Scientific Papers

Scientific approach and attitudes among clinically working physiotherapists in Sweden -a cross sectional survey | Archives of Physiotherapy

The majority of the physiotherapists who participated in the survey had a high interest in science. There were however differences between specialized physiotherapist and non-specialized physiotherapists regarding several aspects, where specialists in general had higher interest and priority of scientific evidence, and perceived ability to interpret and evaluate scientific results.

The perspective on importance of a scientific approach, and views on to what extent clinical practice of physiotherapy in general in Sweden is based on scientific evidence were quite similar among specialists and non-specialists. Both specialists and non-specialists considered a scientific approach to be important within clinical practice, which is in line with previous Swedish studies [7, 18], but the majority considered that the general clinical practice in Sweden is based on scientific evidence only to a low or moderate extent (or not at all).

The scientific evidence was ranked as the highest prioritized foundation for clinical decision making among both specialists and non-specialists, although to a significantly higher extent among specialists. Also own clinical experience was ranked high as foundation. The clinical experience is related to the “clinical expertise” which is one of the three “legs” of EBM. The clinical expertise includes both the general basic skills of clinical practice and the individual experience and is considered to contribute to the balance and integration between different aspects to handle in the clinical decision-making [19]. The clinical expertise and experience may hence also be a valuable basis for the clinical application, especially if it is in line with existing evidence and/or no current evidence with sufficient quality exist. It is however important to be open for updates based on developed evidence, and to be aware that the individual clinical experience can be biased. The third leg; patient preferences, was ranked as a low priority for treatment selections. In a mixed method study regarding perspectives among Australian physiotherapists [20], participants considered evidence as important, but in their clinical decision making they also included patient expectations, colleagues’ treatment choices, and business demands. However, the patient expectations were also considered a major barrier for practical application of evidence in the clinic.

The general interest and perceived abilities to interpret and apply scientific information in clinical practice was higher among specialists than non-specialists. Physiotherapists with higher degree of education (Master and/or PhD) have, in previous studies, reported higher frequency of activities related to assimilation and application of scientific evidence [8] or higher evidence based practice dimension scores [21]. The specialist training includes at least a one-year master’s degree, which may contribute to strengthened scientific perspectives and critical thinking. In this previous study, physiotherapists with higher degree of education also rated their knowledge of EBM higher. However, even if the rated knowledge in general was high, a survey found that only 12–36% answered correctly regarding that EBM contains all the three components: clinical experience; use of the most reliable scientific evidence and patient’s preferences [8]. Rated or perceived knowledge may hence not be the same as actual knowledge. Earlier studies have also indicated that even though it is quite common to have confidence in appraising or interpreting scientific literature, a high proportions of clinicians also consider it difficult to interpret statistical results and/or or have low or limited research skills [4]. This also indicates a discrepancy between ability and practice.

To be able to assimilate and implement scientific results, both time and abilities are required. In our sample, the median number of scientific papers read during a regular month was one among non-specialists and three among specialists, which is approximately in line with previous Swedish studies [7, 8]. Especially among non-specialists, the perceived ability to interpret, evaluate and implement scientific results was not high among most participants. The perceived ability to interpret, evaluate and implicate scientific results was clearly higher among specialists. The cross-sectional design does not allow any causal conclusions, but the specialist education has likely contributed to the development of these skills. Based on the open comments, further education (including specialists training) also contributes to increased interest in science. However, it is also possible that this also works the other way around: clinicians with a higher interest in science continue with a specialist education. So, there can be a bi-directional causality which is not possible to further examine in a cross-sectional study.

The specialists in the sample had also a longer clinical experience, but this aspect did not seem to affect the differences between the groups. There are reasons to believe that specialists can serve as a knowledge bearer in the health care organizations and support less experienced colleagues in scientific matters, but only approximately 6% of Swedish registered physiotherapists hold a specialization and the majority (54%) of these are working in the Stockholm region [16, 17].

The ability to assimilate science is however needed, regardless of specialist level, since it is a foundation for evidence-based practice to be able to update knowledge of current scientific evidence. In previous studies, lacking knowledge and understanding of science has also been considered main barriers for implementation of EBM [9, 11,12,13,14]. Insufficient education within the topic has been lifted as one main inhibiting factor [11], which of course is related to the lacking knowledge and understanding. In our study, the views on whether the undergraduate program provided sufficient education in scientific methodology varied. Even though the program was considered to provide sufficient education, a continuous update and implementation is required to maintain and further develop the abilities through clinical practice [22]. An earlier study has pointed out the importance of promoting motivation for a scientific approach [6]. Some aspects may be required, or at least facilitate, to provide conditions for this development. Engagements from stakeholders to ingrain EBM in the clinical practice was lifted as an important aspect, from an expert view on the education of healthcare professionals. Integrating activities related to EBM in a structured way within everyday clinical practice can have the ability to promote a more consistent implication of the EBM [22]. A Swedish qualitative study that explored what supports physiotherapists use of research in clinical practice lifted aspects on both individual and workplace level [5]. On individual level, attitudes and motivation concerning research use and research-related knowledge and skills were considered supportive aspects. On workplace level, leadership support, organizational culture, research-related resources and knowledge exchange were lifted as supportive for the use of research in clinical practice. Among the physiotherapists in the interview study, available guidelines was found supportive [5]. A qualitative Danish study exploring barriers to use clinical guidelines for low back pain showed that a main perceived barrier was skepticism related to validity and applicability of the guidelines [23]. A critical view based on updated knowledge of scientific evidence is positive but requires knowledge and understanding of the science for a relevant skepticism. The ability to assess the quality of scientific evidence, and to critically appraise results and methodology is also defined as important foundation for the EBM [24].

Our participants rated lack of time as main barriers both for reading scientific papers and implementation of EBM to a higher degree. More allocated time was also rated as the main facilitating aspect for a scientific approach. This aspect has been lifted as main barriers for the implication of EBM within clinical practice in different professions [25]. However, time as such may not lead to increased EBM unless there are relevant competence; knowledge and understanding of the science. Also, more abilities to participate in further education, and access to scientific articles were considered as facilitating factors among almost half of the participants. Scientific conferences and general support and encouragement for EBM from the employer was considered facilitating among approximately one third. These are aspects that put the attention on how employers facilitate with a supporting work organization, that ensures and enables employees to be updated regarding EBM.

According to the “behavior change wheel” [26], changes in behavior are related to sources of behavior within the domains capability, opportunity, and motivation. This is much in line with the barriers and facilitators for applying science on clinical practice, that were reported in this study. The participants reported both individual and organizational aspects and this has also been reported in previous studies [5,6,7,8,9,10]. Interventions aiming to change behavior relate to several aspects including e g education, persuasion, incentivization, training, enablement, restrictions. A systematic meta-review examining barriers and facilitators to clinical behavior changes in primary care related to the theory of the behavior change wheel found that perceived barriers and facilitators were mainly related to the domains of capability and opportunity; factors related to knowledge, environmental context and resources, and social influences [27]. These aspects also relate to the perceived reasons for increased interest in science in our sample. A change in interest could be a step towards clinical behavior change and increased evidence based clinical practice.

In our sample, a better knowledge and understanding of scientific results were considered facilitating among a smaller proportion (less than one third), which may indicate that the majority already consider their knowledge sufficient. Although a lower proportion among non-specialists rated their ability to translate/implement results from scientific studies in clinical practice as high or very high, most of both non-specialists and specialists considered their knowledge and understanding sufficient for making decisions regarding clinical treatment based on scientific evidence. The interest and perceived importance of scientific approach was also mainly rated high. However, there were still a considerable share, especially among non-specialists, who considered their understanding of evaluation and interpretation of scientific results as low or moderate. The perceived knowledge was rated on approximately similar level as among Australian physiotherapists in a study from 2006 [28]. This competence is probably even lower in the general population of physiotherapists, since our sample most likely are affected by a non-response bias leading to over-representativity of physiotherapists with interest in science. Even though the majority of participants in our study considered their knowledge/understanding of research sufficient to make decisions regarding treatment based on a scientific basis, improved skills would probably make it easier to more effectively assimilate the scientific information, and also do it to a higher degree. Knowledge and understanding of the science are central conditions that often need further development not only during education but also during the clinical practice [22, 29]. In Sweden, physiotherapists in primary health care serve as first-line treatment, and no referrals are needed. Physiotherapies must therefore be updated on the most recent research in both diagnostics and treatment. Clinical decision making is not only a matter for the individual physiotherapists, and should be digested in a professional context where pros and cons for different treatment options are continuously discussed [30]. Shared decision making has become more and more recognized in a clinical context [31] and enables the patient to fully participate in his or her treatment. This highlights the importance of a solid EBM-basis, with knowledge and understanding of science as a fundament to be able to apply the scientific evidence. It also requires that the health care professional is updated regarding current state of science, to provide the patient with a solid decision basis to discuss.

For the majority of participants, the interest in science had increased during the years of clinical practice. The main reported reasons for increased interest were an aspiration to increase and update knowledge of scientific evidence for best clinical practice, and the clinical practice as such that had provided better insight and interest in need of knowledge and understanding about specific clinical topics. However, also further education such as courses, research involvement and specialist training were to large extent reported as reasons for increased interest in research. Hence, even if the higher interest and perceived ability and assimilation of research among specialists that we found may be because physiotherapists with higher interest for further education and research may be more encouraged to become specialists, the specialist training as such seem to contribute to the increased interest and understanding of science.

Strength and limitations

Our study includes a relatively large sample, compared to other studies within this topic. However, the sample is most likely not representative for the total population of clinically active physiotherapists in Sweden. The response rate was low, and physiotherapists with a higher interest in science probably responded to a higher degree which may overestimate the positive approach. The descriptive results should hence not be directly generalized to the whole professional corps. Such non-response rate bias may be an issue in different forms of descriptive questionnaire surveys.

The main part of the respondents was recruited by the invitation from Physiotherapy Sweden, but only about two thirds of all registered physiotherapists in Sweden are members of this association. We used social media to also reach non-members, but these respondents were a minor part of the total sample. The complementary stratified analyses of responders via email invitation from The Swedish Association of Physiotherapists vs social media showed no clear differences (results not presented), which indicate that potential non-response bias did not differ mainly between the recruitment paths.

A majority of the respondents were women, which is in line with the gender distribution among all registered physiotherapists in Sweden. The proportion of specialist physiotherapists was however higher in the sample than in the total population of Swedish physiotherapists [17] which may also have affected the results for the total sample.

Lack of time, that is lifted as inhibiting factors both for reading scientific papers and a clinical practice based on scientific evidence to a higher extent, may also have contributed to a low response rate. However, the survey did not take long time to respond to. Despite a potential non-representative sample, the responses may still provide an insightful view of perspectives on the scientific approach. Also, the group comparisons (between specialists and non-specialists) within the sample are likely less affected by the non-response bias.

The questionnaire was created for this specific study, with the aim to focus more on the perspectives on science than the whole/general EBM process and is hence not tested for reliability or validity. Most part of the questionnaire was also developed with the aim to collect and present more direct opinions or perceptions of the defined item/topic, rather than any form of general/combined evaluation. As brought up in the discussion in a study examining adherence to clinical guidelines, forms of assessments of guideline adherence differ between studies, which may give different results [32]. Regarding perceived knowledge and understanding of science and application of EBM, the perceptions may differ from actual knowledge, practical skills or applications. As mentioned, previous studies have shown differences between perceived and actual knowledge [8]. However, the main aim with this study was to examine the perspective and attitudes, which we expect to be more related to the reported perceptions and answers.

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