Icelandic Physical Therapists' Attitudes Toward Adoption of New Knowledge and Evidence-Based Practice: Cross-Sectional Web-Based Survey

Main Findings

The physical therapists who participated in the present study had positive attitudes toward the adoption of new knowledge and EBP. Being a woman was independently associated with more positive attitudes, as measured by the total EBPAS and the requirements, openness, and divergence subscales. Physical therapists with postprofessional education had more positive attitudes, as measured by the openness subscale, and working with at least 10 other physical therapists was associated with more positive attitudes, as measured by the total EBPAS and the openness subscale.

Attitudes Toward EBP

By selecting the EBPAS questionnaire, we were able to obtain a more comprehensive assessment of physical therapists' attitudes toward EBP than have most studies. The existing measures of EBP have been criticized for including a limited number of items for the assessment of attitudes and for lacking a theoretical framework.²⁷ The EBPAS is based on theoretical models and captures dimensions of attitudes that are likely to be important for understanding the dissemination and implementation of EBP.⁷ Our examination of more complex dimensions of attitudes confirmed and expanded the results of other studies on physical therapists' attitudes toward EBP. The physical therapists in our study continue to report positive attitudes toward new knowledge and EBP.^{5,8,9,13,14,28} Moreover, they showed more favorable scores on all parts of the EBPAS than did the mental health providers in the original EBPAS study in the United States,⁷ medical doctors in later research in Greece,²⁷ and allied health care professionals in Australian research.²² In this comparison, it is important to recognize that health care disciplines may have different needs and experience different barriers in the application of EBP. More research is needed to learn about the potential effects of professional backgrounds on willingness to adopt EBP.

Interestingly, the use of EBPAS may minimize the much-discussed effects of the potential social desirability of the EBP concept. The positive attitudes toward EBP in the present study were less likely to have been based on the social appeal of EBP, because no question in the EBPAS questionnaire included the phrase “evidence-based practice.” Furthermore, the present study demonstrated how different dimensions of attitudes are associated with the selection of the personal characteristics of physical therapists and their practice environments.

Association Between Personal Characteristics and Attitudes

The results of the present study demonstrated differences in attitudes toward EBP between the sexes. Women reported more positive attitudes than did men on the total EBPAS and the requirements, openness, and divergence subscales. Other studies have examined differences in attitudes and beliefs regarding EBP between the sexes. In a small study of attitudes among workers in community-based mental health organizations, women scored higher on both the total EBPAS and the openness subscale.²⁹ A study of physical therapists providing service to adults with stroke revealed that women had more positive attitudes toward EBP than did men.⁵ In contrast, Bernhardsson et al⁹ demonstrated that men were more likely than women to consider EBP helpful in decision making, indicating more positive attitudes for men. Although we expect that male and female physical therapists receive the same education and encouragement to use evidence-based practice, our results stress the importance of further research in this area.

Respondents with more postprofessional education were more open to new practices in the field than were those with no postprofessional education. This finding should not be a surprise because graduate university programs should be expected to emphasize research and critical appraisal skills to a greater extent than should undergraduate programs, both of which form the basis for the implementation and adoption of EBP. Therefore, physical therapists with postprofessional education should have the skills to critically evaluate innovations and accept or reject them accordingly. A systematic review of barriers, enablers, and interventions of EBP in physical therapy included studies reporting a positive association between a higher academic level and knowledge of EBP, more positive attitudes, and fewer perceived barriers toward the use and adoption of EBP.¹⁰

Although professional experience was not significant in any of the multivariable models, the univariate analysis revealed that having 1 to 5 years of professional experience was associated with more positive attitudes on the total EBPAS, a result consistent with those of previous studies.^5,8,9,13 In recent years, entry-level education in physical therapy in Iceland has highlighted the importance of EBP, and students learn various EBP skills. Therapists with even a small amount of experience, therefore, may be more confident about EBP concepts and critical appraisal than those who graduated earlier.

Association Between Practice Environments and Attitudes

Physical therapists who work in a group of at least 11 physical therapists were more positive, as measured by the total EBPAS and openness subscale, than were those who worked in small clinics. Salbach et al⁵ found that small institutions were disadvantaged in implementing EBP because of a lack of human resources. They and other researchers²⁸ also found that a lack of peer support is an organizational barrier to EBP. Physical therapists have expressed how they see their colleagues as important in extending experience beyond their own and how the opportunity to converse with colleagues is especially valued by those who work in seclusion.¹² In smaller clinics, social interactions may be lacking, with diminished opportunities to share tools, routines, and stories and to negotiate meaning related to the complexities of the real-life application of evidence in practice.³⁰ Physical therapists working in smaller settings therefore may have the greatest need for help in developing positive attitudes toward EBP and in implementing the approach.⁵

The type of facility was not significant in any of the multivariable models, yet there was a univariate association between working in a private outpatient practice and more negative attitudes toward applying EBP if required to do so. In contrast, in another univariate comparison, physical therapists in an Australian private outpatient practice and hospitals rated their EBP skills equally and practiced EBP with equal frequency.¹⁴ In Iceland, a high percentage of physical therapists work in private outpatient practices (>50% of the respondents in the present study). Further research is needed to explore whether the culture and infrastructure of outpatient clinics are less supportive of clinicians' effort to implement EBP and will eventually lead to more negative attitudes or whether those who are less willing to follow professional guidelines and requirements prefer to be self-employed.

Implications for Practice

The findings of the present study should be of interest for physical therapist clinicians, administrators, and educators. Knowledge about various dimensions of attitudes toward EBP provides a potentially important foundation for design interventions to implement EBP in physical therapy. If attitudes form an individual's psychological framework for building decisions about applying evidence in practice, as Dawes et al⁴ proposed, our results support the conclusion that physical therapists have the background to apply evidence in practice. However, implementation of EBP in practice must account for the complex dimensions of attitudes, dynamic influences, and interplay between the individual and the practice setting.

We support the idea that strategies directed at the individual physical therapist's skills and attitudes toward the use of research must be considered in a wider context of influences on clinical behavior.³¹ When designing interventions to implement EBP in practice, managers must be aware of potential differences in attitudes between men and women. Our results imply that men may need strategies aimed at affecting their attitudes toward EBP.

Additionally, interventions may include raising the educational level of physical therapists as well as increasing both the practical value of research and access to databases with peer-reviewed publications. It is important to create a research-friendly climate involving cooperation with colleagues and academic programs that are available to support clinicians in their understanding and implementation of research results.^10,12

It is also important to recognize that physical therapists working in different settings and with different backgrounds may have different needs and encounter different barriers to applying EBP.¹⁰ Small practices may need to seek help from colleagues in larger institutions and academic settings to develop positive attitudes to EBP and to ensure successful implementation. Another solution is for small practices and geographically dispersed physical therapists to engage in a joint online course to further EBP.

Strengths and Limitations

The results of the present study should be interpreted with several limitations in mind. This was a cross-sectional observational study; therefore, no causal inferences can be made, and there may have been unmeasured confounding factors. The data were based on self-reports, which are inherently subjective and rooted in individual personality, outlook, and context. The population approach and the use of a Web-based survey without any reimbursement may explain the response rate of only 39.5%. This response rate makes the study prone to nonresponse bias, with respondents potentially holding more positive views toward research than the general population of Icelandic physical therapists. Yet, the association between attitudes and background variables should be less influenced by the response rate. Furthermore, our response rate is above the 33% average for surveys delivered via email and reflects meta-analysis results showing that among professionals, email surveys generally have a 23% lower response rate than mail surveys.³²

Despite the low response rate, the generalizability of our findings is strengthened by the fact that the age and sex distributions of the respondents were comparable to those of the total population of IPA members. According to the IPA, in the first quarter of 2013, the mean age of full members was 45.6 years (SD=10.4), and 74.1% were women.

Our sample included only physical therapists who were licensed in Iceland and who understood Icelandic. Therefore, generalization to other groups must be made by logical inference on the basis of close similarities between physical therapist education and practice in Iceland and, for example, northern Europe, North America, and Australia. With no interaction terms included in the regression models, the explanatory power of the present study was restricted to overall (main) effects of the 8 independent variables in the model. A larger and more powerful study is needed to analyze subgroups and various interaction terms, along with additional variables, such as information on workplace and organizational culture. Finally, because no corrections were made for multiple statistical tests, the significance of the findings may have been inflated.

The strengths of the present study include the use of a short standardized questionnaire with established psychometric properties and the potential to improve understanding of the complex phenomenon of attitudes and to minimize social desirability bias related to EBP. Moreover, the factor structure of the EBPAS was confirmed in our sample of physical therapists. The Web-based questionnaire was time and cost efficient and easy to administer. These benefits can facilitate replication of the present study in other contexts. Finally, there is convincing evidence that the EBPAS can be applied in the health care sector in general^7,23,24; therefore, the use of the EBPAS can facilitate cross-disciplinary comparisons.

The present study confirms that physical therapists have generally positive attitudes toward changing practice and the adoption of EBP. The results expand understanding of the phenomenon of attitudes toward EBP and reveal an association between dimensions of attitudes and personal factors. These findings may help educators and managers understand which types of physical therapists are more likely to implement evidence in practice; for example, women and, especially, physical therapists with postprofessional education may be able to lead the implementation of EBP. Moreover, the findings may help managers understand how to create an environment facilitating EBP. Different practice settings may require different strategies for the implementation of EBP. Collaboration between academic settings and institutions can be beneficial, especially for small practice settings.

The results should be used in continuing research on personal and environmental factors that foster a dynamic way of practicing evidence-based physical therapy. Finally, the findings encourage investigation of the effectiveness of strategies aimed at influencing various dimensions of attitudes toward EBP in physical therapy curricula and continuing education courses for physical therapists.