Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke.

Evidence-based practice (EBP) has been defined as "integrating individual clinical expertise with the best available external clinical evidence from systematic research" (1(p71)) and as a culture in which clinicians naturally and consistently consider evidence in every aspect of practice. (2) Although clinicians use research evidence for diverse purposes, 3 primary areas of practice that research evidence informs are: (1) the selection of standardized assessment tools (ie, outcome measures (3)), (2) the interpretation of scores on assessment tools, and (3) the selection of therapeutic, rehabilitative, or preventive interventions. (1) A primary assumption underlying EBP is that the integration of high-quality research findings, clinical expertise, and patient preferences improves the effectiveness of health service delivery and, consequently, client outcomes. Evidence supporting this assumption for people with stroke has been reported. (4,5) Compliance with a clinical practice guideline in postacute stroke rehabilitation was associated with not only physical recovery (4) but also patient satisfaction. (5) Optimizing access to and use of research findings to implement EBP on an ongoing basis requires certain attributes and resources commonly classified as characteristics of the individual practitioner and of the organization. (6-8)

Practitioner characteristics, such as awareness, knowledge, attitudes, skills, and self-efficacy, are viewed as primary influences on the successful implementation of EBP. (6-14) Self-efficacy is defined as a judgment of one's ability to organize and execute activities in a specific domain. (15) We have labeled perceived ability to undertake the activities required to implement EBP as "EBP self-efficacy." The value of this construct lies in its ability to determine behavior. For example, physical therapists with a high level of self-efficacy to perform EBP activities would be expected to engage in these activities more frequently than physical therapists with low EBP self-efficacy. (15,16)

In addition to practitioner characteristics, organizational resources (eg, the presence of a library, a resource person, Internet access, and managerial and peer support) also may affect the implementation of EBP. (7,17,18) For example, access to online databases is an organizational resource that is necessary to enable literature searches. (9) Findings of a qualitative study (17) indicated that the presence of an organizational mandate facilitated the use of standardized assessment tools among physical therapists.

Physical therapy practitioners appear to value the principles of EBP (9,19) but report inconsistent reliance on research evidence in their clinical decision making. (20-22) An understanding of practitioner and organizational characteristics that may impede EBP is needed to inform the development of educational interventions aimed at enhancing the integration of research into physical therapist practice. (23,24)

Studies of practitioner and organizational barriers to EBP have been conducted among physical therapists in the United States (9) and in the United Kingdom. (19) Differences in entry-level training, health care systems, and professional practice across countries, however, limit the generalizability of this research to the Canadian context. Although level of confidence to perform select EBP activities has been evaluated previously, (9,19,25) self-efficacy theory has not been used to understand physical therapists' perceived ability to undertake the entire EBP process. Previous research (4,5) showing improved patient outcomes with the integration of research evidence in stroke rehabilitation supports targeting physical therapists providing services to people with stroke in an evaluation of barriers. Thus, the primary objective of this study was to evaluate practitioner and organizational factors affecting the implementation of EBP by physical therapists providing services to people with stroke. Practitioner factors included education about EBP, attitudes and beliefs, interest and perceived role in EBP, and self-efficacy to perform EBP activities. Organizational factors were support and availability of resources for implementing EBP. A secondary objective was to identify sociodemographic variables and practice and organizational characteristics related to these factors.

Method

Overview of Study Design

A cross-sectional mail survey of physical therapists providing services to people with stroke in Ontario, Canada, was conducted. A modified Dillman three-step mailing procedure (26) was followed to optimize response. A first questionnaire was mailed in May 2005. Three weeks later, a postcard thank-you/reminder card was sent. A second questionnaire was mailed to nonrespondents at the end of June 2005.

Participants and Sampling

Physical therapists were considered eligible for the study if they were: (1) currently practicing and (2) providing physical therapy services to adults with stroke. Potential participants were sampled from the register of the College of Physiotherapists of Ontario, the provincial regulatory body. A request was submitted to the College of Physiotherapists of Ontario for a mailing list of individuals who were currently practicing and who specified neurology as an area of practice at either their primary or secondary workplace. Registrants who indicated pediatrics as a practice area were excluded. Questionnaires were mailed, and recipients were asked to indicate in the first item of the questionnaire whether they provided services to people with stroke. Those recipients who indicated that they did not provide services to people with stroke were considered ineligible and were asked to leave the rest of the questionnaire blank and return it in the envelope provided. Eligible individuals who did not wish to participate also were asked to return the questionnaire with the remaining items unanswered, and these individuals were considered as refusals. Consent was considered implied for physical therapists who returned a completed questionnaire.

Questionnaire

Questionnaire items (Appendix) were designed to identify practitioner and organizational factors influencing EBP. Subgroups of items were used to evaluate education about EBP (items 14-16), attitudes and beliefs (items 2, 3, 5, and 7-10), interest (items 4 and 6) and perceived role (items 11-13) to engage in EBP, self-efficacy to perform EBP activities (items 17.1-17.12), perceived organizational and peer support for EBP (items 25 and 26), and organizational resources and support to promote EBP (items 18-24). One item was used to identify the 3 greatest barriers to updating clinical practice with new knowledge (item 27). Items were added to the end of the questionnaire to evaluate respondent demographics, practice characteristics, and work setting (items 28-47). For the majority of items, respondents indicated their level of agreement with a statement on a 5-point Likert scale with the following response options: "strongly disagree," "disagree," "neutral," "agree," and "strongly agree." Response options for items relating to the presence of organizational resources were "yes," "no," and "do not know."

The primary source of items was a survey tool used by Jette et al (9) to evaluate physical therapists' beliefs, attitudes, knowledge, and behavior in relation to EBP. Investigations by other researchers (17,19) formed the basis for adding items assessing EBP beliefs and the existence of an organizational mandate supporting EBP. We devised 3 new items (items 11-13) to evaluate physical therapists' perceived role in searching and appraising the research literature and interpreting its applicability to individual clients.

EBP Self-efficacy Scale

Self-efficacy to perform EBP activities was measured using a new, 12-item scale that we developed in adherence to guidelines for developing self-efficacy scales. (27) Eight items initially were generated to evaluate self-efficacy to perform each of the following steps of implementing EBP: (1) identify a clinical problem, (2) formulate a question to guide a literature search, (3) effectively search the relevant literature, (4) critically appraise the evidence for reliability and relevance, (5) appropriately apply the evidence to the clinical problem, (6) understand the patient's needs and preferences, (7) decide on an appropriate course of action in collaboration with the patient, and (8) continually evaluate the effect of practice. (1,28-30)

Four items then were added to capture specific aspects of critical appraisal related to understanding psychometric properties of outcome measures, strengths and weaknesses of different study designs, and basic and intermediate statistical procedures. This was done to enable specific identification of a problem area that could be targeted through education. To complete the scale, participants were asked to rate their level of confidence in their ability to perform each activity, using an 11-point scale ranging from 0% ("cannot do at all") to 100% ("certain can do"). Item-level responses were averaged to obtain a summary score ranging from 0% to 100%. Construct validity is inherent in the scale's construction, given that item development was based on the established process of EBP. (31) Internal consistency estimated using data collected in this study (n=261) was .90 (Cronbach alpha), which meets the level required for using the scale at the individual level. (32)

Three physical therapists working in acute care or rehabilitation hospital settings reviewed the questionnaire and the EBP self-efficacy scale and verified their readability and relevance. The questionnaire was shortened and some questions were reworded to enhance clarity based on the feedback provided.

Data Analysis

The prevalence of practitioner and organizational factors was estimated using percentages. Logistic regression then was used to examine relationships between sociodemographic and practice characteristics of respondents (ie, independent variables) and each practitioner factor (ie, dependent variable). Independent variables included age, sex, highest degree obtained, number of years practiced, number of hours worked per week, number of patients seen per day, care delivery within a multidisciplinary team (yes/ no), supervision of physical therapist students (yes/no), membership in a professional organization (yes/no), and participation in research activities (yes/no). Research participation was derived using the percentage of time that respondents reported spending in research activities (>0%=yes, 0%=no). Dependent variables were items used to determine education about EBP, attitudes and beliefs, interest and perceived role in EBP, and self-efficacy to perform EBP activities.

Logistic regression also was used to identify associations between organizational characteristics (independent variables), including facility location and type, number of physical therapists at the facility, and status as a teaching institution, and each organizational factor (dependent variable), including items measuring perceived peer and organizational support and the existence of resources (eg, access to journals, Internet, personnel) to facilitate EBP.

Prior to examining associations among variables, categories were combined in the following manner to produce binary dependent variables for use in logistic regression. (9) For statements with a positive response set rated using a Likert scale, the "strongly agree" and "agree" categories were collapsed to form an "agree" category and the "neutral," "disagree," and "strongly disagree" categories were combined to form a "disagree" category. For items with a negative response set, the "strongly disagree" and "disagree" categories were collapsed to form a "disagree" category and the "neutral," "agree, and "strongly agree" categories were combined to form an "agree" category. For items with response categories of "yes," "no," and "do not know," the latter 2 categories were pooled based on the assumption that the effect of not knowing about the presence of a resource, for example, would have a similar effect as not having the resource. There is no research to guide the selection of a cutoff point for dichotomizing respondents into high and low levels of self-efficacy ratings. Thus, the median self-efficacy rating ([less than or equal to] 63 points/ >63 points) was used because, at a minimum, it resulted in equally large subgroups that would optimize the reliability of estimated associations.

Categories of demographic variables with low cell counts also were collapsed in order to obtain stable estimates in regression analyses. Logistic regression then was performed to estimate the influence of each independent variable on a dependent variable without adjustment for other variables given the exploratory nature of the analysis. Odds ratios (ORs) and associated 95% confidence intervals (CIs) were reported for statistically significant associations at a type I error level of .05. These analyses were considered descriptive and exploratory and were conducted to provide a basis for hypothesis development. Data were analyzed using SAS software, version 9.1. *

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Results

The questionnaire was mailed to 1,155 individuals. Figure 1 illustrates the outcome of sampling. Of the 702 individuals who returned a questionnaire, 334 (48%) were eligible to participate in the study. Among eligible respondents, 64 people (19%) refused to participate and 270 (81%) completed a questionnaire. Analyses were conducted on this sample of 270 physical therapists.

Table 1 presents respondent and practice characteristics. Respondents were between 23 and 68 years of age (mean=40, SD=IO), and 88.8% were women. A bachelor's degree was the most commonly cited highest degree obtained (76.9%), and 45.4% of the respondents reported having more than 15 years of practice experience. Table 2 presents characteristics of the organizations for which the respondents worked. The most frequently cited characteristics were an urban location (60.9%) and employment in an acute care hospital (39.6%) or teaching hospital (67.3%). Table 3 provides the percentages of participants by category of response--disagree, neutral, or agree--to statements concerning education about EBP, attitudes and beliefs, and interest and perceived role in EBP.

Education in EBP

Table 4 shows that age, highest degree obtained, and number of years practiced were associated with academic preparation in EBP and formal training with critical appraisal. Sex also was associated with training in critical appraisal skills; male respondents were 2.9 times more likely than female respondents to report training (95% CI=1.2-7.0). Age, years practiced, hours of work per week, practice in a multidisciplinary team, and participation in research were each associated with formal training with search strategies. For example, compared with respondents who had more than 15 years of practice experience, respondents with less than 5 years of experience were 31.2 times more likely to have learned the foundations of EBP in their academic preparation (95% CI=11.0-88.6), 9.3 times more likely to report having received formal training with search strategies (95% CI=3.8-22.9), and 99.8 times more likely to report having received formal training in critical appraisal skills (95% CI=13.2-754.9).

Attitudes and Beliefs

As shown in Table 5, characteristics associated with attitudes and beliefs included age, sex, highest degree held, hours of work per week, work in a multidisciplinary team, supervision of physical therapist students, and participation in research. For instance, compared with respondents who had a bachelor's degree, respondents holding a certificate or diploma were less likely to agree or strongly agree that EBP improves quality of care (OR=0.4, 95% CI=0.1-0.8) and more likely to be neutral or agree that EBP places unreasonable demands on physical therapists (OR=2.6, 95% CI=1.1-5.7).

Interest and Perceived Role in EBP

Table 6 presents characteristics associated with interest and perceived role in EBP. Compared with respondents who had a bachelor's degree, those with a master's degree were less likely to report interest in learning EBP skills (OR=0.3, 95% CI=0.1-0.8). The number of patients seen per day, number of years practiced, and practice in a multidisciplinary team were associated with perceptions of physical therapists' role in implementing EBP. For example, physical therapists with less than 5 years of practice experience were 9.7 times (95% CI=1.3-74.4) more likely than those with more than 15 years of practice experience to indicate that physical therapists are responsible for applying research findings to clients, and respondents working in a multidisciplinary team were 2.7 times more likely than those not working in such a team to agree with this statement. None of the characteristics evaluated was associated with agreement with the need to increase the use of evidence in practice.

EBP Self-efficacy

Self-efficacy ratings for 12 different activities or skills necessary to implement EBP are shown in Table 7. Average item-level scores were greater than 80% for identifying a clinical problem following a patient assessment, understanding patient needs and treatment preferences, deciding on an appropriate course of action in collaboration with the patient, and continually evaluating the effect of practice. Average ratings were between 50% and 80% for formulating a clinical question to guide a literature search, conducting a literature search, critically appraising the literature, critically appraising different study designs, and appropriately applying evidence from the literature to the individual patient.

Average ratings below 50% were observed for critically evaluating the psychometric properties of outcome measures and interpreting the results of basic or intermediate statistical procedures.

Table 8 shows that age, sex, highest degree held, and number of years practiced were associated with EBP self-efficacy. Compared with respondents aged 30 to 39 years, those over 50 years of age were less likely to rate their EBP self-efficacy above the median (ie, 63%, OR=0.2, 95% CI=0.1-0.3). Men were 3.0 times more likely than women to rate their self-efficacy at greater than 63%. Respondents with a master's degree or less than 5 years of practice experience were more likely than those with a bachelor's degree or more than 15 years of practice experience, respectively, to rate their self-efficacy above 63%.

Peer and Organizational Support

Characteristics associated with perceived support and organizational resources are shown in Table 9. Location and type of facility, the number of full-time physical therapists on staff, and status as a teaching institution were associated with perceived organizational resources to support EBP. Compared with urban settings, organizations in rural settings were less likely to provide journals in paper format (OR=0.4, 95% CI=0.2-0.7), Internet access (OR=0.4, 95% CI =0.2-0.8), or a resource person to assist with EBP (OR=0.2, 95% CI=0.1-0.4). Similar findings were seen for community-based organizations. Organizations with more than 20 full-time physical therapists on staff were 3.7 times (95% CI=1.4-10.1) more likely to mandate the use of research in practice compared with facilities with fewer than 5 full-time staff physical therapists. None of the organizational characteristics evaluated was associated with the provision of protected time. Therapists working in a teaching institution were 6.3 times more likely than respondents working in a non-teaching institution to report receiving financial support (95% CI=3.5-11.4).

Self-reported Barriers to EBP

Figure 2 presents perceived barriers to updating clinical practice with new information noted by more than 10% of the respondents. The 4 most frequently cited barriers were insufficient time provided by management (74.4%), lack of generalizability of research findings to the patient population (33.7%), lack of research skills (30.7%), and lack of understanding of statistical analyses (30.4%). Barriers cited by fewer than 10% of the respondents were lack of support among colleagues (3.7%) and lack of interest (3.3%).

Discussion

The study findings highlight potential practitioner and organizational barriers to the implementation of evidence-based physical therapy for people with stroke and provide new and comprehensive information on physical therapists' level of self-efficacy to undertake EBP activities.

A notable practitioner-level barrier to the implementation of EBP was the lack of formal education in the principles of EBP and in skills related to searching and critically appraising the research literature among half of the respondents. Jette et a1 (9) obtained similar results in a 2002 survey of 488 members of the American Physical Therapy Association, with the exception that a higher proportion of American physical therapists reported training in critical appraisal skills (67%) compared with our respondents (56%). This difference may be due to the higher prevalence of graduate degree training among the American physical therapists compared with individuals in the current study (56% versus 12% held a master's degree, 4% versus 0% held a doctoral degree). As with their American counterparts, (9) the physical therapists in the present study who were youngest or who had practiced less than 5 years were more likely than the reference group to have learned about EBP principles and critical appraisal in their academic program and to have received formal training to search the research literature. These findings suggest that current Canadian university training programs for physical therapists are emphasizing the foundations of and skills to implement EBP, as indicated in their Web-based descriptions. (33,34)

Although we may assume that newly graduated physical therapists are being trained to implement EBP, 45% of the current sample and 38% of physical therapists investigated by Jette et al (9) graduated more than 15 years ago. Thus, a substantial proportion of practicing physical therapists may be inadequately prepared to access, interpret, and integrate findings from well-conducted research into their clinical practice. Our study findings support this interpretation, as respondents with more than 15 years of practice experience were significantly less likely than those with less than 5 years of experience to rate their perceived ability (self-efficacy) to undertake EBP activities above 63%.

Self-efficacy ratings were lowest for effectively searching and appraising the research literature, particularly with respect to understanding statistical procedures and appropriately applying research evidence to the individual patient. Respondents indicated that they also lacked skills in these areas and perceived these deficiencies as important barriers to advancing practice. Low self-efficacy levels have been noted previously among physical therapists, (9,18,19) occupational therapists, (18) nurses, (11,35) and physicians. (36) In Jette and colleagues' survey, (9) more than a third of American physical therapists were either neutral or disagreed that they felt confident in their search (35%) or critical appraisal (45%) skills. As in the current study, agreement was linked with age, years of practice experience, and degree held. The concern, according to self-efficacy theory, (37) is that physical therapists with low self-efficacy for searching and appraising the research literature and integrating the findings into clinical practice are less likely to perform these activities than people who perceive their level of skill to be higher. This has been demonstrated in the medical literature, wherein physicians' self-efficacy has been linked with their prescribing (38,39) and counseling (39) behavior. In the current study, men may have reported higher levels of self-efficacy to implement EBP compared with women because they also were more likely to have been trained in critical appraisal skills. Higher levels of self-efficacy among men than among women have consistently been observed in previous research. (40-47) Authors have proposed that the combined influence of higher education, income, and occupational status (48) or the greater availability of certain roles and opportunities in society for men compared with women (49) may explain this discrepancy.

Interestingly, the average self-efficacy rating to critically appraise the psychometric properties of outcome measures in the current study (43%) is lower than that observed by Kay et al (25) in a survey of staff physical therapists (59%) and professional practice leaders (64%) working in a large Canadian city. However, physical therapists in the study by Kay et al worked in urban, university-affiliated institutions providing inpatient and outpatient services, with potentially greater opportunity for continuing education on psychometric evaluation than participants in the current study. The lack of perceived ability to interpret results of psychometric testing is surprising, however, given extensive efforts in the last decade to promote the use of outcome measures. Nevertheless, this finding may help to explain the lower-than-expected rates of outcome measures use observed among Canadian physical therapists. (17,22,25,50)

As in previous studies of physical therapists, (9,19,51) the respondents in our study held positive attitudes and beliefs about EBP. This was observed despite differences in the predominant practice setting, which ranged across studies from private outpatient clinics, (9) to the rehabilitation setting, (18) to the acute care hospital setting (50) (as in the current study). It was interesting to note that modifiable characteristics, such as working in a multidisciplinary team, supervising students, and participating in research, related to perceptions that EBP improves the quality of care and other positive attitudes regarding EBP. Attitudes are considered an important factor influencing the implementation of EBP, (9,12,51,52) and previous investigations involving nurses have linked attitudes with the use of research findings in clinical decision making. (13,14)

As with American physical therapists, (9) almost all respondents in our study desired to increase the use of evidence in their daily practice and were interested in learning or improving their skill levels to do so. These findings indicate that physical therapists would be receptive to continuing education aimed at increasing the implementation of EBP.

The educational goals, however, are less clear. Although physical therapists perceived their ability to search and critically evaluate the research literature to be low and identified the lack of these skills as a barrier to implementing EBP, a notable proportion of respondents did not believe that these tasks were their professional responsibility. Most respondents in the current study agreed that it is the physical therapists' professional role to determine the relevance of research findings to the individual client. Recently graduated physical therapists were almost 10 times more likely than those with greater than 15 years of practice experience to agree with this sentiment, which suggests that current physical therapy training programs may be effectively developing stronger beliefs concerning the physical therapists' role in implementing EBP.

The lack of protected time to search and appraise the research literature was by far the largest organizational barrier, as indicated by 82% of our respondents compared with only 67% of American physical therapists surveyed. (9) Without protected time or the skill to conduct literature searches, physical therapists cannot take advantage of Internet access to online databases, which were widely available to 80% of the survey respondents.

A consistent observation was that physical therapists working in small, community-based, rural, or nonteaching institutions are particularly disadvantaged to implement EBP due to a lack of educational and human resources. Physical therapists working in these practice settings may have the greatest need for interventions designed to enable EBP. We also attempted to assess social networks and organizational culture, which are considered important influences on the implementation of best practices. (7) Interestingly, a lack of peer support represented a potential organizational barrier to EBP, as approximately one third of the respondents were neutral or agreed that colleagues were skeptical of new practices. Peer support is considered to have an important effect on EBP behavior given that physical therapists rely heavily on peers when seeking information. (18) Although three quarters of the respondents perceived their organization to be supportive of using current research in practice, this support was not in the form of a mandate promoting research use. Physical therapists working in Ontario, Canada, have previously indicated that having an organizational directive facilitated the routine use and reporting of outcome measures. (17) The lack of a directive supporting EBP, however, did not appear to represent a barrier in the current study. Given that few respondents reported having such a mandate, perhaps therapists were inexperienced with the potential benefits of having one. Overall, there is a need to develop a supportive organizational infrastructure in addition to enhancing skills of the evidence-based practitioner to increase research integration in physical therapist practice for people after a stroke. (53)

Limitations

This study was not without limitations. Difficulty with determining the number of eligible physical therapists available for study makes it challenging to interpret the external validity of our findings. In a recent Canada-wide telephone survey, a coauthor (NKB) confirmed that approximately 138 physical therapists were providing services to people with stroke out of 600 physical therapists (23%) in neurology practice in acute care, rehabilitation, or community settings in Ontario (unpublished results). Given that a large proportion of physical therapists work in these settings, it is probable that our sample was representative.

Respondents were likely individuals with some interest in EBP, which may have led to an overestimation of the percentage of physical therapists with positive attitudes toward and beliefs and interest in EBP. Another limitation was that the study was conducted in only one Canadian province, and it is unclear whether the results would generalize to physical therapists working in other provinces. Provincial-level strategies to coordinate and optimize the care for people with stroke are being implemented across Canada, suggesting that resources and perceptions of physical therapists in Ontario may be similar to those in other provinces. Certainly, the availability of university-based physical therapist programs across the country and the wide distribution of age, professional training, practice experience, and work settings among respondents support the internal and external validity of the study findings. The closed-ended nature of the questionnaire items limits our insight into some of the survey results, such as the exact nature of the respondents' participation in research activities. This limits the specificity of recommendations that can be made. Finally, we considered the cutoff thresholds used for reporting self-efficacy scale ratings as meaningful, but formal evaluation is needed to verify their clinical validity.

Conclusions

There is a need for continuing education to enhance skills and self-efficacy to search and critically evaluate the research literature and to solicit patient preferences among Canadian physical therapists. Educational initiatives may enhance the quality of physical therapy care and, ultimately, recovery after stroke. Health care organizations can support the individual practitioner by providing resources to enable EBP and opportunities for interactions among health care professionals, students, and researchers that may foster positive attitudes toward this process.

Invited Commentary

Pamela Woods Duncan 

Good stroke rehabilitation matters. Intense and organized stroke rehabilitation helps improve recovery and quality of life. (1) For over a decade, there have been evidence-based recommendations for post-acute stroke care. (2,3) Compliance with these best-practice recommendations improves functional outcome and decreases the probability of nursing home placement. (4) Yet, even when most physical therapists recognize the importance of evidence-based practice and accept it as a responsibility, they are unaware of the clinical guidelines, do not implement the recommendations for assessment of outcomes, and do not routinely adopt the most proven therapies into routine practice. The chasm between what is recommended and what we do seems to widen every day.

Salbach and colleagues' excellent study (5) has identified several physical therapist-related factors that may limit translation of evidence into practice. Specifically, the effects of education level and time since graduation on evidence-based self-efficacy suggest that there are many experienced physical therapists who may not have the analytical skills or educational background to select and endorse evidence-based practices. As Salbach and colleagues suggest, there is a need to educate those who are more senior in their practice.

Barriers to compliance with evidence-based practice often are attributed to the practitioner. I often hear my academic colleagues say, "Physical therapist practice will become more evidence based when we have more doctorally trained physical therapists in practice." Although Salbach and colleagues' results suggest that more recently prepared physical therapists and more highly educated physical therapists have more self-efficacy for evidence-based practice, we should not underestimate the complexities of implementing best practices for stroke rehabilitation.

Greenhalgh et al (6) have developed a comprehensive conceptual model for considering the determinants of diffusion, dissemination, and implementation. These investigators have synthesized the literature on implementation and have identified the following key factors that will influence uptake of evidence-based recommendations: the intervention itself, the methods of communicating the evidence, the sociopolitical climate of the adopting agencies, the system-level factors, the system readiness for innovation, the characteristics of the adopter, and the implementation process.

Evaluating the scope of Salbach and colleagues' results in the context of the Greenhalgh et al model, (6) I would suggest that there are major organizational barriers disguised in the response that insufficient time is the major barrier to implementing evidence into practice. Is it really insufficient time, or is it inefficiency and lack of informatics to support standardized outcome measurements and clinical decision making?

Most importantly, some barriers to best practice may rest with our research-based interventions. Thirty-four percent of the responders to Salbach and colleagues' survey suggested that research products are not clinically relevant and generalizable to routine care. These results suggest that researchers must: (1) examine restrictions in inclusion and exclusion criteria for participants, (2) evaluate the feasibility of implementing their interventions in clinical practice, and (3) select clinically relevant outcomes that may be valued by patients as well as insurers and health policy experts.

In conclusion, this well-designed and thoughtful study by Salbach and colleagues sheds some light on practitioner characteristics that may influence translation of evidence into practice. The results also challenge us to more systematically explore the complexities of implementing evidence-based practice. Educating practitioners may be a valid initial step, but it is far from sufficient for full implementation of evidence-based recommendations and interventions. Implementing evidence into clinical practice will need to involve cooperation and collaboration, from a variety of fields not traditionally associated with physical therapy. Relevant fields will include medical informatics, clinical decision making, organizational theory, socialbehavioral change agents, health policy, finance, and marketing. Most importantly, successful implementation of evidence will include collaboration with multiple stakeholders from clinical practice settings, as well as patients and their families.

PW Duncan, PT, PhD, FAPTA, FAHA, is Professor and Bette Busch Maniscalco Research Fellow, Doctor of Physical Therapy Division, Department of Community and Family Medicine, Duke University, and Senior Fellow, Duke Center for Clinical Health Policy Research, 2200 W Main St, Suite 220, Durham, NC 27705 (USA). Address all correspondence to Dr Duncan at: [e-mail].

DOI: 10.2522/ptj.20070040.ic

References

(1) Langhorne P, Duncan PW. Does the organization of postacute stroke care really matter? Stroke. 2001;32:268-274.

(2) Gresham G, Duncan PW, Adams H Jr, et al. Post-stroke Rehabilitation Clinical Practice Guideline. Rockville, Md: US Department of Health and Human Services PHS, Agency for Healthcare Research and Quality (formerly Agency for Health Care Policy and Research); 1995.

(3) Duncan PW, Zorowitz R, Bates B, et al. Management of adult stroke rehabilitation care: a clinical practice guideline. Stroke. 2005;36:el00-e143.

(4) Duncan PW, Homer RD, Reker DM, et al. Adherence to postacute rehabilitation guidelines is associated with functional recovery in stroke. Stroke. 2002;33: 167-177.

(5) Salbach NM, Jaglal SB, Korner-Bitensky N, et al. Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke. Phys Ther. 2007;87:1282-1301.

(6) Greenhalgh T, Robert G, Macfarlane F, et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82:581-629.

Author Response

Nancy M. Salbach, Nicol Korner-Bitensky

Duncan has produced a thought-provoking commentary on the current state of evidence-based practice (EBP). Although we agree with her that multiple factors must be favorable to implement EBP effectively, the practitioner is clearly the primary player. Duncan points out that preparing practitioners to implement EBP "may be a valid initial step" toward achieving this process, but this is arguably an understatement. The practitioner is the cornerstone of EBP, and thus education regarding EBP is an essential responsibility of the profession's educators and of the practitioner as a lifelong learner. Even if an organization mandated the use of a specific therapy that research had shown to be effective, the evidence-based practitioner would be expected to understand the research context in which the therapy was evaluated and use clinical judgment informed by an understanding of patient values and preferences when deciding whether to use the treatment or not.

As Sackett et al (1) emphasized, "Research findings should not be regarded as a prescription for clinical care. Instead, they should be combined with clinical expertise and patient preferences to enlighten clinical decisions." The clinician must have knowledge of the research findings, the clinician must use expertise based on past experience, and the clinician must solicit the client's values and treatment preferences and understand these preferences in the context of decision making. She or he must integrate knowledge from these primary sources when making the diverse clinical decisions required in any practice setting, and this makes preparing the practitioner with EBP skills more than simply a valid first step.

Given the complex nature of EBP behavior, the solution to changing behavior is equally complex. A notable number of physical therapists in the United States (2) and in Canada (3) have reported that they lack the ability to search, appraise, or apply the research literature to individual clients. What is the best way to improve these skills? Duncan indicates that, based on reflections from colleagues, professional preparation at a higher degree level is one answer. Certainly our survey findings support a positive association between degree level and academic preparation in EBP, training in critical appraisal skills, and perceived ability to implement EBP. However, we cannot wait until doctoral programs are widely implemented to address this issue. Although doctoral-level degree programs are increasingly available in the United States, it is unclear whether Canada or other countries will follow suit. We, therefore, must act now to integrate sufficient opportunities to learn the breadth of EBP skills in existing physical therapy programs. This poses a challenge, given the necessary focus on development of clinical knowledge and skills. To address the needs of practicing physical therapists, we propose continuing education as the solution, given that more than 84% of American (2) and Canadian (3) physical therapists surveyed expressed interest in learning or improving their EBP skills. Physical therapists who make a substantial financial investment to advance their clinical skills through continuing education courses and workshops may find the quality of their practice enhanced after investing to improve their EBP skills.

Educators must move beyond teaching traditional search and appraisal EBP skills, given the rapidly emerging wealth of information posted on the Internet. Findings from in-depth interviews that we conducted with 23 of our survey respondents show that we need to familiarize physical therapists with what is available. For example, StrokEngine (www. strokengine.org) and the Evidence-Based Review of Stroke Rehabilitation (www.ebrsr.com) are impressive Web-based resources presenting results of systematic reviews relevant to stroke rehabilitation. Without educational opportunities to explore such resources, many busy clinicians will remain unaware of their existence. Only the technologically savvy practitioner will access and use this synthesized information. We appreciate, however, that awareness of a resource does not ensure its use. Based on the theory of self-efficacy, (4) educators also must provide practitioners with opportunities to effectively use EBP resources, to see their peers use these resources, and to receive positive verbal feedback about their EBP skills in a nonthreatening environment. These strategies are designed to elevate perceived ability to perform EBP activities, which then should increase implementation of EBP. (5)

We agree with Duncan's comments that a practitioner skilled in EBP may have limited success in performing EBP without a health care environment that facilitates the process. Organizations must provide technology and a system of care that will enable the practitioner to access needed information in the right place and at the right time in order to have an impact on the quality of health care services. Consider the community-based physical therapist who delivers services in the client's home and who has access to the Internet on a desktop computer located in a central office that she or he visits once a week. The technology to facilitate EBP in this setting exists, but managers and policy makers must be convinced that the benefits outweigh the cost. Creating an appropriate organizational infrastructure and resources to enable EBP may reduce the number of practitioners who report "lack of time" as a barrier to updating their clinical practice with new knowledge.

A final matter to address is the state of our "innovations," that is, the body of research literature that investigators hope will inform clinical practice. This issue is incredibly complex, and we support Duncan's emphasis on the need to develop interventions that are feasible in and relevant to the clinical setting. But there is also the issue of the weight of the evidence that is needed before recommending a change in practice. Clinicians are commonly aware that, compared with other study designs, a randomized controlled trial of an intervention yields the strongest evidence. But is evidence from one trial enough? Or evidence from 2 trials? Take body-weight-supported treadmill training as an example. Practitioners considered "early adopters" may have implemented this intervention to optimize gait outcomes post-stroke after only one study showing effectiveness. Despite intense interest in this method of gait retraining, authors of a 2003 Cochrane systematic review (6) concluded that it was no more effective than other interventions in improving walking speed and independence.

Although the strength of a finding based on a synthesis of the research literature is considered greater than that from a single study, there is another important issue that relates to the presentation of results averaged over a heterogeneous group of people with stroke. For an individual or a subgroup of individuals, a treatment may indeed be effective. Referring again to the example of body-weight-supported treadmill training, evidence from subgroup analyses suggests that this intervention is indeed effective for enhancing endurance and walking speed for people with subacute stroke and low ambulatory status, (7) a finding that clinicians using this intervention likely surmised based on their clinical experience.

In closing, we would like to reiterate that the practitioner remains the champion of EBP. It will take a strong cob laboration among practitioners, researchers, educators, health care organizations, policy makers, and clients to optimize the integration of high-quality research findings into clinical practice, improve the quality of health care services, and--most importantly--have a favorable impact on the health and well-being of people with stroke.

DOI: 10.2522/ptj.20070040.ar

References

(1) Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn't. BMJ. 1996;312:71-72.

(2) Jette DU, Bacon K, Batty C, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83:786-805.

(3) Salbach NM, Jaglal SB, Korner-Bitensky N, et al. Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke. Phys Ther. 2007;87:1284-1303.

(4) Bandura A. Self-efficacy: toward a unifying theory of behavioral change. Psychol Rev. 1977;84:191-215.

(5) Bandura A. Self-Efficacy: The Exercise of Control New York, NY: WH Freeman; 1997.

(6) Moseley AM, Stark A, Cameron ID, Pollock A. Treadmill Training and Body Weight Support for Walking After Stroke (Cochrane Review) [Update Software]. Oxford, United Kingdom: The Cochrane Library, The Cochrane Collaboration; 2003:4.

(7) Barbeau H, Visintin M. Optimal outcomes obtained with body-weight support combined with treadmill training in stroke subjects. Arch Phys Med Rehabil. 2003;84: 1458-1465.

Appendix.

Practitioner and Organizational Barriers to Evidence-based Stroke Rehabilitation (a)

1. Do you currently treat patients who have suffered a stroke?

[] Yes

[] No

If "No," please return the questionnaire in the business-reply envelope enclosed so that we may remove you from our mailing list. You do not have to complete the questionnaire. Thank you.

This section inquires about your personal attitudes toward, use of, and perceived benefits and limitations of evidence-based practice (EBP). EBP is defined as "integrating individual clinical expertise with the best available external clinical evidence from systematic research" (Sacker et al, 1996). (1)

For the following items, place a mark in the appropriate box that indicates your response.

2. Application of EBP is necessary in the practice of physical therapy.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

3. Literature and research findings are useful in my day-to-day practice.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

4. I need to increase the use of evidence in my daily practice.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

5. The adoption of EBP places an unreasonable demand on physical therapists.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

6. I am interested in learning or improving the skills necessary to incorporate EBP into my practice.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

7. EBP improves the quality of patient care.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

8. EBP helps me make decisions about patient care.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

9. EBP does not take into account patient preferences (ie, patients' reported values and preferences for treatment).

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

10. There is a definite divide between research and practice.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

11. Physiotherapists should be responsible for conducting their own literature reviews to answer their clinical questions.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

12. Physiotherapists should be responsible for critically evaluating the quality of the literature to address their clinical questions.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

13. Physiotherapists should be responsible for interpreting whether research findings apply to their individual patients.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

The following section inquires about your educational preparation and about how confident you are in your ability to access, interpret, and apply research evidence to a clinical problem. The information you provide will be used to enhance curriculum development, plan continuing education courses, and develop educational resources.

For the following items, place a mark in the appropriate box that indicates your response.

14. I learned the foundations for EBP as part of my academic preparation.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

15. I have received formal training (eg, workshops, courses) in search strategies for finding research relevant to my practice.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

16. I received formal training in how to critically evaluate research literature as part of my academic preparation.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

For each of the following activities, please indicate how confident you are in your current level of ability by choosing the corresponding number on the following rating scale."

0%   10%   20%   30%   40%   50%   60%   70%   80%   90%   100%
Cannot                     Moderately                    Certain
Do at All                    Certain                     Can Do
                             Can Do

17. How confident are you in your ability to:

    1. identify clinical problems following a patient assessment?   --%

    2. formulate a question based on the clinical problem to guide
       a literature search?                                         --%

    3. effectively search the relevant literature to address the
       question?                                                    --%

    4. critically appraise the literature for reliability and
       relevance?                                                   --%

    5. critically appraise the psychometric properties of outcome
       measures?                                                    --%

    6. critically appraise the strengths and weaknesses of
       different study designs?                                     --%

    7. interpret results of statistical procedures such as t tests
       and chi-square tests?                                        --%

    8. interpret results of statistical procedures such as linear
       or logistic regression?                                      --%

    9. appropriately apply evidence from the literature to the
       individual patient?                                          --%

   10. understand your patient's needs and treatment preferences?   --%

   11. decide on an appropriate course of action in collaboration
       with the patient?                                            --%

   12. continually evaluate the effect of your practice?            --%

The following section inquires about the availability of resources and support to promote EBP.

For the following items, place a mark in the appropriate box that indicates your response.

18. I have access in my facility to current research through professional journals in their paper form.

[] Yes

[] No

[] Do Not Know

19. I have the ability to access relevant databases and the Internet at my facility.

[] Yes

[] No

[] Do Not Know

20. I have the ability to access relevant databases and the Internet at home or locations other than my facility.

[] Yes

[] No

[] Do Not Know

21. A resource person (eg, clinical practice leader, librarian, research therapist) is available at my facility to assist me with implementing EBP.

[] Yes

[] No

[] Do Not Know

22. My facility mandates the use of current research findings in practice (mandate is a written requirement).

[] Yes

[] No

[] Do Not Know

23. My facility provides protected time to conduct literature reviews and appraise the literature.

[] Yes

[] No

[] Do Not Know

24. My facility provides financial support to attend educational meetings and conferences.

[] Yes

[] No

[] Do Not Know

25. My facility supports the use of current research in practice.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

26. Colleagues within my department are skeptical of new EBPs.

[] Strongly Disagree

[] Disagree

[] Neutral

[] Agree

[] Strongly Agree

The following item inquires about the top 3 barriers to updating your clinical practice with new knowledge.

27. Indicate the 3 greatest barriers to updating your clinical practice with new knowledge.

[] Insufficient time provided by management

[] Lack of information resources 

[] Lack of research skills

[] Poor ability to critically appraise the literature

[] Lack of generalizability of research findings to my patient population

[] Inability to apply research findings to individual patients with unique characteristics

[] Lack of understanding of statistical analyses

[] Lack of support among my colleagues in my facility

[] Lack of interest

[] Lack of an organizational mandate

[] Isolation from peers

[] Other, please specify:--

[] Other, please specify:--

[] Other, please specify:--

The following section inquires about personal demographic and practice information.

28. How old are you?

--years

29. What is your gender?

[] Female

[] Male

30. What is your entry-level degree for physical therapy?

[] Certificate

[] Bachelor's

[] Entry-level master's

[] Other, please specify:--

31. In what year did you graduate?--

32. What is your highest degree attained?

[] Bachelor's

[] Entry-level master's

[] Applied or research master's

[] Doctoral

[] Other, please specify:.

33. Do you belong to one or more professional practice-oriented organizations (eg, OPA, CPA)?

[] Yes

[] No

34. For how many years have you been practicing?

--years

35. How many years of clinical experience do you have with a stroke clientele?

--years

36. Do you supervise physical therapist students in your practice?

[] Yes

[] No

37. In a typical week, how many hours do you work?

[] <20 hours

[] 20-30 hours

[] 31-40 hours

[] >40 hours

38. In a typical day, how many patients do you see?

[] <5 patients

[] 5-10 patients

[] 11-15 patients

[] >15 patients

39. In a typical day, approximately how many patients with stroke do you see?

[] <2 patients

[] 2-5 patients

[] 6-10 patients

[] >10 patients

40. How many full-time physical therapists work in the facility in which you do the majority of your patient care?

--physical therapists

41. How many physical therapists in your primary workplace, other than you, treat persons with stroke?

--physical therapists

42. Please indicate the percentage of your total work time that you spend in each type of activity during an average month.

a) Patient care --%

b) Research --%

c) Teaching --%

d) Administration --%

e) Other, please specify:-- --%

43. Which of the following best describes the location of the facility in which you perform the majority of your patient care?

[] Rural (defined as >30 miles or 40 km from a major city)

[] Urban

[] Suburban

44. Which of the following best describes the facility at which you do most of your patient care?

[] General hospital [arrow right]

[] Inpatient

[] Outpatient

[] Rehabilitation hospital/facility [arrow right]

[] Inpatient

[] Outpatient

[] Long-term care facility 

[] Complex continuing care 

[] Community health center

[] Community care access center

[] Home visiting agency

[] Private practice/clinic [arrow right]

Is your clinic designated an OHIP clinic?:

[] Yes

[] No

[] University/educational institution

[] Consulting firm/agency

[] Other, please specify:

45. Is your setting a teaching institution (defined as an institution that provides student therapists with clinical rotations/training)?

[] Yes

[] No

46. Is stroke rehabilitation research conducted in your setting?

[] Yes

[] No

[] Do Not Know

47. Do you work in a team that includes professionals from other disciplines?

[] Yes

[] No

If "Yes," is the team a stroke team (or neurorehabilitation team), specifically, a team that focuses primarily on the assessment and treatment of individuals with stroke?

[] Yes

[] No

(a) The questionnaire is copyrighted and may not be used or reproduced without written permission of the author. OPA=Ontario Physiotherapy Association, CPA=Canadian Physiotherapy Association, OHIP=Ontario Health Insurance Plan.

Dr Salbach, Dr Jaglal, and Dr Rappolt provided concept/idea/research design. All authors provided writing. Dr Salbach provided data collection and analysis and project management. Dr Salbach, Dr Jaglal, and Dr Davis provided fund procurement. Dr Salbach provided subjects. Dr Korner-Bitensky and Dr Davis provided consultation (including review of manuscript before submission).

The Research Ethics Board at the University of Toronto approved the study protocol.

An abstract of part of this work was presented at the 15th International Congress of the World Confederation for Physical Therapy; June 3, 2007; Vancouver, British Columbia, Canada.

Dr Salbach was supported by an Ontario March of Dimes-Canadian Institutes of Health Research postdoctoral fellowship to conduct this study. Dr Jaglal is the Toronto Rehabilitation Institute Chair at the University of Toronto.

This article was submitted January 31, 2007, and was accepted May 29, 2007.

DOI: 10.2522/ptj.20070040

References

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(6) Berwick DM. Disseminating innovations in health care. JAMA. 2003;289:1969-1975.

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(8) Greenhalgh T, Robert G, Macfarlane F, et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q. 2004;82:581-629.

(9) Jette DU, Bacon K, Batty C, et al. Evidence-based practice: beliefs, attitudes, knowledge, and behaviors of physical therapists. Phys Ther. 2003;83:786-805.

(10) Craik J, Rappolt S. Theory of research utilization enhancement: a model for occupational therapy. Can J Occup Ther. 2003; 70:266-275.

(11) Sitzia J. Barriers to research utilisation: the clinical setting and nurses themselves. Intensive Crit Care Nurs. 2002;18:230-243.

(12) Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458-1465.

(13) Eckerling S, Bergman R, Bar-Tal Y. Perceptions and attitudes of academic nursing students to research. J Adv Nurs. 1988;13: 759 -767.

(14) Rizzuto C, Bostrom J, Suter WN, Chenitz WC. Predictors of nurses' involvement in research activities. Western J Nurs Res. 1994;16:193-204.

(15) Bandura A. Self-efficacy: The Exercise of Control. New York, NY: WH Freeman; 1997.

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(17) Huijbregts MPJ, Myers AM, Kay TM, Gavin TS. Systematic outcome measurement in clinical practice: challenges experienced by physiotherapists. Physiother Can. 2002;54:25-31, 36.

(18) Rappolt S, Tassone M. How rehabilitation therapists gather, evaluate, and implement new knowledge. J Contin Educ Health Prof. 2002;22:170-180.

(19) Pollock AS, Legg L, Langhorne P, Sellars C. Barriers to achieving evidence-based stroke rehabilitation. Clin Rehabil. 2000; 14:611-617.

(20) Jette DU, Grover L, Keck CP. A qualitative study of clinical decision making in recommending discharge placement from the acute care setting. Phys Ther. 2003; 83:224-236.

(21) Turner PA, Whitfield TWA. Physiotherapists' reasons for selection of treatment techniques: a cross-national survey. Physiother Theor Pract. 1999;15:235-246.

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* SAS Institute Inc, PO Box 8000, Cary, NC 27513.

NM Salbach, PhD, is Postdoctoral Fellow, Department of Physical Therapy, Faculty of Medicine, University of Toronto, 160-500 University Ave, Toronto, Ontario, Canada M5G 1V7. Address all correspondence to Dr Salbach at: [e-mail].

SB Jaglal, PhD, is Associate Professor, Department of Physical Therapy, Faculty of Medicine, University of Toronto.

N Korner-Bitensky, PhD, is Associate Professor, School of Physical and Occupational Therapy, McGill University, Faculty of Medicine, Montreal, Quebec, Canada.

S Rappolt, PhD, is Associate Professor, Department of Occupational Science and Occupational Therapy, Faculty of Medicine, University of Toronto.

D Davis, MD, is Vice President, Continuing Health Care Education and Improvement, Association of American Medical Colleges, Washington, DC, and Adjunct Professor, Faculty of Medicine, University of Toronto.

[Salbach NM, Jaglal SB, Korner-Bitensky N, et al. Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke. Phys Ther. 2007;87:1284-1303.]

Table 1.
Characteristics of Respondents and Their Practice (N=270)

Characteristic                          n         %

Age (y)
  20-29                                 40       14.9
  30-39                                 93       34.7
  40-49                                 75       28.0
  50+                                   60       22.4
Sex
  Male                                  30       11.2
  Female                               239       88.8
Entry-level degree
  Certificate/diploma                   47       17.5
  Bachelor's                           212       78.8
  Professional master's                 10        3.7
Highest degree
  Certificate/diploma                   30       11.4
  Bachelor's                           203       76.9
  Professional master's                  8        3.0
  Applied or research master's          23        8.7
Years practiced
  <5                                    40       14.9
  5-10                                  59       21.9
  11-15                                 48       17.8
  >15                                  122       45.4
Member of professional organization
  Yes                                  196       73.4
  No                                    71       26.6
Hours of work per week
  <20                                   28       10.4
  20-30                                 51       19.0
  31-40                                154       57.5
  >40                                   35       13.1
No. of patients seen per day
  1-10                                 140       52.4
  11-15                                 94       35.2
  >15                                   33       12.4
% time spent in patient care
  0-75                                  71       26.5
  76-100                               197       73.5
Member of multidisciplinary team (a)
  Yes                                  234 (b)   87.0
  No                                    35       13.0
Clinical instructor (c)
  Yes                                  189       70.3
  No                                    80       29.7
Participation in research activities
  Yes                                   86       32.1
  No                                   182       67.9

(a) Defined as a team that includes professionals from other
disciplines.

(b) Seventy-three respondents (27.1%) identified the team as a
neurorehabilitation or stroke team.

(c) Supervises physical therapist students.

Table 2.
Characteristics of the Practice Setting (N=270)

Characteristic                            n      %
Location
  Urban                                  159   60.9
  Suburban                                52   19.9
  Rural                                   50   19.2
Type of facility
  Acute care hospital                    106   39.6
  Rehabilitation hospital                 43   16.0
  Long-term care facility                 13    4.9
  Complex continuing care                 10    3.7
  Community health center                  3    1.1
  Community care access center            14    5.2
  Home visiting agency                    17    6.3
  Private practice/clinic                 28   10.5
  University/educational institution       1    0.4
  Other                                   33   12.3
No. of physical therapists at facility
  <5                                      88   35.5
  5-10                                    68   27.4
  11-20                                   49   19.8
  >20                                     43   17.3
Teaching institution (a)
  Yes                                    181   67.3
  No                                      88   32.7

(a) Defined as an institution that provides student therapists
with clinical internships.

Table 3.
Education, Attitudes and Beliefs, and Interest and Perceived Role in
Evidence-based Practice (EBP)

    Item                       n     Response (%)

                                     Disagree (a)   Neutral   Agree (b)
Education

    I learned the foundations  265       44.5        11.0       44.5
      for EBP as part of my
      academic preparation

    I received formal trai-    264       44.3         8.7       47.0
      ning in search
      strategies for finding
      research relevant to
      my practice

    I received formal trai-    268       35.4         8.6       56.0
      ning in how to
      critically evaluate
      research literature
      as part of my
      academic preparation

Attitudes/beliefs

    Application of EBP is      265       3.0          3.8       93.2
      necessary in the
      practice of physical
      therapy

    Literature and research    263       5.3         16.7       78.0
      findings are useful in
      my day-today practice

    The adoption of EBP        264       59.5        27.3       13.2
      places an unreasonable
      demand on physical
      therapists

    EBP improves the quality   263       2.7         13.3       84.0
      of patient care

    EBP helps me make deci-    265       2.6         19.3       78.1
      sions about patient
      care

    EBP does not take into     263       20.9        44.9       34.2
      account patient
      preferences

    There is a definite        264       19.7        25.0       55.3
      divide between re-
      search and practice

Interest/perceived role

    I need to increase the     264       3.4          6.8       89.8
      use of evidence in my
      daily practice

    I am interested in lear-   264       3.4          6.4       90.2
      ning or improving the
      skills necessary to
      incorporate EBP into
      my practice

    Physical therapists        265       18.5        32.1       49.4
      should be responsible
      for conducting their
      own literature reviews
      to answer their
      clinical questions

    Physical therapists        265       10.9        24.2       64.9
      should be responsible
      for critically evalua-
      ting the quality of
      the literature to
      address their clinical
      questions

    Physical therapists        265       2.3         13.2       84.5
      should be responsible
      for interpreting
      whether research
      findings apply to
      their individual
      patients

(a) Response categories of "strongly disagree" and "disagree" were
combined.

(b) Response categories of "agree" and "strongly agree" were combined.

Table 4.
Characteristics Associated With Education Around Evidence-based
Practice (N=270)

  Factor              Charac-               Level
                      teristic

Learned foundations   Age (y)               20-29
  in academic                               30-39
  program                                   40-49
                                            50+
                      Highest degree        Certificate/
                                              diploma
                                            Bachelor's
                                            Master's
                      Years practiced       <5
                                            5-10
                                            11-15
                                            >15

Formal training       Age (y)               20-29
  with search                               30-39
  strategies                                40-49
                                            50+
                      Years practiced       <5
                                            5-10
                                            11-15
                                            >15
                      Hours of work         20
                        per week            20-30
                                            31-40
                                            >40
                      Work in a multidis-   No
                        ciplinary team      Yes
                      Participate in        No
                        research            Yes

Formal training       Age (y)               20-29
  with critical                             30-39
  appraisal                                 40-49
                                            50+
                      Sex                   Female
                                            Male
                      Highest degree        Certificate/
                                              diploma
                                            Bachelor's
                                            Master's
                      Years practiced       <5
                                            5-10
                                            11-15
                                            >15

  Factor              Odds            95%        n
                      Ratio          CI (a)

Learned foundations   2.7           1.1-6.6     263
  in academic         Reference
  program             0.3           0.2-0.6
                      0.1           0.0-0.2
                      0.0           0.0-0.3     259
                      Reference
                      1.8           0.8-3.8
                      31.2         11.0-88.6    264
                      10.2          4.9-21.3
                      3.5           1.7-7.2
                      Reference

Formal training       2.8           1.2-6.3     262
  with search         Reference
  strategies          0.9           0.5-1.7
                      0.4           0.2-0.9
                      9.3           3.8-22.9    263
                      1.5           0.8-2.8
                      2.3           1.2-4.6
                      Reference
                      0.3           0.1-0.8     262
                      0.4           0.2-0.7
                      Reference
                      1.1           0.5-2.4
                      Reference                 263
                      2.6           1.2-5.9
                      Reference                 262
                      1.8           1.1-3.1

Formal training       3.2           1.0-9.9     266
  with critical       Reference
  appraisal           0.3           0.2-0.6
                      0.1           0.0-0.2
                      Reference                 267
                      2.9           1.2-7.0
                      0.0           0.0-0.2     262
                      Reference
                      3.0           1.2-7.6
                      99.8         13.2-754.9   267
                      7.5           3.7-15.2
                      5.4           2.6-11.3
                      Reference

(a) CI = confidence interval.

Table 5
Characteristic Associated With Attitudes and Beliefs About Evidence-
based Practice (EBP) (N=270)

  Factor              Charac-               Level
                      teristic

EBP is necessary      Sex                   Female
                                            Male

Literature and        Participate in        No
  research fin-         research            Yes
  dings are
  useful

EBP improves          Highest degree        Certificate/
  quality of care                             diploma
                                            Bachelor's
                                            Master's
                      Hours of work         <20
                        per week            20-30
                                            31-40
                                            >40
                      Work in a multidis-   No
                        ciplinary team      Yes
                      Supervise physical    No
                        therapist           Yes
                        students
                      Participate in        No
                        research            Yes

EBP helps with        Age (y)               20-29
  decisions                                 30-39
                                            40-49
                                            50+
                      Hours of work per     <20
                        week                20-30
                                            31-40
                                            >40

EBP places            Sex                   Female
  unreasonable                              Male
  demands             Highest degree        Certificate/
                                              diploma
                                            Bachelor's
                                            Master's
                      Work in a multi-      No
                        disciplinary team   Yes

EBP does not          Supervise physical    No
  account for           therapist           Yes
  patient               students
  preferences         Participate in        No
                        research            Yes

  Factor              Odds            95%        n
                      Ratio          CI (a)

EBP is necessary      Reference                 264
                      0.3           0.1-0.9

Literature and        Reference                 261
  research fin-       2.8           1.3-5.8
  dings are
  useful

EBP improves          0.4           0.1-0.8     257
  quality of care     Reference
                      1.2           0.4-3.6
                      0.9           0.3-2.8     261
                      1.2           0.5-3.2
                      Reference
                      0.3           0.1-0.8
                      Reference                 262
                      3.6           1.6-8.0
                      Reference                 262
                      2.3           1.2-4.5
                      Reference                 261
                      2.7           1.2-6.4

EBP helps with        0.6           0.2-1.6     263
  decisions           Reference
                      0.3           0.1-0.7
                      0.2           0.2-1.0
                      0.9           0.3-2.6     263
                      0.6           0.3-1.2
                      Reference
                      0.4           0.2-0.9

EBP places            Reference                 263
  unreasonable        2.9           1.3-6.4
  demands             2.6           1.1-5.7     258
                      Reference
                      0.6           0.3-1.4
                      Reference                 263
                      0.4           0.2-0.9
EBP does not          Reference                 262
  account for         0.4           0.2-0.9
  patient             Reference                 261
  preferences         0.5           0.3-0.9

(a) CI = confidence interval.

Table 6
Characteristic Associated With Interest and Perceived Role in
Evidence-based Practice (EBP) (N=270)

  Factor              Charac-               Level
                      teristic

Interested to         Highest degree        Certificate/
  learn EBP skills                            diploma
                                            Bachelor's
                                            Master's

Physical thera-       No. of patients       1-10
  pists are respon-     per day             11-15
  sible for lite-                           >15
  rature reviews

Physical therapists   No. of patients       1-10
  are responsible       per day             11-15
  for critical                              >15
  appraisal

Physical therapists   Years practiced       <5
  are responsible                           5-10
  for applying                              11-15
  research fin-                             >15
  dings to clients    Work in a multi-      No
                        disciplinary team   Yes

  Factor              Odds            95%        n
                      Ratio          CI (a)

Interested to         1.2           0.3-5.5     258
  learn EBP skills    Reference
                      0.3
                                    0.1-0.8
Physical thera-       Reference                 262
  pists are respon-   0.5           0.3-0.8
  sible for lite-     1.4           0.6-3.0
  rature reviews

Physical therapists   Reference                 262
  are responsible     0.5           0.3-0.9
  for critical        0.4           0.2-0.9
  appraisal
Physical therapists   9.7           1.3-74.4    264
  are responsible     1.0           0.5-2.3
  for applying        2.2           0.8-6.0
  research fin-       Reference
  dings to clients    Reference                 264
                      2.7           1.2-6.1

(a) CI = confidence interval.

Table 7.
Self-efficacy to Perform Evidence-based Practice Activities (N=270)

  Activity                      n       Score (/100%)

                                     Mean    SD      Range

Identify clinical problems     269   88.6   10.8     50-100
  following a patient
  assessment

Formulate a question based     269   70.2   22.0      0-100
  on the clinical problem
  to guide a literature
  search

Effectively search the         268   62.3   24.2      0-100
  relevant literature to
  address the question

Critically appraise the        268   57.0   25.4      0-100
  literature for relia-
  bility and relevance

Critically appraise the        264   43.2   25.8      0-100
  psychometric properties
  of outcome measures

Critically appraise the        268   52.0   26.1      0-100
  strengths and weaknesses
  of different study
  designs

Interpret results of sta-      268   31.0   27.0      0-100
  tistical procedures
  such as t tests and
  chi-square tests

Interpret results of sta-      268   26.9   25.6      0-100
  tistical procedures such
  as linear or logistic
  regression

Appropriately apply evidence   267   67.6   19.0      0-100
  from the literature to
  the individual patient

Understand your patient's      268   87.4   11.2     50-100
  needs and treatment
  preferences

Decide on an appropriate       268   89.3   10.1     50-100
  course of action in
  collaboration with the
  patient

Continually evaluate the       268   84.0   12.8     40-100
  effect of your practice

Total score (/100%)            261   63.2   14.4   25.8-96.7

Table 8.
Characteristics Associated With Self-efficacy to Perform Evidence-based
Practice Activities (N=270)

Characteristic    Level                 Odds        95%        n
                                        Ratio (a)   CI (b)

Age (y)           20-29                 0.8         0.4-1.8    268
                  30-39                 Reference
                  40-49                 0.6         0.3-1.0
                  50+                   0.2         0.1-0.3
Sex               Female                Reference              269
                  Male                  3.0         1.3-7.0
Highest degree    Certificate/diploma   0.3         0.1-0.7    264
                  Bachelor's            Reference
                  Master's              5.2         1.9-14.2
Years practiced   <5                    4.7         2.1-10.2   269
                  5-10                  3.0         1.6-5.7
                  11-15                 2.1         1.1-4.1
                  >15                   Reference

(a) Ratio of the odds of observing a summary self-efficacy score above
the median (63%) to the odds of observing a summary self-efficacy
score equal to or below the median.

(b) CI =confidence interval.

Table 9.
Characteristics Associated With Perceived Support and Organizational
Resources for Evidence-based Practice (EBP) (N=270)

Factor        Charac-        Level          Odds       95%     n
              teristic                      Ratio     CI (a)

Perceived     Facility       No           Reference            264
  facility      is a         Yes          1.9        1.1-3.4
  support       teaching
                institution

Facility      Location       Urban        Reference            256
  provides      of setting   Suburban     0.8        0.4-1.5
  journals                   Rural        0.4        0.2-0.7
  in paper-   Type of        Acute        Reference            262
  format        of setting     care
                               hospital
                             Rehabili-    2.4        1.1-5.3
                               tation
                               hospital/
                               complex
                               conti-
                               nuing
                               care
                             Community-   0.4        0.2-0.7
                               based
              No. of         <5           Reference            244
                full-time    5-10         1.9        1.0-3.6
                physical     11-20        2.3        1.1-4.8
                therapists   >20          5.5        2.1-14.3
                on staff
              Facility       No           Reference            264
                is a         Yes          3.6        2.1-6.1
                teaching
                institu-
                tion

Facility      Location       Urban        Reference            256
  provides      of setting   Suburban     0.6        0.3-1.4
  Internet                   Rural        0.4        0.2-0.8
  access      Type of        Acute        Reference            262
                 setting       care
                               hospital
                             Rehabili-    0.8        0.3-2.5
                               tation
                               hospital/
                               complex
                               conti-
                               nuing
                               care
                             Community-   0.1        0.0-0.2
                               based
              No. of         <5           Reference            244
                full-time    5-10         5.3        2.2-13.1
                physical     11-20        7.0        2.3-21.3
                therapists   >20          5.9        1.9-18.1
                on staff

Facility      Facility       No           Reference            264
  provides      is a         Yes          4.8        2.5-9.0
  Internet      teaching
  access        institution

Facility      Location       Urban        Reference            258
  has a         of setting   Suburban     0.4        0.2-0.8
  has a                      Rural        0.2        0.1-0.4
  resource    Type of        Acute        Reference            263
  person        setting        care
  person to                    hospital
  assist                     Rehabili-    4.7        2.0-11.3
  with EBP                     tation
                               hospital/
                               complex
                               conti-
                               nuing
                               care
                             Community-   0.2        0.1-0.4
                               based
              No. of         <5           Reference            245
                full-time    5-10         5.1        2.6-10.2
                physical     11-20        12.0       5.1-28.7
                therapists   >20          11.8       4.8-29.2
                on staff
              Facility       No           Reference            265
                is a         Yes          5.0        2.9-8.8
                teaching
                institution

Facility      Type of        Acute        Reference            262
  provides      setting        care
  financial                    hospital
  support                    Rehabili-    0.9        0.4-2.2
  for con-                     tation
  tinuing                      hospital/
  education                    complex
                               conti-
                               nuing
                               care
                             Community-   0.2        0.1-0.4
                               based
              No. of         No           Reference            264
                full-time    Yes          6.3        3.5-11.4
                physical
                therapists
                on staff

Facility      Facility       <5           Reference            243
  mandates      is a         5-10         1.7        0.6-4.5
  the use       teaching     11-20        1.9        0.7-5.4
  of re-        institution  >20          3.7        1.4-10.1
  search in
  practice

(a) CI-confidence interval.