Determinants of Guideline Use in Primary Care Physical Therapy: A Cross-Sectional Survey of Attitudes, Knowledge, and Behavior

Main Findings

The key findings of this study conducted among a sample of physical therapists in Swedish primary care were that attitudes toward EBP and guidelines were in general very positive, although self-reported behavior did not fully reflect this, and that awareness of and perceived access to guidelines and other EBP resources were limited. Attitudes toward EBP were more positive among younger therapists and those with few years of experience, whereas self-efficacy concerning EBP was greater among those with a postgraduate degree. The most important determinants of frequent guideline use were considering guidelines important to facilitate practice and knowing how to integrate patient preferences with guidelines.

Attitudes, Knowledge, Behavior, Prerequisites, and Barriers to EBP

The positive attitudes toward EBP found in this study are largely consistent with previous surveys in the United States,⁶ Australia,¹⁶ and Sweden.^29,30 A smaller qualitative study in the United Kingdom also showed favorable attitudes toward EBP, although participant understanding of EBP varied.³² The fact that younger and less experienced therapists reported more positive attitudes toward EBP also is consistent with previous studies.^6,16,30 In recent years, undergraduate education in Sweden has increasingly emphasized the importance of EBP and various EBP skills are now taught, whereas those who graduated before the turn of the millennium have not received EBP training to the same extent, possibly contributing to this difference in attitudes. One way to address this difference in attitude would be to offer continued education on EBP, particularly targeting older and more experienced therapists.

The association found between self-efficacy to find research and a postgraduate education, also supported by previous studies,^6,16,30,32 further points to the relevance of providing education and training in EBP skills, possibly as part of a guideline implementation strategy.

Nearly all therapists expressed a desire to learn or improve their EBP skills, and approximately one third expressed low degrees of self-efficacy to find relevant research and to treat patients according to current best evidence. Low self-efficacy and insufficient education are among the previously identified barriers to performing EBP activities,^12,13,17,18 further strengthening the case for educational efforts. A desire for learning also has been identified as a predictor of the propensity to adopt EBP in physical therapy.³³

Respondents in our study appeared to read scientific articles and perform database searches somewhat less frequently than their colleagues in the United States.⁶ These findings possibly can be explained by the fact that a smaller proportion (approximately half of the respondents) knew how to access online databases.

Barnard and Wiles³² reported that access to EBP resources such as libraries and databases was seen as an important facilitator of EBP by British physical therapists, and Iles and Davidson¹⁶ reported poor access to journals and summaries of evidence as the second largest barrier after time among Australian physical therapists. The limited knowledge of how to access databases in our study is most likely an information issue because all employees of the Region Västra Götaland have online access to databases via an electronic library. The youngest therapists knew to a lesser extent how to access databases, suggesting a need for the county council to provide better information on access to evidence resources for recent hires. Online access to research summaries or systematic reviews has been shown to facilitate the implementation of EBP in clinical practice,³⁴ and access to evidence has been identified as a key prerequisite for achieving EBP in physical therapy.³⁵

The frequency of reading scientific articles is somewhat difficult to interpret. Reading scientific articles or searching databases may not be necessary if you have access to summarized research briefings, such as those typically provided in national professional journals and newsletters, or summaries of evidence in clinical guidelines. Fruth et al¹⁵ concluded that summarized and synthesized research findings could lessen the barrier “lack of time” and increase clinician use of EBP. In a recent qualitative study, Dannapfel et al³⁶ reported that Swedish physical therapists perceived this type of research summary as a time saver and an important facilitator of research use.

Attitudes, Knowledge, Prerequisites, and Barriers Related to Guidelines

Nearly all respondents (96%) agreed that guidelines are important, primarily in order to provide best possible treatment to patients but also to provide equal treatment and to facilitate their own work. The proportion of respondents who considered guidelines important was substantially higher in this study than it was in a 2003 survey by Overmeer et al²¹ in which only 56% considered guidelines useful in clinical practice. The difference may be an indication of a growing interest in guidelines and could possibly be attributed to the growth of the evidence-based movement in the last decade, which has resulted in a stronger focus on EBP and guidelines in health care. However, in the Netherlands, a qualitative study demonstrated rather unfavorable attitudes toward guidelines among physical therapists.³⁷ As discussed by that study's authors, this difference in attitude may be related to national or cultural differences, but also may be attributable to participants in qualitative studies possibly being more critical.

Knowledge of where to find guidelines and access to relevant guidelines are obviously key prerequisites to using them. The proportion (9%) who reported having easy access to guidelines in our survey was much lower than the 62% of the hospital-based therapists.²⁹ This finding may have been due to perceived or actual organizational or structural barriers for convenient access to guidelines in primary care. For example, at the time of this study, there was no known website in Sweden where guidelines specifically for primary care physical therapy were published, either within the organization or externally. Organizational barriers are primarily related to time and access to resources. Access to web-based resources has been identified earlier as an organizational barrier to EBP in physical therapy.¹³ Research on organizational barriers for EBP and guideline use in physical therapy is limited, and more research may be warranted.

The proportion who stated knowing how to integrate patient preferences with guidelines was slightly higher compared with the proportion in hospital-based therapists reported by Heiwe et al.²⁹ However, the one third who reported not knowing how to integrate patient preferences can possibly be explained by a poor understanding of the meaning of the EBP concept, as defined by researchers.¹ Many clinicians primarily equate the EBP concept with the use of evidence from research, paying less attention to the other 2 components of EBP (ie, clinical experience and patient preferences).³⁸ This misinterpretation implies a need for educational measures to enhance understanding of the underlying concepts of EBP. Evidence-based practice training programs (eg, workshops) have been shown to improve EBP knowledge and skills among physical therapists.³⁹

Somewhat expectedly, the main barrier to using guidelines was perceived lack of time, consistent with findings from several other studies among physical therapists in both hospital and primary care settings in various countries.^{6,12–17,29,30,32} The proportion of respondents who have reported this as a main obstacle ranges between 46% and 86% in the various studies. Physical therapists have cited the pressures of today's health care environment and the emphasis by administrators on productivity as factors that inhibit their ability to seek, appraise, and integrate research findings into daily practice.⁴⁰ This important barrier is not likely to be reduced without organizational or managerial support (eg, provision of protected work time) and also highlights the need for evidence to be summarized in brief formats, minimizing time spent searching for and reading literature.

Use of Guidelines

The high proportion of respondents who considered it important to use guidelines was not reflected in the proportion of respondents who stated that they used them. Fewer than half of the respondents reported using guidelines “frequently” or “very frequently or always.” This finding can likely be attributed to the relatively low proportion who were aware of guidelines and the even lower proportion who knew how to access them. The frequency of use of guidelines also is likely to vary with various diagnoses and fields. More well-researched diagnoses are associated with abundant evidence, whereas research is lacking for others, resulting in a corresponding variation in the availability and use of guidelines. In fields where therapists feel confident and experienced, the use of guidelines may be lower because they trust their clinical experience and competence. However, the proportion reporting frequent use of guidelines in our study is similar to levels of guideline use reported by physical therapists in the United States (40%) and in Australia (45%)^7,16 but lower than that in the Netherlands (61%).⁴¹ If we also include respondents in our survey who reported using guidelines “sometimes,” the proportion rises to 88%, which is more in line with the guideline use reported in the other Swedish studies.^29,30 It also is possible that the term “use” was interpreted differently by the therapists; use can be explicit (eg, the therapist reads the guideline at the treatment occasion) or implicit (eg, the therapist reads the guideline but integrates it into his or her thinking and clinical reasoning later). In the latter case, it may not have been reported as use; the therapist might not even be aware of using a guideline.

Despite less positive attitudes toward EBP and guidelines, older and more experienced therapists reported similar use of guidelines as their younger colleagues. Previous research on guideline use by various health care professionals has shown that those who are young or less experienced are more inclined to use guidelines than those who are older or more experienced, who are more likely to lean on their clinical expertise.⁴² The non-difference between old and young therapists in our study may suggest that the therapist's choice of whether or not to use guidelines has more to do with individual characteristics than with age. It also may imply that the confidence of younger therapists in their capabilities makes up for their lesser experience, so that they perceive a similar need to use guidelines. In our study, age was correlated with experience; this relationship, however, may not always be the case.

The strongest determinant of frequent guideline use was the attitude that guidelines are important to facilitate practice. This finding seems to indicate a perceived need for guidelines, emphasizing the importance of providing clinicians with the decision support that guidelines offer. An interesting finding was the strong association between integrating patient preferences with guidelines and frequent guideline use, implying an understanding of the EBP concept and of the notion that guidelines can and should be adapted to the individual patient. This finding points to the importance of knowledge about patient preferences. Our study was not designed to explore this issue in more detail, and further study of patient preferences for physical therapy interventions may be indicated.

Disagreeing that EBP creates unreasonable demands and that strong evidence is lacking for most treatment methods also was associated with frequent guideline use in the final regression model. Disagreement with these statements can be considered as positive attitudes toward EBP. This association between attitude and behavior is consistent with a recent systematic review that identified perceptions, attitudes, and beliefs about research and EBP in allied health professionals as significant predictors of self-reported use of research evidence.⁴³ The same association has been found in the nursing literature.⁴⁴

A rather obvious finding was the relationship between awareness that guidelines exist and frequent use. Awareness of, familiarity with, and agreement with guidelines are practitioner characteristics that have been found in previous studies to be associated with guideline use.⁴² Awareness also has been established as an important first step toward adherence to guidelines.⁴⁵ The multiple logistic regression model explained approximately half of the variation in guideline use, indicating that, although not significant in the final model, the other variables likely contributed to the explanation of the variation. There may be other factors not examined in this study that could contribute to an explanation of the variation in guideline use.

The other factors showing significant univariate associations with the use of guidelines were knowledge of where to find guidelines, consideration of EBP and guidelines as important, self-efficacy in performing EBP activities, easy access to guidelines and EBP, and encouragement in the workplace to apply research in practice. Treating these factors as potential facilitators of EBP and guideline use and addressing them in guideline implementation strategies would likely be important for increased guideline use. These factors are among the determinants of practice that were identified by a recent systematic review.⁴⁶ Attitudes, self-efficacy, and social norms concerning a particular behavior are all important behavior change determinants in social-cognitive theories, and research on clinical behavior in general suggests that these determinants are relevant in the explanation of the use of guidelines.⁴⁷ This supports our finding that the tenet that behavior can be influenced by attitudes, beliefs, knowledge, self-efficacy, and social norms²⁷ also is true in the case of guideline use in physical therapy, a finding that needs to be confirmed in future studies.

Limitations and Strengths

Some limitations should be recognized when interpreting the results of this study. The cross-sectional design was used to demonstrate associations, and no causal relationships can be inferred. The survey was limited to publicly employed physical therapists. Private practitioners, who also provide outpatient services at the primary care level, may display different attitudes and behaviors. As with all self-reported data, there is a risk that the results are more positive than what is actually the case. It is not unlikely that the generally positive attitudes found in our study and others can be partially attributed to a social desirability bias.⁴⁸ Considerable focus has been put on EBP in recent years, and it would be rather politically incorrect to express a negative attitude toward this concept.

Measuring clinical practice behavior, such as the use of guidelines, is highly complex. Evidence for the accuracy of clinician self-reported behavior is inconclusive.⁴⁹ Other proxy measures such as medical record review or patient reports or, ideally, some kind of direct observation could possibly be used. All measures, however, would be challenging and have their limitations in the case of measuring guideline use in physical therapy.

Response options for items investigating frequency (eg, use of guidelines) were purposely unspecific. Many physical therapists in Sweden work part-time, the patient populations are diverse, and the availability of guidelines varies considerably among different diagnoses. Hence, the frequency of guideline use (eg, once per day, once per week, once per month) could vary considerably from week to week or month to month for each therapist and was not thought to provide a meaningful answer. Instead, we chose to use the words “never or very seldom,” “seldom,” “sometimes,” “frequently,” and “very frequently or always,” leaving the qualitative definition and interpretation of frequency of guideline use to the respondent. The results for these items, therefore, should be interpreted with caution.

Using a web-based questionnaire can be considered both a strength and a limitation. Drawbacks with a web-based questionnaire are that only a limited depth of response is possible and that it may be perceived as intrusive. However, using a web-based questionnaire had the advantages of being both time- and cost-efficient, as well as being easy to administer and to achieve anonymity. The respondents could complete the questionnaire at their convenience. No manual data entry was required, minimizing the risk for errors in the data.

The population in our survey is likely to be broadly similar to the national population of physical therapists. Sex distribution nationwide of physical therapist members of the Swedish Association of Registered Physiotherapists employed by county councils is 82% women and 18% men (Swedish Association of Registered Physiotherapists, e-mail communication, June 11, 2012). Although our survey was conducted in only 1 county council/geographic region, this particular county council is the second largest in Sweden. Thus, we believe that our results can be generalized to physical therapists working in other county councils in Sweden.

Other strengths of the present study were the use of a validated and reliable questionnaire, a homogenous population, and a fairly high response rate (65%). Response rates in the other studies examining EBP have been 49%,⁶ 54%,¹⁶ and 45%,³⁰ respectively.

Implications for Practice

Our results suggest that the positive attitudes found toward EBP and guidelines constitute important prerequisites for evidence-based physical therapist practice in primary care, but that they need to be accompanied by increased availability of and access to clinical guidelines. The identified determinants can be addressed by organizational and educational measures and could serve as a basis for the development of a tailored guideline implementation strategy specifically addressing key obstacles. Tailoring implementation interventions to identified barriers and facilitators is likely to improve professional practice.⁵⁰ The possibility of achieving behavior change by influencing social cognitive determinants such as attitudes, knowledge, and self-efficacy should be considered, while acknowledging the difficulty of changing established clinical practice.⁵¹

Both local and national initiatives would be beneficial in the facilitation of the uptake of guidelines in primary care physical therapy. The production of guidelines, or at least the synthesis of the evidence base underpinning them, could be (and is to some extent) coordinated on a national level, while implementation may be more suitable for local adaptation. Implementation efforts should be based on strategies that have been proven effective^24,25 and may benefit from taking guidance from implementation theory that specifies important predictors or facilitators of successful implementation. Although not specific for physical therapy, there is tentative evidence in other health care settings that implementation interventions that are informed by theory are more effective than those that are not.⁵² Development and implementation of evidence-based guidelines targeting primary care physical therapists should be a high priority in order to render practice more evidence-based, facilitate effective patient care, and reduce unwarranted variation in practice.