managers influencing the creation of new meaning by staff and supporting them in understanding the benefits of new working approaches (Gioia and Chittipeddi, 1991; Maitlis and Christianson, 2014) applied managerial strategies to break down EBP content into a workable EBP form and provide active guidance for use at the workplace. Such on-the-job coaching massively accelerates individual knowledge acquisition and the ability to use new skills (Fixsen et al., 2005). The effects for managers include a change in the language used and a new awareness of the use of evidence in decision-making (Champagne et al., 2014). The new first-line manager role includes facilitating EBP solutions and acting as a chief knowledge officer in the EBP codification process (Jones et al., 2003). Our study shows that supervision skills, enabling critical reflection and actively stimulating DLL processes jointly with staff, are other useful managerial competencies.

The importance of double-loop learning processes in evidence-based practice implementation

National evaluations have shown that the EBP model is difficult to implement in social service practice. Organizations can be viewed as arenas for ongoing organization, interaction and relations involved in understanding documents and plans (Larsson et al., 2001; Löwstedt, 2018), such as the EBP model. As illustrated by our results, implementation of the EBP model can be dependent on how its content is understood and (perhaps more importantly in relation to education) made to be understood, codified and socialized among the managers and staff in both of the studied workplaces. The ongoing, bottom-up, DLL processes, in turn, formed the basis for developing actionable knowledge in daily practice.

As working with people is dependent on experiencing and learning both in and from lived situations (Bornemark, 2020), the experiences of thinking and practicing knowledge, the new ways of approaching work content and the establishment of teamwork in defining knowledge-based ways to support the individual have proven necessary in establishing new, EBP-based, professional action. Overcoming staff members’ initial fear of doing wrong was another crucial barrier, addressed here by joint exploration while amassing experience. Our study illustrates how knowledge develops from doing, by exposing underlying governing variables (Argyris, 1999) and putting them into words and by integrating knowledge of what should be done with knowledge of how it should be done (Avby, 2018), based on praxis knowledge (Bergmark and Lundström, 2002; Horder, 2007).

This study identifies obstacles to translating the abstract EBP model into social service practice. Yet, building a new professional frame of reference, both during education and continuously afterwards, has proven to be important in making the content of the EBP model actionable in practice. Altogether, the bottom-up development of the contextually relevant and actionable knowledge of EBP has proven to be a productive way of establishing new sustainable, knowledge-based practice in the social service context.