Abstract
Background Although the increasing complexity and expansion of the body of knowledge in physical therapy have led to specialized practice areas to provide better patient care, the impact of specialization on guideline implementation has been scarcely studied.
Objectives The objective of this study was to identify the similarities and differences in barriers to the implementation of a Dutch rheumatoid arthritis (RA) guideline by generalist and specialist physical therapists.
Design This observational study consisted of 4 focus group interviews in which 24 physical therapists (13 generalist and 11 specialist physical therapists) participated.
Methods Physical therapists were asked to discuss barriers to the implementation of the RA guideline. Data were analyzed qualitatively using a directed approach to content analysis. Both the interviews and the interview analysis were informed by a previously developed conceptual framework.
Results Besides a number of similarities (eg, lack of time), the present study showed important, although subtle, differences in barriers to the implementation of the RA guideline between generalist physical therapists and specialist physical therapists. Generalist physical therapists more frequently reported difficulties in interpreting the guideline (cognitive barriers) and had less favorable opinions about the guideline (affective barriers) than specialist physical therapists. Specialist physical therapists were hampered by external barriers that are outside the scope of generalist physical therapists, such as a lack of agreement about the roles and responsibilities of medical professionals involved in the care of the same patient.
Conclusions The identified differences in barriers to the implementation of the RA guideline indicated that the effectiveness of implementation strategies could be improved by tailoring them to the level of specialization of physical therapists. However, it is expected that tailoring implementation strategies to barriers that hamper both generalist and specialist physical therapists will have a larger effect on the implementation of the RA guideline.
In many countries, the development and implementation of evidence-based clinical practice guidelines are major topics of health care policy. Clinical guidelines are systematically developed statements designed to help practitioners and patients make decisions about appropriate health care pathways.1 Important goals of clinical guidelines include higher quality of care, improved cost-effectiveness, and, ideally, improved health outcomes.2–5 However, such guidelines have little impact on clinical practice if they are not successfully integrated into clinical settings.
In line with general trends in health care, physical therapists have become aware of the need for an evidence base to improve quality and cost-effectiveness. This awareness has resulted in a rapid increase in the number of evidence-based clinical guidelines developed by various professional organizations in physical therapy.6,7 A recent study showed strong indications that adherence to guidelines is related to an improvement in physical function and to a lower level of utilization of care.8 However, despite wide distribution and promotion, practice guidelines are not extensively used.9
Implementation strategies, therefore, are essential in promoting the implementation of clinical guidelines by physical therapists. To assist physical therapists in adhering to recommendations in their daily practice, effective implementation strategies need to be developed.
Previous implementation strategies aimed at changing behavior were pursued in the absence of clear information about why practitioners did not exhibit the preferred behavior.10 Consequently, such strategies might have lacked a rationale for the choice of their content and, therefore, might have produced only small to moderate effects.2,9,11 Research has suggested that implementation strategies are more effective if they address specific barriers to change.3,12 Interventions tailored to prospectively identified barriers are more likely to improve professional practice.13 Recently, Harting et al,9 Côté et al,14 and Stevens and Beurskens15 reported about barriers to physical therapists' adherence to clinical guidelines and use of measurement instruments. These barriers can be grouped into 4 categories: physical therapist characteristics, guideline characteristics, patient factors, and environmental factors (including organizational, political, and social factors).3,11,16
Cabana et al11 developed a framework outlining how these barriers to adherence relate to behavioral change. This framework is theoretically grounded in work done by Fishbein and Ajzen17 and others on understanding attitudes and beliefs and predicting social behavior; this work includes the theory of planned behavior, which proposes that intentions are determined by attitude (beliefs about whether the benefits outweigh the costs), subjective norm (perceived normative pressure), and perceived control over the behavior.18 According to the framework of Cabana et al,11 practice guidelines can affect patient outcomes only when they first affect physical therapists' knowledge, attitudes and, finally, behavior. Although behavior can be modified without knowledge or attitudes being affected, behavioral change based on influencing knowledge and attitudes is probably more sustainable than manipulation of behavior alone.11 The framework also suggests that physical therapists may fail to adhere to guidelines because of internal barriers, which have either cognitive (awareness or knowledge) or affective (attitude or motivation) components; external barriers (patient, guideline, and environmental factors), which restrict professionals' ability to adhere to guidelines; or both types of barriers.11
Therefore, according to the framework of Cabana et al11 and other publications,9,14,15 barriers to physical therapists' adherence to guidelines include the following: at the level of cognitive barriers, a lack of awareness of or familiarity with guidelines9,15; at the level of affective barriers, a lack of agreement with guidelines in general,9,15 a lack of agreement with a specific guideline,9,14 a lack of positive outcome expectancy,9,14,15 and a lack of self-efficacy9,14,15; and at the level of external barriers, patient factors,9,14,15 guideline factors,14,15 and environmental factors.9,14,15
Research into the determinants of physical therapists' adherence to guidelines has not assessed whether barriers vary among physical therapists according to their level of specialization. This theme is interesting because increasing specialization in physical therapy is thought to be related to improvements in various aspects of patient care, including recovery times, risk of recurrence, and appropriate management of conditions.19 In addition, the literature has suggested that barriers to adherence may be different in generalist and specialist physical therapists. Clinical specialization of physical therapists helps to promote greater familiarity with and use of evidence-based practice20,21 and higher standards of physical therapy.22 Previous research showed that clinical specialization increases physical therapists' knowledge of pathophysiology and improves diagnosis and treatment of patients within the area of specialization.23 Increased knowledge was found to significantly support the increased use of evidence-based outcome measures.24 Improved familiarity with and use of evidence-based medicine may indicate that internal (eg, awareness of guideline content) and external (eg, guideline characteristics) barriers to adherence to guidelines are different in generalist and specialist physical therapists. Furthermore, other research showed that specialist physical therapists treated their patients with fewer visits and used fewer treatment techniques per patient than generalist physical therapists but that functional improvements were similar for both types of therapists.25 These findings may have been attributable to greater use of evidence-based medicine by the specialist physical therapists. Familiarity with and use of evidence-based medicine by specialist physical therapists can lead to improved knowledge and understanding of guideline content and ultimately to greater adherence to a guideline. Indeed, Nijkrake et al26 found greater adherence to Parkinson disease guidelines by specialist physical therapists than by generalist physical therapists, but their study did not assess the underlying barriers to adherence to guidelines. However, when barriers to adherence to guidelines actually are different in generalist and specialist physical therapists, different strategies are needed to promote adherence to guidelines by generalist and specialist physical therapists.3,12
With respect to adherence to a rheumatoid arthritis (RA) guideline in general, so far most research has focused on medical care; topics have included early referral,27 the continuation of anti–tumor necrosis factor treatment,28 and the execution of regular follow-up.29 The results of all of these studies suggested suboptimal implementation of the RA guideline by rheumatologists. Studies on barriers to and facilitators for the implementation of the RA guideline were performed with rheumatologists and patients. These studies identified several factors, such as concerns that physician autonomy would be restricted and that clinical practice guidelines would be used to bring legal action against physicians,30 differences between rheumatologists' and patients' perceptions about treatment choices,31 and fears about adverse reactions to specific medications.32 So far, studies have not focused on physical therapists' perceptions of barriers to and facilitators for the implementation of the RA guideline.
Given the scarcity of knowledge about the level of specialization of and guideline implementation by physical therapists, the aim of this study was to identify similarities and differences in perceived barriers to the implementation of the RA guideline by generalist and specialist physical therapists. As mentioned earlier, research on adherence to guidelines (specifically, the RA guideline for physical therapists), whether related to level of specialization or not, has not been done. However, differences in the treatment of patients with RA by generalist and specialist physical therapists have been demonstrated.33,34
The identification of similarities and differences in perceived barriers will contribute to a further understanding of physical therapists' attitudes and beliefs that are critical in predicting whether they will engage in a behavior such as using the RA guideline. This understanding will facilitate tailoring implementation strategies to either generalist or specialist physical therapists, with the primary goal of improving the implementation of the RA guideline.
Method
Rationale
The Royal Dutch Society for Physical Therapy (KNGF) developed a national quality assurance program that included the development and implementation of clinical guidelines35,36; this effort resulted in the publication of 20 evidence-based guidelines by 2010. These guidelines are disseminated to physical therapists by the KNGF. A recent report indicated that dissemination of the guideline is well organized but that more attention is needed to promote physical therapists' adherence to guideline recommendations.37 Therefore, the strategy of the KNGF has shifted toward identifying barriers that prevent physical therapists' adherence to clinical guidelines and then designing effective strategies to promote the use of guidelines by the target group. For the present study, we used the KNGF RA guideline.38
Rheumatoid arthritis is an autoimmune disease that affects approximately 1% of the adult population in Western countries.39 Its main feature, chronic inflammatory arthritis, can cause irreversible joint damage and substantial functional impairment. Despite the wide range of effective drugs currently available, a considerable proportion of patients will have a relatively low but persistent level of disease activity that interferes with their daily activities. Therefore, most patients will need long-term care consisting not only of drug therapy but also of education, guidance, and support to cope with the consequences of the disease. Physical therapy plays an important role in the provision of nonpharmacological care, with 25% to 40% of patients with RA using physical therapy in a period of 12 months.40,41 Because RA is a complex disease, specialist physical therapists are available in some countries.34 Moreover, evidence-based practice guidelines covering physical therapy treatment have been developed, either for physical therapists specifically or for all professionals involved in RA management.38,42–45
The Dutch guideline on the physical therapist management of RA was chosen for the present study because it is specifically aimed at RA and has been available for a sufficient period of time to allow physical therapists to become familiar with it but is not outdated. This guideline includes recommendations for the initial assessment, treatment, and evaluation of patients with RA. The guideline is available in English and is accessible online.38,45
A key recommendation for both assessment and evaluative purposes is the use of specific measurement instruments related to relevant functions, activities, and participation of patients with RA. The main recommendation for treatment is that patients with RA (including those with a high level of disease activity) should be offered a high-intensity exercise program aimed at improving aerobic capacity, muscle power, and muscle endurance. This program can be supplemented by range-of-motion exercises to maintain joint mobility.
Study Design
In January 2010, four 2-hour focus group interviews (2 focus groups with specialist physical therapists and 2 focus groups with generalist physical therapists) were conducted to discuss barriers to the implementation of the RA guideline and possible strategies to improve the implementation of the guideline (ie, facilitators). The in-depth nature of data collection in focus group interviews allows exploring of cognitions and motivations of professionals that underlie behavior, thereby providing information on potential interventions to improve adherence to guidelines.46–49 Two focus group interviews were held at the Leiden University Medical Center (LUMC), and 2 were held at the Academic Medical Center Amsterdam (AMC). According to Dutch legislation, neither obtaining informed consent nor obtaining approval by a medical ethics committee was obligatory for the present study.
Recruitment of Participants
A purposive sampling technique was used to identify potential participants. To recruit generalist physical therapists, we invited physical therapists who were from the regional section of the KNGF in North Holland and who attended a meeting concerning the RA guideline (n=225). Their participation in a meeting about the guideline ensured that physical therapists participating in the present study were familiar with the guideline.
To recruit specialist physical therapists, we invited all physical therapists with specific expertise in the management of RA from Fyranet Leiden (a network for collaboration among health care professionals who specialize in the treatment of patients with RA) (n=22) and Arthritis Network Amsterdam (n=23) to participate. Membership in these networks requires the completion of a basic course on rheumatic conditions (including lectures, case presentations, and case work-ups) and participation in 80% of the subsequent continuing educational activities (eg, workshops).23
Both generalist and specialist physical therapists were invited by means of an e-mail comprising information on the aims and methods of the present qualitative study. The physical therapists were offered accreditation for continuing education (2 hours per session) for their participation in the focus groups. All generalist (n=13) and specialist (n=11) physical therapists who expressed an interest in participation were included in the present study. Because of limited time and resources, no attempts were made to collect reasons for nonparticipation from specialist and generalist physical therapists.
Focus Group Interviews
In each focus group session, the physical therapists had a semistructured discussion about the perceived barriers to implementation of the RA guideline. The sessions were moderated by 1 of 3 investigators (I.V., M.D., and M.K.; M.D. moderated 2 sessions). Each of these 3 investigators holds a master's degree in physical therapy for managing chronic illnesses and specializes in the management of rheumatic and orthopedic conditions. These investigators were trained to moderate the focus group sessions by a physical therapist (Florus van der Giesen, PT, PhD) with experience in the conduct of qualitative research, in particular, focus group studies. During each session, 2 of the 3 previously mentioned researchers took notes as observers: 1 focused on nonverbal behavior and group dynamics, and the other monitored the process, kept the time, and audiorecorded the sessions. None of the investigators in the present study, including the moderators and observers, had personal or professional relationships with the participants in either the generalist or the specialist focus groups.
A topic guide with open-ended questions was used to structure the discussion (Appendix). The topic guide was constructed in accordance with the framework of Cabana et al.11 The topic guide consisted of a topic list, meant to ensure that the main issues with regard to the framework of Cabana et al11 would be discussed, and included follow-up prompts to elicit more detailed information. The questions were formulated in an open way to avoid prejudiced interpretation on the part of the researchers and to stimulate free discussion among the participants in the focus groups. For example, the moderator of the focus groups might have used the following questions and prompts:
Question regarding “cognitive barriers”: “We are interested in your opinions about the RA guideline. Can you tell us what you think about the RA guideline?”
Follow-up prompt for “lack of awareness”: “We have not heard anything yet about the way you were informed about the existence and content of the guideline.”
Question regarding “external barriers”: “What can you tell us about the way you apply the RA guideline in your practice?”
Follow-up prompt for “organizational factors”: “Do you come across any obstacles in your practice when you apply the guideline?”
The interview guide was pilot tested with 5 physical therapists not involved in the present study. No adjustments to the interview guide were made between the focus group sessions.
Data Analysis
The audiorecordings of the focus group interviews were independently reviewed by 3 investigators (I.V., M.D., and M.K.) and transcribed verbatim. We performed a qualitative content analysis with a directed approach, which is a widely used qualitative research technique starting with a theory or relevant research findings as guidance for initial codes. A directed approach is appropriate if existing theory and earlier research about a phenomenon (eg, the implementation of guidelines) are incomplete or would benefit from further description.50 This directed approach consisted of 2 steps.50 Step 1 involved reading the transcripts and highlighting all text that, on first impression, appeared to represent potential barriers to or facilitators of adherence to guidelines. Step 2 involved coding all highlighted passages with predetermined codes. This 2-step method ensured that we captured all possible barriers mentioned in the focus group interviews. The predetermined codes were similar to the 3 main categories of adherence to guidelines (ie, cognitive, affective, and external barriers) and subcategories (eg, lack of awareness and lack of outcome expectancy) in the framework of Cabana et al11 and the topics and prompts used in the focus group topic guide (Appendix).
The transcripts were independently coded by hand by I.V., M.D., and M.K. As mentioned earlier, they had all been present during the focus group interviews as moderators or observers. For coding of the transcripts, they all had access to the field notes, so that any information relevant to the interpretation of the transcripts would be used. After coding of the transcripts, disagreements between the reviewers were resolved through another review of the transcripts and the field notes and then group discussion. The results of their data analysis were then discussed with the entire research group, which included 1 specialist physical therapist (E.H.), several generalist physical therapists (I.V., J.V., M.D., and M.K.), and researchers or quality officers with knowledge, skills, and expertise in implementation science (L.B.-V., P.W., and T.V.V.).
Results
Twenty-four physical therapists participated in the focus groups. Table 1 shows the characteristics of these physical therapists. The participating generalist and specialist physical therapists were comparable in terms of sex, age, years of experience as a physical therapist, and self-reported knowledge about the RA guideline. The specialist physical therapists had, on average, more years of experience with diagnosis and treatment of patients with RA and treated, on average, more patients with RA per year than the generalist physical therapists.
Characteristics of Participants in a Focus Group Study of a Guideline for the Management of Rheumatoid Arthritis (RA) by Physical Therapists
General Observations
According to the observers, all 4 focus group interviews were characterized by a pleasant and open atmosphere. The investigators obtained agreement regarding the coding and the further analysis and interpretation of the data. The use of field notes did not prove to be necessary.
Although the physical therapists in the focus groups expressed a wide variety of opinions, there were common feelings about barriers to adherence to the RA guideline. Table 2 shows all of the barriers, grouped according to the categorization in the framework of Cabana et al,11 along with the most representative remarks.
Barriers Reported by Generalist and Specialist Physical Therapists (PTs)a
Cognitive Barriers
According to the stages of behavioral change, physical therapists first must become acquainted with a guideline and then must develop an adequate understanding of the guideline.11 Likely cognitive barriers for this “knowledge” stage of behavioral change are a lack of awareness and a lack of familiarity.11 Both generalist and specialist physical therapists indicated that they are typically not motivated to read guidelines. However, all focus group participants had read the RA guideline because of their participation in an educational meeting (generalist physical therapists) or in a specialist network (specialist physical therapists). Therefore, both generalist and specialist physical therapists participating in the present study were aware of and familiar with the RA guideline.
Generalist physical therapists considered the RA guideline to be a guiding principle for diagnosis and treatment of patients with RA but were not motivated to read the guideline. According to the generalist physical therapists, this lack of motivation was caused by the enormous amount and inconvenient arrangement of text within the RA guideline. They suggested that key words and a summary of new insights could improve the readability of the RA guideline. They also indicated that the guideline “suddenly” overloaded them with information. This feeling was caused by the fact that they had not been involved in or were poorly informed about the development of the guideline by the KNGF. This lack of involvement in the development of the guideline created a lack of trust in the KNGF among the generalist physical therapists. According to the generalist physical therapists, this feeling could have been prevented had the KNGF involved them in the development of the guideline or been more explicit about the names, areas of expertise, and professional experience of the authors.
Specialist physical therapists, on the other hand, considered the RA guideline to be a reference guide and agreed that guidelines support quality improvement and transparency. They thought that the guideline was complete and conveniently arranged but also that it did not contain any “new” information for them. As a consequence, they were not motivated to consult the guideline.
Affective Barriers
After physical therapists have become acquainted with a guideline, they should develop a positive attitude toward the guideline.11 According to the model of Cabana et al,11 there are 5 types of affective barriers that influence the development of this positive attitude: lack of agreement with guidelines in general, lack of agreement with a specific guideline, poor outcome expectancy, low self-efficacy, and lack of motivation.
Lack of agreement with guidelines in general.
From the focus groups it appeared that the generalist physical therapists and, to a lesser extent, the specialist physical therapists thought that the presentation of guidelines generally does not fit in with their practical learning methods. In addition, the generalist physical therapists expressed a lack of confidence in the KNGF, which develops the guidelines. According to the generalist physical therapists, education that focuses on key recommendations of guidelines and meetings with (practicing) colleagues to discuss guideline content may facilitate familiarity with guideline content and stimulate the development of a positive attitude toward guidelines.
Lack of agreement with the RA guideline.
In addition to concerns about guidelines in general, the generalist and specialist physical therapists expressed doubts about the levels of evidence used for the recommendations in the RA guideline. They indicated that the levels of evidence were not described very well and seemed to be based primarily on expert opinions. Additionally, the generalist physical therapists expressed a lack of agreement with the RA guideline because they thought that it was not sufficiently tailored to serve the needs of individual patients with their unique characteristics.
Poor outcome expectancy.
Outcome expectancy is the expectation that adherence to guideline recommendations will lead to better patient outcomes. Poor outcome expectancy hampered a positive attitude toward the RA guideline in the generalist and specialist physical therapists. Although the generalist and specialist physical therapists were aware of and may have agreed with the guideline recommendations, many stated that they did not adhere to these recommendations, especially recommendations about measurement instruments. According to the physical therapists, an important reason for nonadherence was the lack of clarity about the purposes of the measurement instruments and the added value of each diagnostic test for individual patients. After all, physical therapists see patients individually and do not discern success at the population level.
Low self-efficacy.
Physical therapists' attitudes toward the RA guideline were also negatively influenced by low self-efficacy, that is, a lack of belief that they could actually perform the guideline recommendations. Some generalist and specialist physical therapists believed that they could not apply the guideline recommendations because of a lack of routine use of or experience with the recommended measurement instruments. Specialist physical therapists suggested practical learning sessions with small groups of physical therapists as a way to learn to use the measurement instruments. Generalist physical therapists indicated that an information exchange network, the availability of RA experts to answer questions, and interactive learning sessions during which they could learn from colleagues would help improve their skills.
Lack of motivation.
Generalist and specialist physical therapists indicated that they have difficulties changing their working methods because of a lack of motivation.
Generalist physical therapists stated that they were less motivated because they frequently had no contact with patients who had RA. To address this issue, the generalist physical therapists proposed referring patients with RA to specialist physical therapists or dividing tasks among physical therapists within a practice so that each therapist focuses on the diagnosis and management of specific complaints or disorders.
Specialist physical therapists attributed a lack of motivation to their gained experience and persistence in their own working methods. Specialist physical therapists mentioned several strategies that could motivate them to change their working methods: rewarding the use of guidelines through financial incentives or accreditation for continuing education, using reminders in electronic health records, and having a joint and positive mission and a vision about the implementation of guidelines within a practice.
External Barriers
After physical therapists have developed a positive attitude toward a guideline, other factors, such as patient, guideline, and environmental factors, can hamper the actual application of the guideline.11 These factors also have an indirect influence on improving knowledge and self-efficacy and developing a positive attitude toward the guideline.11
Patient factors.
Generalist physical therapists—and, to a lesser extent, specialist physical therapists—thought that physical therapy management in accordance with the RA guideline would not be in accordance with the expectations and preferences of patients. According to the physical therapists, patients generally have too little knowledge of what a physical therapist is and does. The focus group participants thought that it would be helpful to better manage patients' expectations for physical therapy by, for example, providing patients with information leaflets about the general skills of physical therapists, up-to-date diagnosis and treatment strategies, and the value of the application of measurement instruments.
Guideline factors.
Although the generalist and specialist physical therapists shared the opinion that the guideline format did not fit in with their practical learning methods, the factors hampering the actual application of the guideline by the generalist and specialist physical therapists differed. Generalist physical therapists indicated that they missed case examples and supporting materials illustrating the use of guideline content in practice. Specialist physical therapists indicated that the lack of “computer-facilitated” measurement instruments hampered the actual application of the guideline recommendations.
Environmental factors.
Both generalist and specialist physical therapists indicated that environmental factors also influenced their behavior. Environmental factors can be divided into organizational, political, and social issues. Organizational issues raised by all physical therapists included a lack of time to perform all diagnostic tests and the related administrative work. In addition, the physical therapists indicated that they could not apply the guideline as intended because of a lack of availability of training facilities, a lack of access to the measurement instruments mentioned in the guideline, and a lack of integration of diagnostic tests into electronic health records. Solutions suggested by the physical therapists for these organizational issues included developing short versions of several diagnostic tests, providing diagnostic questionnaires online, providing 1 preferred diagnostic test, and more effectively integrating outcomes of diagnostic questionnaires into electronic health records.
Political issues also played a role. Some generalist and specialist physical therapists questioned whether guidelines must become part of contracts with insurers. These contracts involved many compulsory measurements that decreased some physical therapists' satisfaction with their jobs. However, other physical therapists viewed the involvement of insurance companies as a facilitator of adherence to guidelines. They perceived the involvement of insurance companies not as a threat but as a factor motivating adherence.
Social issues influencing the use of guidelines included a failure of practice management to develop and use strategies promoting the implementation of the RA guideline and a lack of discussions with colleagues about the use of the guideline in daily practice. In addition, the specialist physical therapists indicated that a lack of agreement among medical professionals involved in diagnosis and treatment about roles and responsibilities limited their ability to optimally treat patients. Therefore, on the basis of the information collected from the specialist physical therapists, it seems important for health care providers with various professional backgrounds to work collectively to reach agreements about their roles in RA management, such as providing advice on lifestyle modifications or the use of assistive devices, and to communicate this unified message to patients with RA.
Discussion
The barriers and facilitators identified in the present study largely match the previously described determinants of adherence to guidelines.9,14,15 Many of the cognitive, affective, and external barriers (patient, guideline, and environmental factors) hampered the application of the RA guideline by both generalist and specialist physical therapists; specific barriers included poor outcome expectancy, a lack of time, and a lack of practice requirements. However, our results also showed some previously unidentified important—but subtle—differences in barriers between generalist and specialist physical therapists.
With respect to internal barriers, the results of the present study were generally similar to those described in the literature. Cognitive barriers included a lack of motivation9 and the large amount of information in the guideline.9,15 Affective barriers included a lack of practical usefulness,9,15 a lack of confidence in the guideline developers and doubts about the credibility of the recommendations,9 an inability to tailor the guideline contents to individual patients,9,14 perception of a lack of impact of measurement instruments,14,15 therapists lacking belief in their own competencies,15 therapists being resistant to change and being persistent about their own working methods,9,15 and a lack of routine use of or experience with measurement instruments.14,15 In addition, our results suggested that internal barriers were notably more present in generalist physical therapists than in specialist physical therapists. Generalist physical therapists had more difficulties in interpreting the RA guideline (cognitive barriers) and had fewer favorable opinions about the RA guideline (affective barriers). For example, generalist physical therapists were hampered in interpreting the RA guideline by the enormous amount of text in the guideline. This barrier was not relevant for specialist physical therapists because they were already familiar with the RA guideline content as a result of their special interest in RA and their participation in networks for physical therapists who specialize in RA management. Generalist physical therapists also agreed less with the RA guideline content than specialist physical therapists because of a lack of confidence in the guideline developers, a belief that the guideline cannot be tailored to individual patients, and a belief that measurement instruments are not applicable to all patients. In addition, generalist physical therapists frequently had no contact with patients who had RA.
Although the specialist physical therapists had more knowledge of RA guideline content and generally had more positive attitudes about the guideline than the generalist physical therapists, they had an unfavorable attitude about the recommended measurement instruments. As in previous studies,15,51 this unfavorable attitude resulted from a lack of time, a lack of clarity about the value of the instruments in the plan of care, and a lack of practice requirements. In contrast, Copeland et al24 found that having a master's degree and having an increased level of knowledge about outcome measurements were significantly related to the use of measurement instruments. The findings of Copeland et al24 suggested that specialist physical therapists would have a positive attitude about measurement instruments. A possible explanation for this discrepancy is that the specialist physical therapists in our focus groups finished their education years before and, therefore, were not taught to regularly use measurement instruments.
The considerable number of external barriers identified in the present study are in line with previous studies on barriers to guideline implementation by physical therapists, including the findings that patients had different expectations for physical therapy services,9,14,15 that the guideline was not easy to use, and that the recommended measurements were too extensive.14,15 Furthermore, physical therapists lacked the time to apply the guideline,9,15 reported a lack of practice requirements or practice policy for applying the guideline,9,15 showed resistance to insurance companies using guidelines to establish reimbursement policies,9 and mentioned a lack of discussions, meetings, and feedback from colleagues about applying the guideline.15
In addition to these findings, our results suggested that the specialist physical therapists were hampered by external barriers not encountered by the generalist physical therapists, including a lack of agreement among medical professionals involved in diagnosis and treatment about roles and responsibilities. Surprisingly, despite the fact that the generalist physical therapists attended an educational session and the focus group sessions on a voluntary basis, some of them indicated that they had no contact with patients who had RA. Moreover, although the specialist physical therapists encountered problems in applying the RA guideline because of a lack of agreement among professionals, the generalist physical therapists were not concerned with this coordination of care. This finding could imply that generalist physical therapists have little insight into the complexity of the disease and its management. More research is needed to substantiate this hypothesis and to explore whether it pertains to other chronic conditions involving care by multiple health care providers.
To our knowledge, the present study is the first to explore whether barriers to the implementation of a guideline differ in generalist and specialist physical therapists. Although our results are helpful for promoting the use of guidelines by physical therapists, the present study had several limitations. First, because of our focus on the RA guideline in the present study, we cannot be certain that the barriers identified apply to physical therapy guidelines in general. As a consequence, the findings may not be transferable to other specialty areas. Second, we did not explicitly assess whether data saturation was reached. Third, it is possible that the study results were affected by selection bias. Only 13 of the 225 generalist physical therapists expressed an interest in participating in the present study, and the reasons for nonparticipation by the specialist and generalist physical therapists were not collected. Because of the limited number of participants, no further selection with respect to factors such as age, sex, or years of experience could be made to ensure a balanced composition of the focus groups. However, because the results obtained with both focus groups (generalist and specialist physical therapists) were similar, we do not believe that more focus groups or the participation of more physical therapists would have led to contradictory results. Fourth, the fact that 3 researchers (E.H., J.V., and T.V.V.) were involved in the development of the guideline could be another source of bias. However, those researchers did not play a role in conducting the focus group interviews or in coding the transcripts, so it is not likely that their involvement in the development of the guideline had an impact on the outcomes of the present study. Finally, another limitation of the present study was the possibility of censorship, with the specialist physical therapists coming from the same network and the generalist physical therapists coming from the same region. Given that the participants in the focus groups likely knew each other, individual interviews might have prevented potential censorship.
Despite the described limitations, the present study provided an in-depth understanding of the factors that influence adherence to the RA guideline by generalist and specialist physical therapists. This understanding of barriers to change is a prerequisite for developing effective strategies for the implementation of the RA guideline by physical therapists.3,12 On the basis of the findings of the present study, we suggest that future implementation studies and initiatives to improve RA guideline implementation need to be practical and sensitive to the context of clinical practice for physical therapists and patients. To further improve effective implementation of the RA guideline, implementation strategies could be tailored to the subtle differences in barriers in generalist and specialist physical therapists. One avenue could be the development of 2 guidelines: a simplified guideline for generalists and a more advanced and detailed guideline for specialists. For example, future education about RA for generalist physical therapists could focus on RA guideline content and application to patients in interactive sessions with key messages, whereas future education for physical therapists who specialize in RA management could take the multidisciplinary context into account. One strategy could be to involve specialist physical therapists in the training of generalist physical therapists. This strategy would provide specialist physical therapists with the opportunity to share their knowledge and experiences; such sharing also might improve their own attitudes toward the RA guideline. Another distinction could be made in strategies to improve the use of measurement instruments by generalist and specialist physical therapists. For generalist physical therapists, the strategy could focus on upgrading knowledge and use of the measurement instruments, whereas for specialists physical therapists, the strategy could focus on interventions that help them incorporate measurement instruments into daily practice and inform other medical specialists about their skills.
The increasing complexity and breadth of physical therapy, coupled with an increase in the number of specialist physical therapists, strengthen our recommendation to take differences in specialization into account when developing implementation strategies to improve adherence to the RA guideline.19 However, we hypothesize that tailoring implementation strategies to the barriers that hamper the application of the RA guideline by both generalist and specialist physical therapists will have the greatest positive effect on the implementation of the RA guideline.
Appendix.
Topic Guide
Footnotes
Dr Verhoef, Ms Dickmann, Ms Kleijn, Ms van Vliet, Dr Hurkmans, Dr van der Wees, and Dr Vliet Vlieland provided concept/idea/research design. Dr van Bodegom-Vos, Dr Verhoef, and Dr Vliet Vlieland provided writing. Ms Kleijn, Ms Dickmann, Ms van Vliet, and Dr Hurkmans provided data collection. Dr van Bodegom-Vos, Dr Verhoef, Ms Dickmann, Ms Kleijn, and Ms van Vliet provided data analysis. Dr Verhoef and Dr van der Wees provided project management. Ms Kleijn, Ms Dickmann, and Ms van Vliet provided study participants. Dr Verhoef and Dr Vliet Vlieland provided institutional liaisons. Dr Verhoef, Dr Hurkmans, Dr van der Wees, and Dr Vliet Vlieland provided consultation (including review of manuscript before submission). Dr van der Wees is an employee of the Royal Dutch Society for Physical Therapy (KNGF), which issued the development of the rheumatoid arthritis guideline. The authors are indebted to Florus van der Giesen, PT, PhD, who gave advice and training on the conduct of focus groups.
A poster presentation of this research was given at the Guidelines International Network Conference; August 28–31, 2011; Seoul, South Korea.
- Received March 29, 2011.
- Accepted June 15, 2012.
- © 2012 American Physical Therapy Association
References
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