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2012 12: 364 originally published online 2 March 2011Journal of Social WorkLisa Wallander

survey approach in the study of professional judgementsMeasuring social workers' judgements: Why and how to use the factorial

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Article

Measuring social workers

judgements: Why andhow to use the factorialsurvey approach in thestudy of professional

judgements

Lisa WallanderMalmo University, Sweden

Abstract

Summary: The factorial survey approach, which was first introduced in the socialsciences around the beginning of the 1980s, constitutes an advanced method formeasuring human judgements of people or social situations. At the general level, thisquasi-experimental approach involves presenting respondents with vignettes (fictive

descriptions), in which selected characteristics describing the vignette person orsituation are simultaneously manipulated. The aim of this article is to present a con-ceptual and an analytical framework for factorial survey studies of professional judge-ments in social work. Findings: In the first part of the article, I develop and discuss the proposition that thisapproach may be used in order to study the contents of professional judgements aboutthe diagnosis and treatment of clients. The contents is discussed in terms of knowledgeassumptions that practitioners explicitly and tacitly use as a basis for their professional

judgements. Second, I outline a strategy for modelling social workers judgements.

This modelling strategy proceeds from the possibilities afforded by multilevel regressionanalysis. Applications: Findings from analyses of factorial survey data may reveal both profes-sional agreement and disagreement in practitioners judgements. While results thatreveal high levels of disagreement in judgements about what constitutes a particulardiagnosis or about which intervention is the most suitable for a particular client mayraise questions as regards the professionalism of practitioners judgements, results thatreveal professional agreement in diagnostic and treatment assumptions may be trans-formed into hypotheses that can be tested further in research.

Corresponding author:

Lisa Wallander, Senior Lecturer in Health and Society, Faculty of Health and Society, Malmo University, SE-205

06 Malmo, Sweden

Email: [email protected]

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Keywords

factorial survey approach, knowledge use, multilevel analysis, professional judgements,vignette

As a consequence of the advancement of the evidence-based practice (EBP) move-

ment in social work (see Trinder, 2000), increasing note is currently being taken of

the subject of social workers judgements and decisions. At the most basic level,

evidence-based medicine (EBM), which may be regarded as the forerunner of EBP,

involves the conscientious, explicit, and judicious use of current best evidence in

making decisions about the care of individual [clients] (Sackett, Rosenberg, Gray,

Haynes, & Richardson, 1996, p. 71). It has also been described as a guide forthinking about how decisions should be made (Haynes, Devereaux, & Guyatt,

2002, p. 2) and as a decision-making process (Gambrill, 2006, p. 215).

Although the introduction of evidence-based decision-making in social work may

in some cases involve the substitution of a new mode of practice for an older one

(e.g. Gambrill, 1999), more often than not it will set out from, and gradually

reshape, already existing modes of decision-making. Accordingly, the successful

application of EBP to social work will require that we have some knowledge

about what is already out there. As expressed by Ashford and LeCroy (1991,

p. 309), before we can encourage [evidence-based] knowledge utilization insocial work, we must first understand how social workers use knowledge in their

interventions and in their decision-making processes. Although there are signs of

some current research activity in the field of professional judgements in social

work, particularly in the area of child protection (see e.g. Children and Youth

Services Review, 2005), social workers judgements and decisions have over the

years been largely neglected by researchers as a subject of interest (see Cuzzi,

Holden, Grob, & Bazer, 1993; OSullivan, 1999; Taylor, 2006).

In recent years, the authors of a number of articles, both in nursing (e.g. Lauder,

2002; Ludwick et al., 2004) and in social work (Taylor, 2006), have proposed thatresearchers interested in the empirical study of professional judgements could start

employing a method labelled the factorial survey approach (FSA). This approach,

which may be described as quasi-experimental, was introduced in the social sci-

ences around the beginning of the 1980s as a means of thoroughly studying human

judgements of people or social situations (Rossi & Nock, 1982). At the general

level, it involves presenting respondents with a number of vignettes (fictive descrip-

tions), in which selected characteristics describing the vignette person or situa-

tion are simultaneously manipulated. In sociology, the factorial survey approach

has been used in many fields of study, including crime and deviance (e.g. Miller,Rossi, & Simpson, 1991), social stratification (e.g. Will, 1993) and urban sociology

(e.g. Shlay, 1986). Further, an extensive review of the FSA studies published in

selected sociology journals (Wallander, 2009) shows that the method has also been

employed to study professional judgements, with a focus on the members of such

Wallander 365



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occupational groups as nurses (e.g. OToole, OToole, Webster, & Lucal, 1993),

case managers (e.g. Corazzini-Gomez, 2002) and police officers (Son, Davis, &

Rome, 1998).

Even though the factorial survey approach has already been introduced to the

study of professional judgements in health care and social work, no attempt has

been made to identify at a more theoretical level which particular aspects of

professional judgements the approach can be employed to investigate. Nor has

there been any thorough exploration of the full potential of the factorial survey

approach as a tool for modelling professional judgements. Only a few authors

concerned with the investigation of professional judgements have chosen to com-

bine the factorial survey approach with multilevel analysis (e.g. Degenholtz, Kane,

Kane, & Finch, 1999; Wallander & Blomqvist, 2005, 2009), for example, even

though the questions commonly at issue in such studies may in effect be describedas true multilevel problems, in the sense that the determinants of the outcome may

be defined at a number of different levels in the analysis. To take one example,

studies of this kind often include questions about whether professional judgements

are influenced not only by considerations associated with the client, but also by

characteristics of the practitioners who make the judgements, as well as by con-

textual conditions, such as the practitioners workplaces. Accordingly, the aim of

this article is to explore the questions of why and how the factorial survey approach

might be used in the study of professional judgements in social work. Since other

authors have already described the general principles of the factorial surveyapproach and have incorporated extensive illustrations of how to plan and to

carry out studies based on this design in their articles (see e.g. Ludwick et al., 2004;

Taylor, 2006) the current article will content itself with only a brief description of

the method itself. The main focus will instead be directed at developing a number

of concepts that may capture the aspects of professional judgements that the design

has the potential to detect. In addition, I will present a strategy for modelling social

workers judgements a strategy which makes use of the possibilities afforded by

multilevel analysis. Although the occupation of interest in this article is social

work, the conceptual framework and modelling strategy proposed are naturallyapplicable to the study of professional judgements in any of the human service

professions.

An introduction to the factorial survey approach

The main components of factorial surveys are the vignettes that are judged by the

respondents. For respondents in an FSA study, vignettes constitute fictive descrip-

tions of people or social situations (see Alexander & Becker, 1978). In studies of

professional judgements in health care and social work, the vignettes as a ruleportray the characteristics and current situation of (potential) clients, such as chil-

dren, for example (e.g. OToole et al., 1993), elderly people (e.g. Degenholtz et al.,

1999) or substance users (e.g. Wallander & Blomqvist, 2005, 2009). An example is

presented below of a vignette from a study of social workers judgements of

366 Journal of Social Work 12(4)



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problem substance users eligibility for compulsory care (Wallander & Blomqvist,

2005).1 In this study, each of 205 social workers, sampled from 18 municipalities in

Stockholm County (Sweden), judged the need for compulsory care among 15

fictive problem substance users. Each of the 3075 vignettes (205 15) that were

presented to the respondents was uniquely constructed by randomly selecting

a value, or level, in the form of a textual fragment, from a set of variables (dimen-

sions), and by combining these levels into unique scenarios. The vignette described

in Figure 1 comprises information about 11 different client variables or

dimensions, which were considered by the authors of the study to constitute poten-

tial determinants of social workers judgements of their clients need for compul-

sory care.

Apart from the dimensions linked to the criteria outlined in the Care of Abusers

(Special Provisions) Act (1988, 870), this vignette also describes the clients pri-mary drug, age and sex (for a description of the dimensions, levels and wordings

used in this design, see the Appendix). The practitioners judgements were mea-

sured by a rating task comprising two options: the respondents were asked to judge

whether or not they believed that the client described in the vignette was in need of

compulsory care. Because each of the approximately 3000 vignettes that were

judged by the respondents was constructed by the random selection of dimension

levels, the characteristics describing the problem substance users making up the

vignette sample were completely uncorrelated with one another. Accordingly, the

authors were able to disentangle the unique effects of variables that are normallyvery highly correlated. For example, it was possible to make a distinction between

the effect on social workers judgements of the clients primary drug and of vari-

ables describing the clients physical and mental health conditions respectively (for

further results, see Wallander & Blomqvist, 2005). This possibility of completely

separating the influences of the independent variables promotes high internal valid-

ity of results from studies using this design. In addition, the fact that the FSA

makes it possible to simultaneously study and control for a large number of

variables (in contrast to the more common factorial experiment), points to high

For each of the fictive clients presented in the following, we ask you to state whether or

not you judge him or her to be in need of compulsory care.

The client is a 25-year-old man who misuses heroin on a more-or-less daily basis. He does

not consider himself to be in need of any type of intervention from the social services and

he has failed to complete treatment on several occasions during the past year. He has an

unstable social situation and lives alone, without children. He has no inclination towards

violence. He seems to be in poor physical health but has no known mental health

problems.

In need of compulsory care

Not in need of compulsory care

Figure 1. An example of a vignette (Wallander & Blomqvist, 2005, p. 68).

Wallander 367



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levels of external validity (see realism) of the study results (for further information

about the technical and analytical advantages of the factorial survey approach, see

e.g. Lauder, 2002; Rossi & Anderson, 1982; Taylor, 2006; Wallander, 2008).

Because the situations generated in accordance with the principles of the facto-

rial survey approach are hypothetical in character, this method is not suitable for

replicating the judgements and decisions made in the complex context of everyday

practice. However, it can be used for studying practitioners professional judge-

ments. The concept of professional judgement may be defined in various ways. To

take one example, in the above-mentioned studies of the judgements made by social

workers and their choices of interventions for problem substance users (Wallander

& Blomqvist, 2005, 2009), the professional judgement concept was used to denote

individual practitioners judgements about which interventions in their own opin-

ion serve best to promote the welfare and best interests of their clients.2 Thisreadiness on the part of the practitioners to act as the clients advocates and to try

their best to help the [clients] (Parsons, 1951, p. 464), is frequently referred to as

one of the essential characteristics of a professional. By making ideal judgements

rather than real-world judgements the object of study, the responses to the vign-

ettes will (at least in the eyes of the respondents themselves) be disengaged from

factors that are often considered in the context of real-world judgements and

decision-making, such as the financial situation at a given practitioners workplace,

for example, and the range of services available. These factors may instead be

examined as potential predictors of the practitioners professional judgements.3

Conceptual framework

Knowledge use in diagnosis and treatment

Inevitably, the professional practice of social workers is permeated by judgements

and decisions. However, not all of the judgements made by practitioners are

directly associated with actions central to the promotion of the welfare and best

interests of their clients. In order to identify some of the most central judgementsmade in professional practice, we will start out from one of the theoretical prop-

ositions put forward by Andrew Abbot (1988, 1995), that professional practice may

be viewed as being essentially composed of the intellectual tasks of diagnosis,

inference and treatment. Undoubtedly, judgements associated with the acts of

classifying problems (diagnosis) and taking action on them (treatment) consti-

tute key judgements to be made prior to the initiation of any form of intervention.4

As described by Abbott (1988, p. 41), diagnosis involves collecting information

about the client and forming a professional opinion about the current status of the

client based on a dictionary of professionally legitimate problems. Although theconcept of diagnosis has a long history in social work (see Richmond, 1917), over

the years it has acquired a rather negative status. According to Turner (2002), this

is because diagnosis has been associated with medicine and with certain theoretical

schools of social work, and because it has come to imply a search for pathology




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and the assignment of single labels to clients. In this article, and in line with Abbott

(1988) and Turner (2002), the concept of diagnosis will be used as a metaphor as a

neutral descriptor of a particular element of professional practice in any given

occupation. Treatment, the last of the three tasks mentioned by Abbott (1988), is

equivalent to prescription, that is, to suggesting interventions or treatments that are

deemed, on the basis of a classification system, to be the most suitable for the

particular diagnosis found. Here, it should be emphasized that the concept of

treatment not only includes the prescription of those interventions that are cus-

tomarily regarded as treatment, but suggestions about any form of action that is

initiated with the aim of changing the clients circumstances for the better.

Examples of FSA studies that investigate professional judgements associated

with the acts of diagnosis and treatment include those by the OTooles and their

colleagues, which have focused on nurses (e.g. OToole et al., 1993) recognition(diagnosis) of potential child abuse and their estimated likelihood of reporting

(treatment) this potential abuse.

In theory, and as mentioned above, the tasks of diagnosis and treatment involve

the use of a system of professional knowledge that formalizes the skills of the

particular type of work at issue (Abbott, 1988, p. 52). Despite current efforts to

systematize the results from research on social work practice in the form of meta-

analyses and practice guidelines (e.g. The Campbell Collaboration, 2010; The

Cochrane Collaboration, 2010), there are as of today still no general and wide-

spread dictionaries that social work practitioners can directly consult when makingjudgements about the diagnosis and treatment of clients (such as those used by

medical practitioners, for example, the United States Pharmacopeia [USP] and the

electronic Medicines Compendium [eMC]). However, notwithstanding the fact that

the current body of knowledge on social work may be described as unstandardized

and eclectic (Tucker, 1996), practitioners performing the tasks of judging what is

wrong with the client, and what may be done in order to remedy the clients

problems, inevitably make use of knowledge of some kind (see Rosen, 1993). In

this context, knowledge is widely defined as those assumptions which contribute to

the professions understanding of its own practice (see Rosen, 1994).5

Thus, afruitful approach for researchers who are interested in studying professional judge-

ments is to focus on the knowledge used by practitioners when making judgements

in relation to the tasks of diagnosis and treatment. This article argues that the

factorial survey approach constitutes one of the most advanced instruments for

measuring the use of knowledge in professional judgements.

Naturally, this proposition gives rise to the question of what forms of knowl-

edge, the use of which can be detected using an FSA design. In the contemporary

social work literature, suggestions about the forms of knowledge that may best

inform practice tend to be inspired by one of two opposing viewpoints. On the onehand, there is a group of researchers, practitioners and politicians who argue that

the work performed by social workers ought to proceed from evidence-based

knowledge, produced to academic standards (see e.g. Gambrill, 1999; Gibbs &

Gambrill, 2002; National Board of Health and Welfare, 2003). On the other

Wallander 369



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hand, many authors believe that social work practice is best guided by so-called

practice wisdom, stemming primarily from practice itself (e.g. Chu & Tsui, 2008).6

However attractive the concepts of evidence-based knowledge and practice wisdom

are, the multidimensional character of these concepts including as they do

assumptions not only about different qualities of the knowledge involved but

also about the its source makes them ill suited to the task of serving as a theo-

retical basis from which to study the knowledge actually used by social workers

when making judgements about the diagnosis and treatment of clients. For exam-

ple, identifying the source of knowledge (research or practice) used in the perfor-

mance of a particular task tells us nothing about the actual content of this

knowledge. In effect, the same substantive hypotheses that are derived from scien-

tific knowledge might also be derived on the basis of practical experience, provided

that the same regularities that form the basis of scientific results are also noticeablein real-world practice.7 Further, there is evidence from research that the process of

applying scientific knowledge in practice involves a transformative element,

whereby the knowledge so acquired is adapted to the conditions of a particular

situation (e.g. Daley, 2001). Thus when evidence-based knowledge is applied in

practice, it inevitably becomes intertwined with knowledge that originates in prac-

tice. In conclusion, the empirical study of knowledge use in professional judge-

ments requires concepts of knowledge that are unequivocal in their content, and

that are not dependent upon particular sources of origin (such as research or

practice). The following discussion will involve a number of concepts of knowledgethat are argued to capture the aspects of professional judgements that can poten-

tially be detected by a factorial survey design.

Empirically useful concepts of knowledge

For authors interested in studying professional judgements, a first distinction must

be made between the process of making a judgement, and the content of the

specific judgement made. In the rich literature on judgement and decision-making

within the field of psychology, this distinction is well-established, and researchershave tended to focus either on tracing the process of judgements and/or decisions,

or on establishing the relationships between the input of information to the deci-

sion-maker and the output (the judgement or decision actually made)

(Benbenishty, 1992; Payne, Bettman, & Luce, 1998). Thus, in line with the sugges-

tion above, the making of professional judgements may be viewed as involving the

use of knowledge both in relation to the process of the judgement task itself, and in

relation to the subject matter involved in a particular judgement. In the social work

literature, process knowledge has been defined as the methodology of practice

decision making, focusing on the processes by which judgements are made(Sheppard & Ryan, 2003, p. 157). Although the past few years have seen a growing

interest in the study of the cognitive processes inherent in social work judgements

and decision-making (e.g. Osmo & Rosen, 2002; Sheppard & Ryan, 2003;

Sheppard, Newstead, Di Caccavo, & Ryan, 2000, 2001), we do not as yet know




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very much about social workers methodologies of practice decision-making.

Thus, this subject area is clearly one that would benefit from more research.

While the factorial survey approach cannot be used in order to study the process

knowledge that is used in practice, other methods may be employed for this pur-

pose, such as the think aloud protocol (e.g. Sheppard et al., 2000), for example.

The factorial survey approach is however most suitable for studying the way pro-

fessionals use knowledge relating to the subject matter of judgements, so-called

subject knowledge. In line with the psychological research referred to above, the

object of this research involves establishing relationships between the information

considered by a practitioner who is making a specific judgement (input) and the

judgement actually made (output). While process knowledge may be described as

generic the cognitive processes involved in social workers judgements and deci-

sions are not necessarily different from the cognitive processes characterizing pro-fessional judgements and decision-making in general subject knowledge is

ultimately domain-specific. Social work practitioners working with problem sub-

stance users, for example, need to have knowledge about the problems typically

faced by members of this client group, and about the different ways in which these

problems may best be responded to.

As has been argued by Rosen and his colleagues (Rosen, 1978; Rosen, Proctor,

Morrow-Howell, & Staudt, 1995; Rosen, Proctor, & Staudt, 1999), the literature

has overlooked the fact that the successful performance of the different functions of

professional practice including the tasks of classifying clients problems and ofsuggesting interventions with the capacity to change the natural or social circum-

stances of the clients for the better may require different forms of (subject)

knowledge. Thus, while the task of diagnosis is best guided by descriptions of

human behaviour, of so-called descriptive knowledge, the prescription of suitable

interventions must be based on so-called control knowledge, denoting knowledge

about the effects of particular interventions on groups of clients. In his early work,

Rosen (1978) criticized the social work research community for focusing too much

on the development of descriptive (and explanatory) knowledge, at the expense of

control knowledge. In the current debate about knowledge development in socialwork, however, more attention is being directed at the advancement of knowledge

about what works than at the equally important goal of improving the knowledge

that may guide practitioners attempts to make sense of all the information col-

lected about their clients, in part via different types of assessment instruments

(White & Stancombe, 2003). While these forms of knowledge are not interchange-

able with one another in social work practice,8 both descriptive and control knowl-

edge may be decomposed into a series of statements, or assumptions, that guide

practitioners work with their clients. Assumptions guiding the primary task of

diagnosis, that is, that of linking information about the clients to more abstractproblem profiles, may be viewed as specific instances of subject knowledge that is

focused on description. Similarly, the assumptions involved in treatment assump-

tions linking the problems identified (. . .) with the responses that those problems

require (Sheppard & Ryan, 2003, p. 165) may be treated as specific instances of

Wallander 371



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subject knowledge that is focused on control. This article argues that the factorial

survey approach may be used in order to investigate the diagnostic and treatment

assumptions involved in practitioners professional judgements. In order to shed

light on this proposal, examples of interpretations of selected results from two FSA

studies of professional judgements will follow.

First, a study by OToole and her colleagues (1993) on nurses recognition and

reporting of child abuse made use of vignettes in which seven dimensions of a

family situation were varied. These dimensions included type of act (sexual, phys-

ical, emotional), for example, perpetrator status (father, mother, sibling) and

victim sex (girl, boy).9 The results showed that sexual acts were more likely to

be recognized as child abuse than were other physical or emotional acts. In addi-

tion, by comparison with vignettes in which the perpetrator was a sibling, those

involving the mother or father were more often rated as cases of child abuse. Thegender of the child involved was also an important predictor of nurses ratings of

child abuse, with girls on average more frequently being regarded as the victims of

child abuse than boys. In sum, each of these three variables influenced nurses

recognition, or diagnosis, of child abuse. The results may be interpreted as reflect-

ing the following assumptions about what constitutes child abuse (i.e. diagnostic

assumptions): a) by comparison with (other) physical or emotional abuse, sexual

abuse is more constitutive of child abuse; b) cases that involve mothers and fathers

are more typical of child abuse than those that involve siblings; c) child abuse is

more likely to be present when girls are involved than when boys are involved.Second, in the study by Wallander and Blomqvist (2005) about social workers

judgements of problem substance users eligibility for compulsory care (see above),

it was found that, by comparison with problem users of alcohol and amphetamines,

problems users of heroin were more likely to be judged as being in need of com-

pulsory care. In addition, the results showed that on average, compulsory care was

more often judged to be required when the substance users were young than when

they were middle-aged or old. These results reflect the following treatment assump-

tions: a) by comparison with problem users of alcohol and amphetamines, problem

users of heroin are more in need of compulsory care; b) young clients are more inneed of compulsory care than are middle-aged or older clients.

The results described above reveal the diagnostic and treatment assumptions

that guide the judgements of many, but most probably not all of the practitioners

taking part in the studies. As will be demonstrated further below, the strategy

proposed for modelling data from a factorial survey makes it possible to discern

the existence of collective, subgroup-specific and context-specific diagnostic and

treatment assumptions.

The detection of knowledge actually-in-useThe most common course of action taken by researchers who are interested in

studying the subject knowledge used by social workers in judgement and deci-

sion-making is that of asking the practitioners to state the rationales supporting




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their judgements (e.g. Rosen, 1994; Rosen et al., 1995). However, as of today, most

researchers would agree that conclusions with regard to what knowledge is actually

used in action cannot be based merely on individuals own accounts. For example,

the rationales provided by any one practitioner will in all probability never amount

to anything more than a thin representation of the thick version which includes

all the motives behind the judgement that is made (Eraut, 2000, p. 134). Further, as

a rule, accounts are tidied up and subject to post-hoc rationalisation, so as to be

easily defendable if challenged (Eraut, 2000, p. 134). Since the respondents in an

FSA study are most probably not fully attentive to the experimental manipulation

(i.e. the controlled variation) of the dimensions included in the vignettes, this

approach may be used for the study of the diagnostic and treatment assumptions

that are truly used by practitioners as a basis for their professional judgements. In

other words, the employment of this approach makes it possible to detect theknowledge practitioners actually use, irrespective of whether this knowledge is expli-

cit or tacit (see Polanyi, 1966) to the practitioners themselves at the moment of

judgement. Another benefit of the design is that problems associated with social

desirability are limited (see Alexander & Becker, 1978). Since it is virtually impos-

sible to obtain a complete overview of the manipulations of the vignette dimensions

(at least when the time given for filling out the questionnaire is limited), the con-

scious weighting of dimensions in accordance with the supposed wishes of research-

ers or others constitutes an insurmountable task.

Modelling social workers professional judgements

According to the pioneers of the factorial survey approach (Rossi & Anderson,

1982, p. 10), the principal objective of the factorial survey design is to uncover the

shared and idiosyncratic principles of judgements. In studies of professional

judgements, the shared principles of judgements may be expressed in terms of

professional agreement in judgements, while the variation in judgements between

individual respondents and between groups of respondents (see idiosyncratic prin-

ciples) may be referred to as professional disagreement in judgements. As far asprofessional disagreement in judgements is concerned, several conditions of social

work practice facilitate or make room for the existence of such variation in judge-

ments. For example, most of the laws that regulate social work practice are not

specified in detail, but generally allow for the exercise of discretionary judgement

on the part of the practitioner. In addition, and as mentioned above, because there

is as of today no common body of knowledge for social workers to consult, social

workers assumedly make use of a variety of forms of knowledge, whose content

also varies, in their daily practice with clients. Finally, we may presume that the

practice of social workers who make judgements in relation to the diagnosis andtreatment of clients is to some degree formed by conditions related to their local

work environments, such as organizational guidelines, for example, and the aver-

age problems of the local clientele. Thus, the suggestion that the professional

judgements of social workers are formed not only by shared principles of

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judgements, but also by idiosyncratic principles of judgements is rather plausible,

and it may be put to test in studies based on an FSA design.

A modelling strategy based on multilevel regression analysis

Multiple regression analysis constitutes the analytical technique most preferred by

sociologists using the factorial survey approach (Taylor & Zeller, 2007; Wallander,

2009). Further, it has been pointed out that the multilevel extension of regression

analysis provides special opportunities for authors who want to model judgements

of people or social situations (Hox, Kreft, & Hermkens, 1991; Jasso, 2006;

Wallander, 2009). Thus, the modelling strategy described here will proceed from

the possibilities afforded by multilevel regression analysis (using e.g. the HLM

software, see Raudenbush, Bryk, Fai Cheong, & Congdon, 2000). Throughoutthis section, examples from two studies, in which the factorial survey was combined

with multilevel (logistic) regression analysis, will be used (Degenholtz et al., 1999;

Wallander & Blomqvist, 2005). While both these studies refer to judgements made

in relation to the treatment of clients, the modelling strategy outlined below is

naturally equally applicable to judgements related to client diagnoses.

This modelling strategy proceeds from an assumption that each of the practi-

tioners involved in the study judges a minimum number of 15 to 20 vignettes.

When multiple vignettes have been judged, the dataset to be analysed has a

hierarchical structure by design. This means that units in the dataset are clus-tered, or nested, within units at a higher level (Snijders, 2004). In addition, since

it is of interest to research on professional judgements to determine whether the

judgements made by practitioners are to some degree also influenced by contex-

tual characteristics (see above), the initial sampling frame may consist of the

practitioners workplaces rather than of the practitioners themselves. Actually,

the full use of the modelling strategy described below presupposes that the prac-

titioners taking part in the study are clustered within their workplaces (i.e. each

workplace must be represented by several individuals), in which case the dataset

also reflects a natural hierarchy. In the designs used in the studies taken asexamples (Degenholtz et al., 1999; Wallander & Blomqvist, 2005), the vignettes,

which constituted units at level one, were clustered within respondents (units at

level two), which were nested within their workplaces (units at level three).10

Multilevel regression analysis is an advanced technique employed to analyse

just such hierarchical data (Snijders, 2004). The output from multilevel regression

models is typically split into two parts: the fixed part, consisting of estimations of

regression coefficients, their standard errors, t-values and probability values, and

the random part, comprising the decomposition of the unexplained variance into

variance components for each level. In so-called random intercept models, avariance component measuring the unexplained variance in the intercept across

units is specified for each of the higher levels of the design. When so-called

random slope models are employed, it is also possible to specify variance com-

ponents for the regression slopes of predictors introduced at lower levels of the




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model (Snijders, 2004). Comprehensive interpretations of variance components

will be provided in the examples that follow.

In general, authors of factorial surveys begin by modelling the social component

of judgements (i.e. agreement), after which they continue with the investigation of

potential variation (i.e. disagreement) between judgements (Wallander, 2009). The

estimation of professional agreement is straightforward, and it involves including

the vignette dimensions as predictors of the respondents pooled judgements. In the

study by Wallander and Blomqvist (2005), 10 of 11 dimensions describing the

fictive problem substance users proved to be significantly related to social workers

judgements about eligibility for compulsory care. As has already been noted, one of

the effects of the vignette dimension measuring the clients primary drug on the

respondents judgements could be interpreted as indicating the presence of a treat-

ment assumption stating that by comparison with problem users of alcohol andamphetamines, problem users of heroin are more in need of compulsory care.

Naturally, it is not only the main effects of vignette dimensions on judgements

that can be estimated, but also the effects of interactions between vignette dimen-

sions. For example, Wallander and Blomqvist (2005) showed that for clients con-

senting to enter voluntary treatment, the probability of being judged to be in need

of coercion substantially increased if the clients involved had a history of failed

treatments. As mentioned above, the results from these analyses reveal assumptions

that are shared by many, but most probably not by all of the practitioners taking

part in the study. In addition, any given practitioner whose practice is guided by aparticular assumption in a particular situation may disregard it in another situa-

tion, if it comes into conflict with one or more equally or more critical assump-

tions. However, although the professional agreement indicated by the results does

not equal professional unanimity, these assumptions may be termed collective

treatment assumptions.

The first step in modelling professional disagreement involves the inspection of

what are referred to as the variance components provided in the output. As has

already been noted, the variance components capture unexplained variance in the

intercept or in selected regression slopes across units at different levels of the model.In their study of case managers decisions as to whether or not to recommend an

out-of-home placement for elderly clients, Degenholtz and his colleagues (1999)

started by specifying a model with no predictors, but in which the intercept was

allowed to vary across case managers and across the agencies in which these case

managers were working. Due to the statistical significance of the variance compo-

nents at both levels, the authors were able to conclude that individual case man-

agers varied in their average levels of judgements (individual variation), and that

case managers practising in different agencies varied in their average levels of

judgements (contextual variation). This means that the general propensity to rec-ommend an out-of-home placement for the elderly clients presented in the vignettes

varied between individual practitioners and between practitioners working in dif-

ferent agencies. This result is of interest in itself. However, the next step in the

analysis involves attempting to explain this variation in judgements, by including

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variables relating to the case managers and to their agencies as predictors in the

analysis. Once they had done this, the authors (Degenholtz et al., 1999) were able

to conclude that some of the individual and contextual variation in case managers

general propensity to recommend an out-of-home placement could be explained by

reference to the task specialization of the case managers and to the supply of

services at the agencies.

Next comes the inspection of the variance components measuring (potentially)

unexplained variance in the regression slopes for selected vignette dimensions. To

take an example, Degenholtz and his colleagues (1999) specified a model in which

they allowed the slopes of the three dimensions representing various client prefer-

ences to vary randomly across Level-2 and Level-3 units. An inspection of the

Level-2 variance components for the slopes showed significant variance between

case managers in the attention paid to client preferences when deciding whether ornot to recommend an out-of-home placement. This means that the (treatment)

assumptions linking client preferences to interventions varied between individual

practitioners. A model which included variables describing the case managers as

determinants of the regression slopes for client preferences (see cross-level inter-

actions, Snijders, 2004), showed that a higher workload, for example, was associ-

ated with less weight being placed on the clients preferences regarding the use of

family care (as an alternative to an out-of-home treatment). Thus, by comparison

with social workers with a low workload, those with a higher workload less often

used the treatment assumption an in-home care plan is more suitable for clientswho are willing to have family help than for clients who are not willing to have

family help as a basis for judgements. This result shows that treatment assump-

tions may indeed be subgroup-specific. If a variable describing the practitioners

workplaces, or another contextual variable, had also affected the slope for client

preferences, we would have concluded that this treatment assumption had been

context-specific.

If the size and significance of the variance components decrease with the inclu-

sion of respondent or contextual variables, it may be concluded that the variables

added (if significant) account for some of the previously unexplained variance. As afinal step in this modelling strategy, it is useful to inspect what remains of the

variance components subsequent to the inclusion of potential predictors of judge-

ments. For example, due to the remaining significance of the variance components

in a random intercept model with three levels, Wallander and Blomqvist (2005)

were able to conclude that the respondent and contextual variables included as

predictors of compulsory care judgements could explain some, but far from all

between-respondent and between-context variation in the general propensity to

judge clients need for compulsory care. The authors noted that the unexplained

variance at the respondent level could either be systematic, due to respondentpredictors that were not included in the models, or random, and that the remaining

unexplained variance at the contextual level provided additional support for the

view that social workers are indeed socialized at their workplaces into different

ways of viewing clients needs.




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Concluding remarks

Proceeding from the understanding that the factorial survey approach has already

been introduced to the study of professional judgements in health care and social

work at the general level, the articles primary objectives have been to provide a

conceptual framework for interpreting the results from studies based on this

design, and to present a modelling strategy for researchers who are interested in

investigating the professional judgements of social work practitioners. In the fol-

lowing, we will recap on some of the most central ideas presented in the article. As

far as the conceptual framework is concerned, this article proposed that the facto-

rial survey approach constitutes an advanced instrument for studying practitioners

use of knowledge in the context of professional judgements, and more specifically

for studying the assumptions they employ as a basis for judgements associated withthe dual tasks of diagnosis and treatment. In addition, it was maintained that this

approach provides opportunities for detecting diagnostic and treatment assump-

tions irrespective of whether they are used explicitly or tacitly in professional judge-

ments. Thus, by using this instrument, researchers may achieve an objective that

has been called for by a number of authors in the field of social work (e.g. Scott,

1990) and which has been succinctly described by Michaud (1998, p. 13) as that of

identifying the variables upon which the practitioner is focusing in (. . .) instances

of intuition. Although many researchers, and particularly those associated with the

EBP movement, question the influence of intuition (i.e. the antonym of analysis) inprofessional practice (e.g. Gambrill, 1999), there is reason to believe that certain

conditions of social work practice, such as the low degree of structure associated

with certain tasks for example, may encourage the use of intuition rather than

analysis (see Hammond, 1996). Moreover, as has been suggested by two frequently

cited brothers (Dreyfus & Dreyfus, 1986), practitioners regarded as experts in

their fields may be assumed to make intuitive judgements and decisions more

often than novices. While recognizing that the complete transparency of practice

will always remain an unattainable goal, the factorial survey approach may be used

in order to make explicit some of the tacit knowledge that is used in professionaljudgements. Naturally, even given this substantial methodological potential there is

still a need for social work practitioners to continue to develop their own profes-

sional abilities to make the rationales for their judgements and decisions accessible

for scrutiny and critique (see Gambrill, 2006; Rosen, 1993).

As is the case with all methods used in social science, there are a number of

limitations associated with the use of the factorial survey approach in the study of

professional judgements. First, the FSA design cannot be used in order to study the

whole chain of judgements and decisions in the context of a dynamic professional

environment. Rather, it allows you to study a number of frozen moments in thischain (see Wallander, 2008), since you both abstract the judgements from real-life

practice, and deconstruct their determinants into a number of variables. Thus,

results from an FSA study will never give the whole picture and should be

regarded as representations rather than replicas of professional judgements

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(see Benbenishty, 1992). Second, the FSA design only has the potential to detect

those diagnostic or treatment assumptions which relate to variables that have been

included as dimensions in the vignettes. The construction of a factorial survey

therefore requires extensive preparation on the part of the researchers involved

(for a detailed description, see Wallander, 2008). Notwithstanding careful prepa-

rations, studies using the factorial survey approach obviously fall short of explain-

ing how the dynamics of the particular situation in which a social worker and a

client are interacting, as well as their personal chemistry, may influence social

workers professional judgements. Third, the results of a factorial survey, which

may reveal the collective, subgroup-specific or context-specific use of diagnostic or

treatment assumptions as a basis for professional judgements, do not provide any

explanations for these assumptions. For example, even though we know that many

social work practitioners taking part in the study by Wallander and Blomqvist(2005) believe that problem users of heroin are more in need of compulsory care

than are problem users of alcohol or amphetamines, we do not knowwhy this is the

case. The clues suggested by the results, however, indicate that it cannot be because

heroin users have greater physical and mental health problems, for example, or

more problematic social situations, because these conditions (among others) were

controlled for in the design. One potential means of countering this limitation of

the approach would be to combine an FSA study with group interviews, in which

the practitioners discussed and justified the diagnostic and/or treatment assump-

tions revealed by the results.Notwithstanding these limitations, by employing a combination of the factorial

survey approach and multilevel modelling, it is possible to arrive at findings with

important implications for social work decision-making. While results that reveal

high levels of disagreement in practitioners judgements about what constitutes a

particular diagnosis or about which intervention is the most suitable for a partic-

ular client may raise questions as regards the professionalism of practitioners

judgements, other results may strengthen the sense of professionalism in judgement

and decision-making. This is due to the fact that the factorial survey approach

contrary to the traditional case vignette method has the potential to detectprofessional agreement, that is, knowledge assumptions that are shared by many

of the practitioners taking part in the study. Because these assumptions are most

probably not always based on scientific knowledge, but on knowledge that origi-

nates in social work practice or in personal experience from other domains of life

they cannot be directly transformed into formal advice about what should consti-

tute a particular diagnosis, or about which treatment is the most suitable for a

particular client group. However, they may serve as hypotheses that can be tested

further in research. For example, assumptions used collectively by practitioners as

a basis for their judgements regarding the suitability of different treatments fordifferent clients could be employed as a means of structuring evaluations in which

the benefits of these particular treatments for groups of clients were compared.

The results from such evaluations could subsequently be utilized by practi-

tioners for validating or modifying the assumptions detected in an FSA design.




17/22

This suggestion is in line with Payne (2001), who criticizes the concept of a pro-

fessional knowledge base for implying that knowledge is something static, when

the knowledge used in real-world professional practice must actually be continually

revised and reconstructed.

Appendix

Table A1. Description of vignette dimensions, levels and wordings (Wallander & Blomqvist,

2005)

Dimensions and levels Wordings

Misuse pattern

Regular A couple of times a week

Frequent More-or-less daily

Accelerating Daily and accelerating

Consent to treatment

Strong Wants help

Medium Recognizes that he/she has misused the drug to a high extentlately

Weak Does not consider himself/herself to be in need of any type ofintervention from the social services

Failed treatments

None No treatment during the last year

One Failed to complete treatment on one occasion during the pastyear

Several Failed to complete treatment on several occasions during the pastyear

Physical health

No problems No known physical health problems

Some problems Seems to be in poor physical healthAcute problems Recently treated for medical injuries caused by the drug misuse

Mental health

No problems No known mental health problems

Some problems Seems to be mentally unstable

Acute problems Recently hospitalized following a suicide attempt

Social situation

Stable Stable social situation

Unstable Unstable social situation

Acute Is on the road to social marginalizationViolent behaviour

None No inclination towards violence

Earlier signs Earlier violent acts under influence of drugs

Recent signs Recent violent acts under influence of drugs

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Notes

1. According to the current compulsory care legislation in Sweden (the Care of Abusers

(Special Provisions Act) [LVM], 1988: 870), problem substance users can, under certain

conditions, be forced into care for a period of up to six months.2. Another example of a professional judgement consists in practitioners judgements about

what constitutes a particular diagnosis (see below).

3. Real-world constraints, such as the range of services available, for example, may natu-

rally also be incorporated in the vignettes themselves.

4. In social work, the judgement as to what particular outcome is desirable for a client is not

given by the formulation of that particular clients problems. Therefore, the formulations

of ultimate and intermediate outcomes may be regarded as additional tasks with impor-

tant implications for the clients future welfare (see Rosen, 1993).

5. In this article, practitioners assumptions are recognized as knowledge, whether or not

they are true in the scientific sense of the term.6. Views regarding what is actually meant by practice wisdom are numerous (see e.g.

Dybicz, 2004; Klein & Bloom, 1995; OSullivan, 2005; Scott, 1990).

7. Naturally, the employment of scientific methods of investigation may lead to the discov-

ery of regularities that are difficult to trace in everyday practice. In addition, because

scientific methods have evolved to become humankinds most powerful form of enquiry

(Reid, 2001, p. 273), knowledge produced by research is inevitably more reliable and

more valid (however, not necessarily more useful) than knowledge gained in practice.

8. While the ability to describe a phenomenon does not necessarily imply that you are also

able to control it, you may also be able to control a phenomenon without being able to

fully describe it (see Rosen, 1978).9. The following is an example of a vignette made up of selected dimension levels from the

study: The mother struck the 11-year-old girl with a wooden stick. The mother said, I

became carried away in disciplining the child. The mother appears outgoing (OToole

et al., 1993, p. 349).

Primary drug

Alcohol Misuses alcohol

Amphetamines Misuses amphetamines

Heroin Misuses heroinSex

Male Man

Female Woman

Age

Young A 25-year-old

Middle aged A 39-year-old

Old A 56-year-old

Family status

No family Lives alone, without childrenFamily Lives with partner and children




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10. As a rule of thumb, Snijders (2004) has suggested that the smallest acceptable sample

size at the highest level is 20 units.

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