Evidence-based practice and management-by-knowledge of disability care: rigid constraint or fluid support?

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  • 1 University of Gothenburg, , Sweden
  • | 2 Jönköping University and Bräcke Diakoni, , Sweden
  • | 3 Vrije Universiteit Amsterdam, , Netherlands
  • | 4 University of Gothenburg, , Sweden
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Background:

Although increasingly accepted in some corners of social work, critics have claimed that evidence-based practice (EBP) methodologies run contrary to local care practices and result in an EBP straitjacket and epistemic injustice. These are serious concerns, especially in relation to already marginalised clients.

Aims and objectives:

Against the backdrop of criticism against EBP, this study explores the ramifications of the Swedish state-governed knowledge infrastructure, ‘management-by-knowledge’, for social care practices at two care units for persons with intellectual disabilities.

Methods:

Data generated from ethnographic observations and interviews were analysed by applying a conceptual framework of epistemic injustice; also analysed were national, regional and local knowledge products within management-by-knowledge related to two daily activity (DA) units at a social care provider in Sweden.

Findings:

In this particular case of disability care, no obvious risks of epistemic injustice were discovered in key knowledge practices of management-by-knowledge. Central methodologies of national agencies did include perspectives from social workers and clients, as did regional infrastructures. Locally, there were structures in place that focused on creating a dynamic interplay between knowledge coming from various forms of evidence, including social workers’ and clients’ own knowledge and experience.

Discussion and conclusions:

Far from being a straitjacket, in the case studied management-by-knowledge may be understood as offering fluid support. Efforts which aim at improving care for people with disabilities might benefit from organisational support structures that enable dynamic interactions between external knowledge and local practices.

Abstract

Background:

Although increasingly accepted in some corners of social work, critics have claimed that evidence-based practice (EBP) methodologies run contrary to local care practices and result in an EBP straitjacket and epistemic injustice. These are serious concerns, especially in relation to already marginalised clients.

Aims and objectives:

Against the backdrop of criticism against EBP, this study explores the ramifications of the Swedish state-governed knowledge infrastructure, ‘management-by-knowledge’, for social care practices at two care units for persons with intellectual disabilities.

Methods:

Data generated from ethnographic observations and interviews were analysed by applying a conceptual framework of epistemic injustice; also analysed were national, regional and local knowledge products within management-by-knowledge related to two daily activity (DA) units at a social care provider in Sweden.

Findings:

In this particular case of disability care, no obvious risks of epistemic injustice were discovered in key knowledge practices of management-by-knowledge. Central methodologies of national agencies did include perspectives from social workers and clients, as did regional infrastructures. Locally, there were structures in place that focused on creating a dynamic interplay between knowledge coming from various forms of evidence, including social workers’ and clients’ own knowledge and experience.

Discussion and conclusions:

Far from being a straitjacket, in the case studied management-by-knowledge may be understood as offering fluid support. Efforts which aim at improving care for people with disabilities might benefit from organisational support structures that enable dynamic interactions between external knowledge and local practices.

Key messages

  • Examining one case of disability care in Sweden, both social workers’ and clients’ experiences were included in EBP infrastructures.

  • In this study, Swedish EBP infrastructures functioned more like fluid support than a straitjacket.

  • Organisational structures that combine different knowledge sources at service providers can minimise the risk of epistemic injustice within social care.

Introduction

Sackett et al (2000) defined evidence-based practices (EBP) as the integration of evidence, professional experience and clients’ values within healthcare. This definition has also been widely adopted in the models of EBP within the field of social work. EBP has, during the last two decades, become an accepted means for improving social care as well as a cherished goal for many actors in the public sphere, and for numerous professionals as well (Eriksson and Karlsson, 2016). While few object to the need for knowledge from research, the usefulness and appropriateness of standardised interventions and randomised controlled trials (RCTs) that are often emphasised in EBP have been vigorously debated. Early proponents of EBP argued that those seeking social work services had a right to receive empirically evaluated treatments, and that it is unethical not to do so (Myers and Thyer, 1997). While many supported this idea, others objected that EBP’s focus on standardised interventions impinges oppressively on social workers’ professional autonomy to make decisions according to their practice-based expertise or wisdom, and that knowledge gained from RCTs is unhelpful for the complex problems that social workers grapple with (Addis et al, 1999; Witkin and Harrison, 2001; Wampold, 2015). The result, others claim, is a devaluation of clients’ knowledge, needs and values (Johansson et al, 2015).

In recent years, there have been many attempts to solve the issue of how to balance different knowledge sources (from professionals, clients and evidence) within EBP. There are now various ‘co-creative’ approaches that seek to include clients and professionals in knowledge production and implementation (Metz et al, 2019; Nicholas et al, 2019). Methods include: service user expertise in systematic review processes (Braye and Preston-Shoot, 2005; Synnot et al, 2018; Stewart et al, 2020); systematic ways to include knowledge from experiences held by clients (Bate and Robert, 2006); and creative approaches designed to avoid the pitfalls of linear research implementation. These latter focus on professionals and clients as innovators rather than as passive recipients of knowledge (Andrews et al, 2020). Such developments all aim to decrease potential injustice arising from imbalanced power structures which value knowledge from RCTs higher than professionals’ and clients’ knowledge. While these studies constitute a positive development within EBP, they do highlight that many challenges for a more optimal deployment of EBP in social work still exist (Andrews et al, 2020).

Sweden was an early adopter of EBP within social care (Gray, 2009), and this development was in line with Sweden’s long tradition of centralised social engineering. EBP was introduced in Swedish social work in the late 1990s (Bergmark and Lundström, 2006; Gray, 2009). A parallel development, in line with EBP, was an increased focus on evaluation of social work in research (Bergmark and Lundström, 2006). A significant event in this regard was release of the Government official report, ‘Evidence-based practice within social services – to the benefit of the user’ (SOU, 2008), which formed the basis of a number of interventions aimed at developing evidence-based social work. As with many other countries having strong welfare states, EBP in Swedish social work has been propelled along with a national infrastructure for both healthcare and social care – sometimes internationally translated as ‘management-by-knowledge’ (Kalkan et al, 2015; Sandberg et al, 2019; Jacobsson and Meeuwisse, 2020).

The term ‘management-by-knowledge’ denotes a centralised infrastructure created to support local providers of welfare services with knowledge in line with the ideals and methods of evidence-based practice and policy. Many social work scholars in Sweden and elsewhere have objected to this kind of operationalisation of EBP. Their main concern is that EBP has been implemented as a top-down, centrally-driven bureaucratic project within which social workers are expected to follow standardised procedures produced by governance agencies in the management-by-knowledge infrastructure (Otto and Ziegler, 2008; Gray, 2009; Johansson, 2019; Bergmark and Lundström, 2011). Such critics often describe EBP as an overly positivistic approach that relies on formal techniques and methods too rigid to encompass the complexity, uniqueness and unpredictability of the context of social work. Instead, social work is seen as needing to rely on the practitioners’ ability to establish trusting relationships with their clients, not primarily relying on specific methods and manuals (Trinder and Reynolds, 2000; Norcross et al, 2006; Johansson et al, 2015). Critics of EBP claim that the operationalisations of EBP have therefore constrained, distorted and disturbed social workers’ central practices and knowledge base (Bergmark and Lundström, 2011; Martinell Barfoed, 2018; Jacobsson and Meeuwisse, 2020).

According to these critiques, EBP can become oppressive, creating a power imbalance which values RCT evidence higher than professionals’ own experience and knowledge.

Further, the critique of the management-by-knowledge infrastructures is that these power imbalances become systematised in those infrastructures. Notwithstanding this critique, evidence and evidence-based practice have become important hallmarks of quality and legitimacy, and it is nearly impossible not to encounter them as a professional in Swedish social work. On the one hand, it is obvious that EBP has become well-established in social work in Sweden (Eriksson and Karlsson, 2016), in one sense. On the other hand, debates and some empirical studies have pointed to the lack of strong coupling between management-by-knowledge at a governance level and the actual practices of professionals in social work (Björk, 2016; Franzén, 2018). It still seems to be quite unclear how EBP is done in practice (Johansson, 2019).

As such, it is necessary to better understand how EBP is enacted at the different levels of the state-governed management-by-knowledge infrastructure. In the present study, data generated from ethnographic observations, interviews and national, regional and local knowledge products related to two daily activity (DA) units at a social care provider in Sweden were analysed, with the aim of exploring the ramifications of management-by-knowledge infrastructure for this social work setting. Against the backdrop of criticism regarding the potentially oppressive dimensions of EBP, the concept of epistemic injustice offers important analytic resources. By applying a conceptual framework of epistemic injustice, this study seeks to empirically examine what the interplay is between knowledge from evidence, professionals and clients in actual social care practices.

Epistemic injustice

A growing number of studies draw attention to the epistemic aspects of power asymmetries and injustice within EBP by using Miranda Fricker’s conception of epistemic injustice (2007). Fricker suggests that there are distinctively epistemic forms of injustice where persons are wronged in their capacity as knowers due to a dysfunction in the epistemic practices caused by an identifiable agent (Fricker, 2007: 1). In her theory, epistemic injustice falls into two main categories: testimonial injustice and hermeneutical injustice. Testimonial injustice occurs when a personal account is dismissed or not given appropriate credibility. In Fricker’s words (2007: 7) ‘someone is wronged in their capacity as a giver of knowledge’. This form of injustice is often due to identity prejudice (that is, a person’s membership in a marginalised group causes a devaluation of credibility where their accounts are seen as less competent and thereby less trustworthy). Testimonial injustice has been used in healthcare to describe situations where patients have unique experiential knowledge which is not given appropriate credibility (Greenhalgh et al, 2015; Crichton et al, 2017; Grim et al, 2019; Michaels, 2020). The category of hermeneutical injustice, by contrast, refers to the lack of epistemic resources by which experiences may become comprehensible to disenfranchised communities, as well as to others. Here, ‘someone is wronged in their capacity as a subject of social understanding’ (Fricker, 2007: 7). Hermeneutical injustice occurs when a lack of shared interpretative resources put a person at a disadvantage trying to make sense of his/her experience (Grim et al, 2019). The concept has been used extensively to highlight and analyse marginalisation of people with illness in general (Carel and Kidd, 2014), more specifically those with disabilities (Kalman et al, 2016; Scully, 2020) and mental health problems (Crichton et al, 2017; Tate, 2019; Grim et al, 2019). Certainly, every chosen procedure will include and exclude specific methods, studies and experts (thereby risking epistemic injustice for particular patients or clients). However, in discussions on EBP, the dominant claim is that the injustices inflicted are particularly harmful to certain vulnerable groups (Persad, 2017; Michaels, 2020). In the context of EBP, epistemic injustices have been pointed out in the methodologies of systematic reviews, RCTs, evidence-based policy processes (Michaels, 2020; Moes et al, 2020), medical decision making (Grim et al, 2019) and in care practices (Carel and Kidd, 2014).

The aim of this study is to explore potential epistemic injustice caused by the exclusion of important knowledge sources at different levels in the management-by-knowledge infrastructure operationalised in relation to a specific social care provider. We focus our analytical attention on the dynamics of epistemic interactions in the different levels of management-by-knowledge. Specifically, we use hermeneutical and testimonial injustice as guiding notions to sensitise our analysis to power dynamics between evidence, social workers and clients, within the knowledge practices of management-by-knowledge: are these practices (for example, methods, guidelines, routines and daily care practices) including or excluding important sources of knowledge from professionals and clients? How are professionals and clients recognised, or going unrecognised, as credible knowers?

Methods

Background of the current study

The data for this study are derived from the ethnographic phases of a larger multiphase project at a non-governmental social care provider. The source for these data is the initial explorative phase of the project and focused mainly on mapping the management-by-knowledge infrastructures related to two daily activity units at the provider. The provider chosen for this research is dedicated to becoming increasingly evidence-based. Additionally, the units selected are staffed predominantly by social workers without formal academic training. For the purpose of this study, exploring the operationalisation of EBP in the management-by-knowledge infrastructure through the lens of epistemic injustice, the provider and the units can be said to be a ‘critical case’, having ‘strategic importance in relation to the general problem’ (Flyvbjerg, 2001: 78).

Data collection

The data collection focused on mapping the infrastructures of management-by-knowledge and its consequences at a national, regional and local care level. Two of the authors (IP and AL) were given access to do observations at two daily activity (DA) units, an improvement course held by the provider, and meetings at the quality department of the care provider. The research was conducted during several periods across a total of 12 months between November 2019 and November 2020.

During the initial observations and interviews, the most significant issue that affected the DA units at that time was how to increase clients’ participation in their daily activities. Related to this specific issue we searched for relevant knowledge products by national and regional actors such as the National Board of Health and Welfare (NBHW), the Swedish Association of Local Authorities and Regions (SALAR), the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU), and the municipality. We identified key knowledge products within the management-by-knowledge that were highly relevant for the DA units: knowledge support from the NBHW (2017), information from Open Comparison (NBHW, 2020), and a procurement document from the municipality. Within these documents it was possible to trace management-by-knowledge for the specific issue of increasing clients’ participation that the DA units dealt with.

In addition to informal conversations during observation sessions, interviews were conducted with staff at the units, their supervising managers and their quality coordinator. Interviews were semi-structured and focused on themes relating to working cultures, knowledge sources and formalisations. Due to the vulnerability of the clients in these settings and the severity of their intellectual disabilities, we did not conduct interviews with individual clients. Instead, we observed the daily practices and the interplay between social workers and clients. The observations were written down in field notes soon after the observations had taken place. All interviews were audio recorded and transcribed.

Data analysis

Abductive analysis principles informed analysis of the qualitative data in this study. ‘Abduction’ refers to the process of producing theoretical hunches for unexpected research findings. The approach depends on iterative processes of working with empirical materials in relationship to theoretical literature, with a special focus on an openness to unexpected findings that can contribute to developing theory (Tavory and Timmermans, 2014).

The data were approached from a theory-driven perspective on epistemic injustice. First, the literature on epistemic injustice was reviewed. Since the discussions, debates and many empirical studies within the field of social work circulate around questions about power and injustice in relation to professionals and EBP, an epistemic injustice framework was deemed germane for sensitising our analysis and informing discussion. In particular, Fricker’s (2007) concepts, testimonial and hermeneutical injustice were chosen to provide a basis for the abductive analysis. Two main guiding questions were formulated in relation to these concepts: are the different knowledge practices within the chain of management-by-knowledge (for example, methods, guidelines, routines and daily care practices) including or excluding important sources of knowledge from professionals and clients? How are professionals and clients recognised or going unrecognised as credible knowers in these knowledge practices?

It is important to point out that the lack of data directly derived from clients imply limitations on what can be said about the epistemic justice of clients. However, by being immersed in the daily operations of the units, we believe that at least some aspects of injustice regarding clients would become visible, even if through their being silenced or excluded. Of course, lack of exclusion is not the same as inclusiveness, a nuanced topic of its own, measuring which is beyond the scope of the present paper. The transcripts, field notes as well as internal and external documents, were read several times in order to get a sense of the whole. Words and phrases related to the guiding questions were identified and highlighted. These initial insights were then followed by a period of shifting back and forth between data and theory and viewing them in light of each other. One of the core principles in abductive analysis is the sensitivity to unexpected empirical findings in relation to established theory. The analysis of the empirical data has therefore consisted in an iterative process of reading and analysing interview transcripts, field notes and documents, discussing the findings in the research group and continually gathering more data when needed.

Results

The results comprise the answers to the two main questions: ‘Are these practices (for example, methods, guidelines, routines and daily care practices) including/excluding important sources of knowledge from professionals and clients?’ and ‘How are professionals and clients recognised or going unrecognised as credible knowers?’, and are presented in three sections. The first section describes two key knowledge products from the central agencies of the Swedish knowledge infrastructure management-by-knowledge that were salient in the ongoing work of the DA units during the time of observations. Next, we will address the organisation of social care on a regional level. Finally, the third main section will be devoted to the local care practices.

Centralised management-by-knowledge

In this section, we will focus on the authoritative knowledge products of NBHW and SALAR, to explore if and how the EBP methodologies utilised by these agencies exclude clients and professionals.

The National Board of Health and Welfare: thwarted methodological domination

In 2017, the NBHW published a knowledge support that concerns intellectual disability care (NBHW, 2017). This agency did not find any research robust enough, according to the hierarchical pyramid of evidence and the methods of systematic reviews. The conclusion of the NBHW’s initial systematic review was simply that: ‘… there is not strong enough evidence to recommend individual methods and working methods in order to increase the participation of people with intellectual disabilities’(NBHW, 2017: 12). However, NBHW did not stop at the lack of studies at the top of the pyramid, but produced a knowledge support that focused on giving advice for social care on the central topic of participation (NBHW, 2017). In the knowledge support, four systematic knowledge processes were used. First, a consensus method was used by creating and consulting an expert group consisting of researchers, regional development leaders, and representatives of client organisations. Second, a survey was sent out to professionals. Third, a systematic mapping of research and regional developmental work was carried out. Fourth, a needs inventory was generated by drawing on focus groups with social workers and unit heads of providers. The NBHW then used these findings to give advice on methods for increasing participation. Due to the lack of rigorous studies, the report refrains from any strong claims about general methods, but highlights several methods and models that are currently in use and accepted among professionals (NBHW, 2017).

There was a lack of RCTs in NBHW’s systematic review, but this did not imply discrediting current social care practices. In this case, the NBHW went to great lengths to generate systematic knowledge about how to increase client participation by using a plurality of methods to capture knowledge from professionals and clients. The methodological domination of RCTs in systematic reviews was thwarted by systematic efforts to include professionals’ experiences and clients’ perspectives into the knowledge production in ways that go beyond narrow evaluations of knowledge from RCTs.

The national client survey: oversimplified measures

Another important role in management-by-knowledge is played by Open Comparisons organised by SALAR. It is published yearly, and its national client survey is published with it (NBHW, 2020). At the observed DA units, the yearly results of the open comparisons were important for planning where to focus their quality improvement work during the year. In the national user survey, there are a total of 11 items that focus on clients’ experience of involvement and participation in their daily activity service. A central item that clients are asked to answer reads: ‘Are you allowed to decide what things are important for you at your Daily Activity unit?’ (authors’ translation).

One significant feature of Open Comparisons and the national client survey is the fact that it gives clients a voice. It can thereby be understood as an attempt to include experiential knowledge from clients into management-by-knowledge. Of course, the survey’s 11 items formulated like this proffer a simplification of the complexities in the practices of DA units. Even so, such simplifications do align with the purpose of giving clients with intellectual disabilities one more voice in deliberations on care quality. Intellectual disabilities of clients can pose difficulties when it comes to evaluating their experiences in surveys. While the 11 items and the limited scope of the national user survey are simplifications, they may also be understood as necessary adjustments to clients’ level of understanding. At this level in management-by-knowledge, the yearly survey can be seen as an effort to build structures that systematically include knowledge from clients in central parts of management-by-knowledge. In this sense, clients are included as credible knowers. Of course, the fate of the survey data depends strongly on how they are put to work in regional and local care practices. In the next sections the uses will be explored.

Regional level of management-by-knowledge

In social work, the next link in the chain of management-by-knowledge consists in local uptake of reports and performance measures such as the knowledge support, manuals or standardised instruments. There are no sanctions against, or demands for, adherence to guidelines. There is, however, another option proposed for governance. In this case the operation of the DA units is publicly funded but regularly involved in procurement processes, in which the municipality decides on who will provide the care at the DA unit for the next couple of years.

Procurement processes: ‘methods must be evidence-based’

In these procurement processes, various providers offer their bids. These processes have become part of the management-by-knowledge since the conditions for procurement require ‘evidence-based methods’ to be used:

Methods used must be evidence-based or have been shown to give good results from professional experience. In order to maintain continuity, a method that has given good results should not be replaced. In the event that the method is changed, staff must have received appropriate training before implementation. (Authors’ translation, tender document from the municipality, 2015: 22)

These texts are ambiguous. First, it must be noted that demands for evidence-based methods are coupled with results from professional experiences and the respect for current practices as well as staff competencies. It is interesting that ‘evidence-based methods’ are mentioned accompanied by the qualifier ‘must’ – this implies that is quite self-evident not only what these methods are but that they are available. The NBHW did recommend some methods based on their consensus processes, but they did not use the term ‘evidence-based’ (NBHW, 2017).

In interviews with the staff at the quality department, it became clear that references to evidence-based methods or programmes for quality improvement are important in procurements. As a response to the quest for evidence-based methods in the tender from the municipality, the provider specifies a list of methods that were used at DA units within the organisation:

… The task of daily activities is to eliminate what prevents the participant from living his life and performing his activities as independently as possible. … daily activities will therefore be based on the following methods: structured teaching, AAC [augmentative and alternative communication], social stories and comic strip conversations, low arousal approaches, positive behavioural support, physical activity. (Offer document from the provider to the municipality)

The staff at the quality department were well aware of the importance of referring to recommended methods – even if these are not ‘evidence-based’ in a strict sense. The provider’s offer, nevertheless, is congruent with the methods mentioned in NBHW’s knowledge support. One of the managers admits that procurement negotiations are permeated by rhetoric (field notes, quality department, February 2020). There are a number of ways to monitor whether the formulations about methods are actualised in care practices, for example, the national client surveys. Nonetheless, there are few means for sanctioning non-adherence. Rhetoric may be completely decoupled from operational realities, depending on the ethos of the providers and routines of their professionals. The documents from the municipality emphasise the importance of using methods that have been shown to ‘give good results’. While they do highlight evidence-based methods, they are equally pointing to the role of social workers’ experience of the results of methods.

In the formulation in the tender document there is a lack of acknowledging experience from clients. While the practical consequences of this lack of recognising clients’ experiences in the formulation in the tender is unclear, this lack does point to an exclusion of client knowledge in this specific context. To follow up on this issue, we now turn to the work at the quality department of the provider.

The provider’s improvement programme and courses: participation!

The quality department of the provider is responsible for the ways in which the organisation is influenced according to legal regulations, management-by-knowledge, the promises made in procurements, and the provider’s visions. The provider regularly offers courses for staff about the methods mentioned in the previous section. One of the courses is part of a larger improvement programme introducing ideas and tools from the research field of improvement science. What is particular to the improvement programme is its design. This design has been developed to involve professionals and clients in both the selection and analysis of problems, planning of interventions, measuring the outcomes, and communicating the lessons learned. In a Swedish context, this is somewhat unusual within social service, and speaks to the high level of management engagement. The operations run by the provider get the opportunity to sign up for the improvement course. The operations send an ‘improvement team’ of three to five staff from the unit. The team are then supposed to lead an improvement project within their operation with the guidance of the course leaders. The formal tools of improvement work force the teams to systematically measure their interventions in order to evaluate if the improvement project actually led to any improvement.

Within the improvement course there are also built-in structures that acknowledge the necessity of integrating clients’ needs and values. Part of the course specifically focuses on the importance of ‘co-creation’. Recently, the provider collaborated with a research group focused on co-creation at a university in Sweden. Here, researchers were collaborating to integrate co-creation into the existing structures of the improvement course. The result was that the improvement course challenged the improvement teams to include clients in every stage of the process. Without any sanctions or linear governance, there is a reproduction of major aspects of management-by-knowledge, such as a specific methodological portfolio, certain social care approaches, and the emphasis on participation. The efforts to develop ‘co-creation’ structures within the knowledge practices at the provider signal that clients and social workers are recognised as credible knowers in these contexts – but is this realised in actual care practices?

Local care practices

Considering the ambitions of central actors of management-by-knowledge, municipalities and the provider, what are the ramifications regarding epistemic (in)justice for social workers and clients? Are the latter parties recognised as credible knowers, or does the management-by-knowledge disqualify the professional judgments of social workers and the values and views of clients?

The relative autonomy of social workers

The social workers at the units had no formal higher education, though some had taken short courses in communication or for interacting with individuals having specific diagnoses. While the social workers recognised that courses and education might be important in order to understand the client group and their special needs, they emphasised that ‘being the right person for the job’ and having the right chemistry with clients are the most important factors for doing a good job. When discussing the role of methods taught to the staff at a course, one social worker argued that some persons are suitable for this type of work and others are not. She put it like this:

If you are not [suitable for this type of work], it does not matter if you read about these methods, you will not be good at work anyway. If you are the right person then you can go in and do the work regardless. (Interview, social worker, DA-unit 1, January 2020)

To be effective, you must know the clients or, perhaps more correctly, they must know you. In a field note from observations at one of the DA units, it is concluded:

… it is obvious that you learn this work via colleagues and through the situations that you are exposed to, but this is not enough, another crucial aspect is that you have to have a good relationship with the clients you work with: a mutual understanding that develops over the years. Remember that the clients often stay at the unit their whole ‘working life’ until retirement and, often, so do the social care staff too (Field notes, DA unit 1, December 2019)

These quotes indicate that a mutual understanding between clients and social workers is of crucial importance in order to get the unit to function. The specific character of daily activities therefore seems to demand a high degree of participation and inclusion of both social workers’ and clients’ knowledge and experiences. Acknowledging both as credible knowers is at the core of getting the daily activity unit to function at all.

Turning to the actual daily work at the units, there are other efforts based in local knowledge. Every day, work is done to involve the clients in each and every part of the units’ daily activities to the best of each individual client’s capacity. These efforts are difficult to pinpoint as originating in a specific method or approach, and seem to be more about an attitude and a culture of practice that the social workers take for granted. An example of this is when one client wanted to use a sewing machine but did not have the ability to do so. A social worker sat down with him at the sewing machine and handled the fabric and the needle while the client handled the machine’s power pedal. The result was random stiches across a piece of fabric whose sole purpose was to create an opportunity for participation for the client in question (field notes, DA unit 1, January 2020). This was one of many similar examples.

In these situations, the social workers continuously adapt and accommodate to each individual client’s abilities so that they are given the opportunity to partake equally in the activities at hand. In interviews, several of the social workers state that their ability to do so stems both from their experience of working with people with intellectual disabilities, and from knowing and having a trusting relationship with the clients at the units, but also from their own suitability for the job. This echoes the views of the social worker who claimed that what matters is who you are, not the methods you have learnt.

In interviews, there were few indications that social workers, although epistemically self-directing, are at all defensive or negative in their attitudes towards EBP. The social workers of the DA units did not perceive management-by-knowledge as a threat, at least not in the form of knowledge supports, partly because they barely knew about them. The DA units were, according to staff, quite untouched by demands of EBP or management-by-knowledge. Instead, the knowledge of social workers was dominant.

Clients: in the hands of social workers or the organisation?

Despite the social workers’ experience of professional autonomy in their daily work at the units, the organisation popped up everywhere in conversations with individual social workers. The organisation mirrors management-by-knowledge on a number of points. In courses, methods recommended in the knowledge support are taught and picked up by staff: augmentative and alternative communication (AAC), structured teaching, social stories and comic strip conversations, low arousal approach, physical activity and others. In individual conversations and practices, the central concern of participation is brought up again and again. Some of these methods are written down in work routines. In improvement projects, experiences and impressions from local practices are picked up and turned into practical changes drawing on a broad methodological portfolio. While social workers experience themselves as autonomous, they are, simultaneously, embedded in management-by-knowledge without any hard sanctions or implementations. Through structures internal to the organisation, social workers are involved in integration of external knowledge. We will present one example to illustrate how this happens.

In the 2019 national client survey by SALAR (NBHW, 2020), it was noted that one of the units scored lower than the country average on the ‘clients’ influence’ section (described earlier in the results). The management and the unit’s staff then decided to engage in an improvement project focusing on client participation and influence. In the improvement course this simplification of participation in a national client survey was situated through the combination of the staff’s local knowledge and their clients’ responses. After observing and interpreting a slight decrease in the measure on participation, they decided to initiate an improvement work on participation. This improvement work sparked more conversations with other practitioners and clients.

The team responsible for the improvement project decided to focus on improving their clients’ level of participation in their ‘participant councils’. Such meetings are held at each unit, both as an occasion to inform the clients, and to provide an opportunity for clients to voice their concerns regarding the DA. During the planning phase, the project team had ongoing discussions about the meaning of ‘participation’. They were not aware of a clear definition and commented that it might mean something different to the participants.

To clarify these concerns the social workers invited two clients to be part of the improvement team. The clients were in that way included in the planning process so they could provide their own insights and suggestions. The team visited meetings at all units and noted both difficulties and successes in the planning. After this, one of their conclusions was that they themselves, the staff, might be the problem. They note: ‘it is us that is the problem, we have too little knowledge’, and ‘the staff takes over and informs instead of letting the participants bring up what they want to talk about’ (field notes, DA unit 1, March 2020). The team then decided to improve the written routine for unit meetings, in order to clarify the different roles of both employees and participants in such meetings. They also decided to create a template agenda for meetings to be used by all units to provide a better structure for the meetings. Through developing these formalised elements, it was thought, meetings would be framed in a way that increased the opportunity for participation. Participation thus started as a survey item, a simplified quantification. What might seem an oversimplified measurement of clients’ experiences in one survey item was situated and developed through local knowledge, and was then made transferable to other units at the provider through routines and templates.

The organisational structures that embodied management-by-knowledge at this local level were opened up for client participation by the efforts that were made by the social care staff to find ways to increase client participation. The provider’s initiative to build structures to encourage co-creation appears to open up pathways for epistemic inclusion. The improvement team did invite clients to be a part of the improvement team and went to great lengths to achieve client participation. While the organisational structures seemed to avoid obvious traps of active silencing or excluding clients’ knowledge, lack of exclusion does not equate with inclusiveness, a difficult topic of its own requiring further treatment elsewhere.

Discussion

In this section, we further analyse the results through an epistemic injustice framework. We also discuss the usefulness and limitations of using that framework.

Central management-by-knowledge practices

In the study, we have explored the ramifications of management-by-knowledge in disability care by empirically examining how evidence, social workers and clients are included and excluded in knowledge practices across the different levels of management-by-knowledge. Epistemic injustice in the context of the systematic review methods have, in previous studies, been characterised as a devaluing of clients’ and professionals’ credibility as knowers in relation to the high value placed on knowledge from empirical research (mainly RCTs) (Michaels, 2020; Moes et al, 2020). This is said to result in a systematic exclusion of these perspectives in the methodological structures deployed. The problem is that these structures decide what counts as credible knowledge. Johansson (2019) argued that Swedish implementation of management-by-knowledge at a central level excluded knowledge from social workers and clients, and concluded that this exclusion leads to significant power asymmetries. By analysing the most centralised part of management-by-knowledge, we did not come across specific instances of injustice caused by such power imbalances. On the contrary, we discovered more potential for hermeneutical and testimonial justice than injustice in this specific case. The many approaches that were used by the NBHW in order to include knowledge from both evidence, professionals and clients could be interpreted as a recognition of social workers’ and clients’ credibility as knowers. The contrast to parts of the literature critical of EBP is stark, with its focus on the constraints placed on social workers’ autonomy (Jacobsson and Meeuwisse, 2020), or the incompatibility of EBP demands and social workers’ daily work (Martinell Barfoed, 2018; Björk, 2019).

Management-by-knowledge at a regional level: risk of client exclusion, but organisational structures for inclusion

At a regional level, the procurement processes did demand that providers work according to evidence-based methods in a way that showed the municipality’s interest in being actors in the management-by-knowledge chain. But at the same time they emphasised the role of professional experience of working with these methods as a credible source of knowledge. That being so, as noted above, the clients’ experience was not mentioned in this formulation in the municipality’s tender. This kind of exclusion carries the potential risk of producing epistemic injustice for clients, which makes this finding worth investigating further.

The findings also suggested that the municipality’s demands for evidence-based methods were mostly rhetorical and that there were few means for sanctioning non-adherence. This implies that the management-by-knowledge at the regional level puts a lot of responsibility on the individual provider to ensure the quality of their operations. In this case, how the management-by-knowledge was operationalised by the municipality did not seem to constrain the provider much.

Local situations: entwinement of knowledge sources in fluid management-by-knowledge

In the local care practices, the results from the open comparisons user survey initiated an improvement project in order to increase participation at the DA units. In the structures for improvement work at the provider, the efforts to systematically co-create in these knowledge practices encouraged the improvement team to include clients in the process. The social workers showed an awareness that they might be part of the problem, and therefore invited two clients to be a part of the improvement team. Rather than merely accepting the simplifications of the survey items, in this case the simplification became an opportunity for increased interplay between social workers and clients, an interplay combining local knowledge from social workers and clients. This entwinement of central management-by-knowledge and knowledge from social workers and clients implies a dynamic interplay between various forms of evidence, social workers and clients, rather than indicating obvious signs of epistemic injustice caused by management-by-knowledge infrastructures.

The results thus indicate that the organisational structures at the provider facilitated epistemic inclusion of clients’ knowledge, and therefore seemed to avoid obvious structural oppression resulting in epistemic injustice. However, the design of the study did not include formal interviews with clients. This methodological constraint makes it hard to draw any strong conclusions as to whether epistemic justice of clients follows from these structures. This is a clear methodological limitation of this study but justified by the nature and severity of the disabilities of the clients at these units.

In the findings from local social care practices there was an interesting ambiguity: while the social workers did mention that they were quite untouched by demands of EBP or management-by-knowledge, our results show that they were affected by management-by-knowledge in many senses, but that they did not seem to reflect upon this. The social workers considered themselves to be rather autonomous, even though working within EBP. This is in striking contrast to the claims made by some critics of EBP. Instead, the organisation surrounding the social workers enabled an interplay between many different knowledge sources: clients, professionals, the client survey from SALAR, procurement documents and methods recommended in the knowledge support from NBHW. In this case, no potentially oppressive dimensions of a linear management-by-knowledge were visible, or at least not perceived as such. Instead, management-by-knowledge seemed to permeate the daily practices through a kind of ‘nudging’ that the social workers were largely unaware of.

Interestingly, had the present study only focused on observing the social workers’ daily practice, a conclusion could easily have been that these units were unaffected by management-by-knowledge, suggesting that the implementation of Swedish management-by-knowledge for these kinds of operations may not yet have been realised. A similar conclusion was drawn by Johansson (2019), who suggests that it is still unclear how EBP is operationalised in Swedish social care practice. However, by examining different levels of management-by-knowledge, this study shows that while the social care staff at the units did not reflect upon EBP, management-by-knowledge was indeed detectable in their practices and the surrounding organisational structures. In this study, the fluidity of management-by-knowledge can be characterised as a kind of nudging of practices as opposed to the kind of top-down standardised EBP that is widely criticised by social work scholars (Bergmark and Lundström, 2006; Johansson et al, 2015). This finding speaks to the need for keeping one’s eyes open towards different empirical versions of management-by-knowledge, and the fact that it can be realised in diverse ways; not merely the form of a straitjacket, but manifest also in more dynamic, flexible forms.

What does the concept of epistemic injustice do?

The findings suggest that claims about the constraints of management-by-knowledge causing epistemic injustice to social workers or clients ought to be carefully examined. By applying an epistemic injustice perspective, we were sensitised to potentially exclusive and inclusive knowledge practices within the different levels of management-by-knowledge. In this particular case we did not find obvious risks of management-by-knowledge infrastructures causing epistemic injustice in the local care practice. Instead, we found a potentially inspiring case where knowledge from various forms of evidence, social workers and clients were entwined in dynamic knowledge practices at the provider and the DA units. Pointing this out does risk the hijacking of our analysis by narrow proponents of EBP for their own purposes. It should be noted that this study concerns one case and thus cannot claim to be wholly representative of the entire field. Furthermore, it is important to recognise that epistemic injustice can be difficult to assess because, in practice, power asymmetries are often more complex than first assumed. Care must be taken to ameliorate potential risks of missing important aspects of how local practices are concretely enacted. And, of course, one’s analytic gaze is guided by the particular definitions and constructs of epistemic injustice being applied. Grim et al (2019) recognised that a framework based on epistemic injustice theory carries the potential risk of adopting value-laden presuppositions regarding injustice from the outset of the study that could bias the analysis. The results of this study stress that assumptions about epistemic injustice based on the relative powerlessness of social workers should be scrutinised before acceptance (see Lipsky, 1980; Zuiderent-Jerak, 2016).

Conclusions

The aim of this study has been to examine management-by-knowledge in a social work setting. Two core sets of conclusions have been reached. Firstly, the parts of management-by-knowledge that we examined in disability care do not support the most dire warnings from social work scholars. The methodologies that inform management-by-knowledge, in the case studied, do not seem to impose epistemic injustice on either social workers or clients. On the contrary, there are several elements at the NBHW, SALAR, the municipality’s procurement processes, and the provider’s organisational structures, that seem to prevent epistemic injustice. Among them are: a diversity of approaches within social care, a set of broad methodologies to evaluate different care approaches, and an emphasis on participation. These observations challenge a widespread image of management-by-knowledge and national EBP infrastructures. Various agencies, the provider and practitioners are nudging each other, without hard sanctions or demands.

Secondly, just as management-by-knowledge is not a linear process, power is not always distributed according to a neat chain of command. Against the backdrop of claims about the constraints on social workers’ knowledge and practice, the relative autonomy of social workers in the case studied puts these claims in perspective. In this case, various approaches and enactments of participation challenged social workers’ practices by nudging rather than through strict control.

In sum, the findings of this study point to the importance of organisational structures that support – rather than rigidly constraining – social workers and clients in their daily practices. Efforts aiming to improve care for people with disabilities might benefit from focusing on organisational structures that combine external knowledge with local practices. As shown in this study, management-by-knowledge does not have to imply a choking constraint. Instead, it can be realised through a greater focus on creating organisational structures that support the coexistence of social workers’ and clients’ knowledge and various sorts of evidence. Management-by-knowledge can in this sense become more like a fluid influence than a straitjacket.

Funding

This work was supported by FORTE under Grant 2018-0051.

Acknowledgements

The authors thank all the social care staff at the two daily activity units, and the staff at the quality department who kindly agreed to participate in interviews and to be observed in their daily practice.

Research ethics statement

Ethics approval was obtained by Etikprövningsmyndigheten in Sweden 2019-11-08.

Contributor statement

IP and AL conducted the fieldwork. IP and MS wrote the first and subsequent drafts of the manuscript, with contributions from AL, TZJ, IB and TS. AL introduced the theoretical concept of epistemic injustice. IB wrote the first version of the theoretical section. IP and MS conducted the data analysis with contributions from AL, IB, TS and TZJ. All authors contributed to the conceptualisation of the study.

Conflict of interest

The authors declare that there is no conflict of interest.

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    • Search Google Scholar
    • Export Citation
  • Andrews, N., Gabbay, J., Le-May, A., Miller, E., Petch, A. and O’Neill, M. (2020) Story, dialogue and caring about what matters to people: progress towards evidence-enriched policy and practice, Evidence & Policy, 16(4): 597618.

    • Search Google Scholar
    • Export Citation
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    • Search Google Scholar
    • Export Citation
  • Bergmark, A. and Lundström, T. (2006) Mot en evidensbaserad praktik? Om färdriktningen i socialt arbete’ [Towards an evidence-based practice? About the direction in social work], Socialvetenskaplig Tidskrift, 13(2): 99113.

    • Search Google Scholar
    • Export Citation
  • Bergmark, A. and Lundström, T. (2011) EBP i svenskt socialt arbete: om ett programs mottagande, förändring och möjligheter i en ny omgivning’ [EBP in Swedish social work: about a programme’s reception, change and opportunities in a new environment], in I. Bohlin and M. Sager (eds) Evidensens Många Ansikten [The Many Faces of Evidence], Linköping: Arkiv Förlag, pp 16384.

    • Search Google Scholar
    • Export Citation
  • Björk, A. (2016) Evidence, fidelity, and organisational rationales: multiple uses of motivational interviewing in a social services agency, Evidence & Policy, 12(1): 5371.

    • Search Google Scholar
    • Export Citation
  • Björk, A. (2019) Reconsidering critical appraisal in social work: choice, care and organization in real-time treatment decisions, Nordic Social Work Research, 9(1): 4254.

    • Search Google Scholar
    • Export Citation
  • Braye, S. and Preston-Shoot, M. (2005) Emerging from out of the shadows? Service user and carer involvement in systematic reviews, Evidence & Policy, 1(2): 17394.

    • Search Google Scholar
    • Export Citation
  • Carel, H. and Kidd, I. (2014) Epistemic injustice in healthcare: a philosophical analysis, Medicine, Health Care and Philosophy, 17(4): 52940.

    • Search Google Scholar
    • Export Citation
  • Crichton, P., Carel, H. and Kidd, I. (2017) Epistemic injustice in psychiatry, British Journal of Psychiatry Bulletin, 41(2): 6570.

  • Eriksson, B.G. and Karlsson, P.A. (2016) Utvärdering av Nationell Satsning på att Utveckla EBP Inom Verksamhetsområdet Stöd Till Personer Med Funktionsnedsättning’ [Evaluation of National Investment in Developing EBP Within the Business Area Support for People with Disabilities], Stockholm: Swedish Association of Local Authorities and Regions, FoU Sjuhärad and Hedmark University College.

    • Search Google Scholar
    • Export Citation
  • Flyvbjerg, B. (2001) Making Social Science Matter: Why Social Inquiry Fails and How It Can Succeed Again, Cambridge: Cambridge University Press.

    • Search Google Scholar
    • Export Citation
  • Franzén, C. (2018) State governance versus dentists’ autonomy: the case of Swedish dental care, Acta Odontologica Scandinavica, 76(2): 12529.

    • Search Google Scholar
    • Export Citation
  • Fricker, M. (2007) Epistemic Injustice: Power and the Ethics of Knowing, Oxford: Oxford University Press.

  • Gray, M. (2009) Evidence-based Social Work: A Critical Stance, London, New York: Routledge.

  • Greenhalgh, T., Snow, R., Ryan, S., Rees, S. and Salisbury, H. (2015) Six ‘biases’ against patients and carers in evidence-based medicine, BMC Medicine, 13(1): 200.

    • Search Google Scholar
    • Export Citation
  • Grim, K., Tistad, M. , Schön, U.K. and Rosenberg, D. (2019) The legitimacy of user knowledge in decision-making processes in mental health care: an analysis of epistemic injustice, Journal of Psychosocial Rehabilitation and Mental Health, 6(2): 15773.

    • Search Google Scholar
    • Export Citation
  • Jacobsson, K. and Meeuwisse, A. (2020) ‘State governing of knowledge’: constraining social work research and practice, European Journal of Social Work, 23(2): 27789.

    • Search Google Scholar
    • Export Citation
  • Johansson, K. (2019) Evidence-based social service in Sweden: a long and winding road from policy to local practice, Evidence & Policy, 15(1): 85102.

    • Search Google Scholar
    • Export Citation
  • Johansson, K., Denvall, V. and Vedung, E. (2015) After the NPM Wave: evidence-based practice and the vanishing client, Scandinavian Journal of Public Administration, 19(2): 6988.

    • Search Google Scholar
    • Export Citation
  • Kalkan, A., Sandberg, J. and Garpenby, P. (2015) Management by knowledge in practice: implementation of National Healthcare Guidelines in Sweden, Social Policy & Administration, 49(7): 91127.

    • Search Google Scholar
    • Export Citation
  • Kalman, H., Lövgren, V. and Sauer, L. (2016) Epistemic injustice and conditioned experience: the case of intellectual disability, Wagadu: A Journal of Transnational Women’s and Gender Studies, 15: 6381.

    • Search Google Scholar
    • Export Citation
  • Lipsky, M. (1980) Street-level Bureaucracy: Dilemmas of the Individual in Public Services, New York: Russell Sage Foundation.

  • Martinell Barfoed, E. (2018) From stories to standardised interaction: changing conversational formats in social work, Nordic Social Work Research, 8(1): 3649.

    • Search Google Scholar
    • Export Citation
  • Metz, A., Boaz, A. and Robert, G. (2019) Co-creative approaches to knowledge production: what next for bridging the research to practice gap? Evidence & Policy, 15(3): 33137.

    • Search Google Scholar
    • Export Citation
  • Michaels, J.A. (2020) Potential for epistemic injustice in evidence-based healthcare policy and guidance, Journal of Medical Ethics, 47(6): 41722.

    • Search Google Scholar
    • Export Citation
  • Moes, F., Houwaart, E., Delnoij, D. and Horstman, K. (2020) Questions regarding ‘epistemic injustice’ in knowledge-intensive policymaking: two examples from Dutch health insurance policy, Social Science & Medicine, 245: 112674, doi: 10.1016/j.socscimed.2019.112674.

    • Search Google Scholar
    • Export Citation
  • Myers, L.L. and Thyer, B.A. (1997) Should social work clients have the right to effective treatment? Social Work, 42(3): 28898.

  • NBHW (National Board of Health and Welfare) (2017) Vägar Till ökad Delaktighet. Kunskapsstöd för Socialtjänsten om Arbete Med Stöd Och Service Enligt LSS [Roads to Increased Participation. Knowledge Support for the Social Services About Work with Support and Service According to LSS], Stockholm: NBHW.

    • Search Google Scholar
    • Export Citation
  • NHBW (National Board of Health and Welfare) (2020) Öppna Jämförelser [Open Comparisons], https://www.socialstyrelsen.se/oppnajamforelser.

    • Search Google Scholar
    • Export Citation
  • Nicholas, G., Foote, J., Kainz, K., Midgley, G., Prager, K. and Zurbriggen, C. (2019) Towards a heart and soul for co-creative research practice: a systemic approach, Evidence & Policy, 15(3): 35370.

    • Search Google Scholar
    • Export Citation
  • Norcross, J.C., Beutler, L.E. and Levant, R.F. (2006) Evidence-based Practices in Mental Health: Debate and Dialogue on the Fundamental Questions, Washington, DC: American Psychological Association.

    • Search Google Scholar
    • Export Citation
  • Otto, H.U. and Ziegler, H. (2008) The notion of causal impact in evidence-based social work: an introduction to the special issue on what works? Research on Social Work Practice, 18(4): 27377.

    • Search Google Scholar
    • Export Citation
  • Persad, G. (2017) What is the relevance of procedural fairness to making determinations about medical evidence? American Medical Association Journal of Ethics, 19(2): 183.

    • Search Google Scholar
    • Export Citation
  • Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, W. and Haynes, R.B. (2000) Evidence-based Medicine: How to Practice and Teach EBM, 2nd edn, Edinburgh: Churchill Livingstone.

    • Search Google Scholar
    • Export Citation
  • Sandberg, J., Persson, B. and Garpenby, P. (2019) The dilemma of knowledge use in political decision making: National Guidelines in a Swedish priority-setting context, Health Economics, Policy and Law, 14(4): 42542, doi: 10.1017/S1744133118000233.

    • Search Google Scholar
    • Export Citation
  • Scully, J.L. (2020) Epistemic exclusion, injustice, and disability, in A. Cureton and D.T. Wasserman (eds) The Oxford Handbook of Philosophy and Disability, Oxford: Oxford University Press.

    • Search Google Scholar
    • Export Citation
  • Stewart, E., Smith-Merry, J., Geddes, M. and Bandola-Gill, J. (2020) Opening up evidence-based policy: exploring citizen and service user expertise, Evidence & Policy, 16(2): 199208.

    • Search Google Scholar
    • Export Citation
  • SOU (2008) Evidensbaserad Praktik Inom Socialtjänsten – Till Nytta för Brukaren: Betänkande av Utredningen för Kunskapsbaserad Socialtjänst [Evidence-based Practice Within Social Services – for the Benefit of the User], Stockholm: Fritzes.

    • Search Google Scholar
    • Export Citation
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  • 1 University of Gothenburg, , Sweden
  • | 2 Jönköping University and Bräcke Diakoni, , Sweden
  • | 3 Vrije Universiteit Amsterdam, , Netherlands
  • | 4 University of Gothenburg, , Sweden

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