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Measuring social workers' judgements: Why and how to use the factorial survey approach in the study of professional judgements
Lisa Wallander Journal of Social Work 2012 12: 364 originally published online 2 March 2011 DOI: 10.1177/1468017310387463 The online version of this article can be found at: http://jsw.sagepub.com/content/12/4/364

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Article

Measuring social workers judgements: Why and how to use the factorial survey approach in the study of professional judgements
Lisa Wallander
University, Sweden Malmo

Journal of Social Work 12(4) 364384 ! The Author(s) 2011 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1468017310387463 jsw.sagepub.com

Abstract  Summary: The factorial survey approach, which was first introduced in the social sciences around the beginning of the 1980s, constitutes an advanced method for measuring human judgements of people or social situations. At the general level, this quasi-experimental approach involves presenting respondents with vignettes (fictive descriptions), in which selected characteristics describing the vignette person or situation are simultaneously manipulated. The aim of this article is to present a conceptual and an analytical framework for factorial survey studies of professional judgements in social work.  Findings: In the first part of the article, I develop and discuss the proposition that this approach may be used in order to study the contents of professional judgements about the diagnosis and treatment of clients. The contents is discussed in terms of knowledge assumptions 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 regression analysis.  Applications: Findings from analyses of factorial survey data may reveal both professional agreement and disagreement in practitioners judgements. While results that reveal high levels of disagreement in judgements about what constitutes a particular diagnosis or about which intervention is the most suitable for a particular client may raise questions as regards the professionalism of practitioners judgements, results that reveal professional agreement in diagnostic and treatment assumptions may be transformed into hypotheses that can be tested further in research.
Corresponding author: University, SE-205 Lisa Wallander, Senior Lecturer in Health and Society, Faculty of Health and Society, Malmo , Sweden 06 Malmo Email: lisa.wallander@mah.se

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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) movement 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 for thinking 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 in social work, we must rst 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 eld 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 that researchers 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 sciences 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 (ctive descriptions), in which selected characteristics describing the vignette person or situation are simultaneously manipulated. In sociology, the factorial survey approach has been used in many elds of study, including crime and deviance (e.g. Miller, Rossi, & Simpson, 1991), social stratication (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

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occupational groups as nurses (e.g. OToole, OToole, Webster, & Lucal, 1993), case managers (e.g. Corazzini-Gomez, 2002) and police ocers (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 combine 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 eect be described as true multilevel problems, in the sense that the determinants of the outcome may be dened at a number of dierent levels in the analysis. To take one example, studies of this kind often include questions about whether professional judgements are inuenced not only by considerations associated with the client, but also by characteristics of the practitioners who make the judgements, as well as by contextual 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 survey approach 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 aorded by multilevel analysis. Although the occupation of interest in this article is social work, the conceptual framework and modelling strategy proposed are naturally applicable 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 ctive descriptions of people or social situations (see Alexander & Becker, 1978). In studies of professional judgements in health care and social work, the vignettes as a rule portray the characteristics and current situation of (potential) clients, such as children, 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

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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 ctive 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 (dimensions), and by combining these levels into unique scenarios. The vignette described in Figure 1 comprises information about 11 dierent client variables or dimensions, which were considered by the authors of the study to constitute potential determinants of social workers judgements of their clients need for compulsory 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 primary drug, age and sex (for a description of the dimensions, levels and wordings used in this design, see the Appendix). The practitioners judgements were measured 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 eects of variables that are normally very highly correlated. For example, it was possible to make a distinction between the eect on social workers judgements of the clients primary drug and of variables describing the clients physical and mental health conditions respectively (for further results, see Wallander & Blomqvist, 2005). This possibility of completely separating the inuences of the independent variables promotes high internal validity 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).

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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 factorial 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 judgements. The concept of professional judgement may be dened 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 opinion serve best to promote the welfare and best interests of their clients.2 This readiness 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 vignettes 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 nancial 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 judgements made in professional practice, we will start out from one of the theoretical propositions 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) constitute 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 the concept 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 classication 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 customarily 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 eorts to systematize the results from research on social work practice in the form of metaanalyses and practice guidelines (e.g. The Campbell Collaboration, 2010; The Cochrane Collaboration, 2010), there are as of today still no general and widespread dictionaries that social work practitioners can directly consult when making judgements 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 dened as those assumptions which contribute to the professions understanding of its own practice (see Rosen, 1994).5 Thus, a fruitful approach for researchers who are interested in studying professional judgements 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 knowledge, 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 one hand, 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

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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 dierent qualities of the knowledge involved but also about the its source makes them ill suited to the task of serving as a theoretical basis from which to study the knowledge actually used by social workers when making judgements about the diagnosis and treatment of clients. For example, identifying the source of knowledge (research or practice) used in the performance of a particular task tells us nothing about the actual content of this knowledge. In eect, the same substantive hypotheses that are derived from scientic knowledge might also be derived on the basis of practical experience, provided that the same regularities that form the basis of scientic results are also noticeable in real-world practice.7 Further, there is evidence from research that the process of applying scientic 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 practice. In conclusion, the empirical study of knowledge use in professional judgements 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 knowledge that are argued to capture the aspects of professional judgements that can potentially be detected by a factorial survey design.

Empirically useful concepts of knowledge


For authors interested in studying professional judgements, a rst distinction must be made between the process of making a judgement, and the content of the specic judgement made. In the rich literature on judgement and decision-making within the eld of psychology, this distinction is well-established, and researchers have 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 decision-maker and the output (the judgement or decision actually made) (Benbenishty, 1992; Payne, Bettman, & Luce, 1998). Thus, in line with the suggestion 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 dened 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 benet 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 purpose, 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 professionals 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 specic 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 decisions are not necessarily dierent from the cognitive processes characterizing professional judgements and decision-making in general subject knowledge is ultimately domain-specic. Social work practitioners working with problem substance users, for example, need to have knowledge about the problems typically faced by members of this client group, and about the dierent 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 dierent functions of professional practice including the tasks of classifying clients problems and of suggesting interventions with the capacity to change the natural or social circumstances of the clients for the better may require dierent 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 eects 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 social work, 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 collected about their clients, in part via dierent types of assessment instruments (White & Stancombe, 2003). While these forms of knowledge are not interchangeable with one another in social work practice,8 both descriptive and control knowledge 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 abstract problem proles, may be viewed as specic instances of subject knowledge that is focused on description. Similarly, the assumptions involved in treatment assumptions linking the problems identied (. . .) with the responses that those problems require (Sheppard & Ryan, 2003, p. 165) may be treated as specic instances of

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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, physical, 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 addition, 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. The gender 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 inuenced nurses recognition, or diagnosis, of child abuse. The results may be interpreted as reecting 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 compulsory 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 reect the following treatment assumptions: 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 in need 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-specic and context-specic diagnostic and treatment assumptions.

The detection of knowledge actually-in-use


The most common course of action taken by researchers who are interested in studying the subject knowledge used by social workers in judgement and decision-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 the knowledge practitioners actually use, irrespective of whether this knowledge is explicit or tacit (see Polanyi, 1966) to the practitioners themselves at the moment of judgement. Another benet of the design is that problems associated with social desirability are limited (see Alexander & Becker, 1978). Since it is virtually impossible to obtain a complete overview of the manipulations of the vignette dimensions (at least when the time given for lling out the questionnaire is limited), the conscious weighting of dimensions in accordance with the supposed wishes of researchers 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 principles) may be referred to as professional disagreement in judgements. As far as professional disagreement in judgements is concerned, several conditions of social work practice facilitate or make room for the existence of such variation in judgements. For example, most of the laws that regulate social work practice are not specied 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 and treatment of clients is to some degree formed by conditions related to their local work environments, such as organizational guidelines, for example, and the average 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 aorded by multilevel regression analysis (using e.g. the HLM software, see Raudenbush, Bryk, Fai Cheong, & Congdon, 2000). Throughout this 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 practitioners 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 clustered, 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 inuenced by contextual 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 practitioners 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 reects a natural hierarchy. In the designs used in the studies taken as examples (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 xed part, consisting of estimations of regression coecients, 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, a variance component measuring the unexplained variance in the intercept across units is specied for each of the higher levels of the design. When so-called random slope models are employed, it is also possible to specify variance components 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 ctive problem substance users proved to be signicantly related to social workers judgements about eligibility for compulsory care. As has already been noted, one of the eects of the vignette dimension measuring the clients primary drug on the respondents judgements could be interpreted as indicating the presence of a treatment assumption stating that by comparison with problem users of alcohol and amphetamines, problem users of heroin are more in need of compulsory care. Naturally, it is not only the main eects of vignette dimensions on judgements that can be estimated, but also the eects of interactions between vignette dimensions. For example, Wallander and Blomqvist (2005) showed that for clients consenting 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 a particular assumption in a particular situation may disregard it in another situation, if it comes into conict with one or more equally or more critical assumptions. However, although the professional agreement indicated by the results does not equal professional unanimity, these assumptions may be termed collective treatment assumptions. The rst 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 dierent 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 signicance of the variance components at both levels, the authors were able to conclude that individual case managers varied in their average levels of judgements (individual variation), and that case managers practising in dierent agencies varied in their average levels of judgements (contextual variation). This means that the general propensity to recommend an out-of-home placement for the elderly clients presented in the vignettes varied between individual practitioners and between practitioners working in different 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) specied a model in which they allowed the slopes of the three dimensions representing various client preferences to vary randomly across Level-2 and Level-3 units. An inspection of the Level-2 variance components for the slopes showed signicant variance between case managers in the attention paid to client preferences when deciding whether or not 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 interactions, Snijders, 2004), showed that a higher workload, for example, was associated 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 clients who 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 assumptions may indeed be subgroup-specic. If a variable describing the practitioners workplaces, or another contextual variable, had also aected the slope for client preferences, we would have concluded that this treatment assumption had been context-specic. If the size and signicance of the variance components decrease with the inclusion of respondent or contextual variables, it may be concluded that the variables added (if signicant) account for some of the previously unexplained variance. As a nal step in this modelling strategy, it is useful to inspect what remains of the variance components subsequent to the inclusion of potential predictors of judgements. For example, due to the remaining signicance 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 respondent predictors 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 dierent 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 following, 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 factorial survey approach constitutes an advanced instrument for studying practitioners use of knowledge in the context of professional judgements, and more specically for studying the assumptions they employ as a basis for judgements associated with the dual tasks of diagnosis and treatment. In addition, it was maintained that this approach provides opportunities for detecting diagnostic and treatment assumptions irrespective of whether they are used explicitly or tacitly in professional judgements. Thus, by using this instrument, researchers may achieve an objective that has been called for by a number of authors in the eld 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 inuence of intuition (i.e. the antonym of analysis) in professional 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 elds 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 professional judgements. Naturally, even given this substantial methodological potential there is still a need for social work practitioners to continue to develop their own professional 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 this chain (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 preparations, studies using the factorial survey approach obviously fall short of explaining how the dynamics of the particular situation in which a social worker and a client are interacting, as well as their personal chemistry, may inuence social workers professional judgements. Third, the results of a factorial survey, which may reveal the collective, subgroup-specic or context-specic 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 know why 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 justied the diagnostic and/or treatment assumptions 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 ndings 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 particular 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 detect professional 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 scientic knowledge, but on knowledge that originates in social work practice or in personal experience from other domains of life they cannot be directly transformed into formal advice about what should constitute 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 dierent treatments for dierent clients could be employed as a means of structuring evaluations in which the benets of these particular treatments for groups of clients were compared. The results from such evaluations could subsequently be utilized by practitioners for validating or modifying the assumptions detected in an FSA design.

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This suggestion is in line with Payne (2001), who criticizes the concept of a professional 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 Misuse pattern Regular Frequent Accelerating Consent to treatment Strong Medium Weak Failed treatments None One Several Physical health No problems Some problems Acute problems Mental health No problems Some problems Acute problems Social situation Stable Unstable Acute Violent behaviour None Earlier signs Recent signs

Wordings A couple of times a week More-or-less daily Daily and accelerating Wants help Recognizes that he/she has misused the drug to a high extent lately Does not consider himself/herself to be in need of any type of intervention from the social services No treatment during the last year Failed to complete treatment on one occasion during the past year Failed to complete treatment on several occasions during the past year No known physical health problems Seems to be in poor physical health Recently treated for medical injuries caused by the drug misuse No known mental health problems Seems to be mentally unstable Recently hospitalized following a suicide attempt Stable social situation Unstable social situation Is on the road to social marginalization No inclination towards violence Earlier violent acts under influence of drugs Recent violent acts under influence of drugs

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Primary drug Alcohol Amphetamines Heroin Sex Male Female Age Young Middle aged Old Family status No family Family

Misuses alcohol Misuses amphetamines Misuses heroin Man Woman A 25-year-old A 39-year-old A 56-year-old Lives alone, without children Lives with partner and children

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 naturally 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 important 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 discovery 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).

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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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