The consideration of EBP principles in clinical practice depends on the healthcare professional’s willingness and ability to combine the current best research evidence with patient preferences and his/her clinical experience.
This study aimed to describe the EBP adherence of healthcare professionals working in Germany and to explore barriers and facilitators to the implementation of and adherence to EBP. This is, to our knowledge, the first study to provide comprehensive evidence concerning the EBP adherence across healthcare professionals in Germany.
EBP adherence
Our results showed that EBP adherence varied considerably across dimensions. In dimension 1 (attitude) and 3 (perceived behavioural control) more than 50% of the participants demonstrated a marked adherence to EBP, whereas in other dimensions, participants were more ambivalent (e.g., dimension 2 – subjective norm).
The findings from this study are in line with results from other international research findings. In 2011, Heiwe et al. [
27] assessed EBP adherence and knowledge among Swedish healthcare professionals. Their findings showed positive attitudes towards EBP and its use to support clinical decision-making. Although literature and research findings were rated as useful in clinical practice, EBP was not perceived as taking into account the patient and healthcare professionals’ preferences. This finding mirrors a major criticism of EBP in general: the insufficient appreciation of the patients’ preferences is criticised as probably the most difficult and poorly mapped facet of EBP and was considered to receive the least attention in EBP research [
28], which was explicitly not intended by Sackett et al. [
29]. Hoffmann et al. [
30,
31] advocated the incorporation of a shared decision making skills training into the actual EBP training for medical and health care students as a potential means to overcome this discrepancy in clinical practice.
Facilitators and barriers
According to the literature, a major influencing factor regarding the adherence to and implementation of EBP is the healthcare professional’s individual attitude towards EBP [
32]. With reference to the answers to dimension 1, the overall attitude of the current study sample towards EBP, was positive. However, still 20 to 30% were of the opinion that EBP does not sufficiently account for their clinical experience and individual differences between patients. This indicates an incomplete understanding of the EBP construct, which clearly incorporates external evidence with patient’s preferences and clinician’s individual expertise [
1]. An academic training [
33] or EBP workshops [
34] could help to improve a healthcare professional’s knowledge of EBP principles and hence reduce current misconceptions.
To ensure sound clinical decision making, research evidence must be transformed into healthcare professional’s knowledge [
1]. Regarding answers to dimension 3, participants in this study generally assessed themselves as being able to enact EBP in clinical practice, although keeping up with latest research evidence from the literature was stated to be the most challenging aspect (question 20). As most respondents reported to feel able to apply the 5 steps of EBP (questions 14 to 19), this inability needs to be further investigated, as external factors, such as lack of time and/or internet access could explain this issue and were reported in the literature to be barriers to EBP in clinical practice [
35]. However, 52% (
n = 458) of the respondents from the current study sample had a diploma or bachelor degree as highest professional degree. Therefore, the general self-reporting of being able to enact all 5 steps of EBP in clinical practice should be viewed cautiously, as it could also be estimated that some clinicians might not be interested in acquiring the necessary level of training to critically appraise research evidence [
36]. However, Dawes et al. [
1] stated that not all health care professionals needed to be able to appraise evidence from the ground up. Instead, individuals on different levels of responsibility within an organisation needed varying levels of sophistication in appraising research evidence. Managers and educators should use their critical appraisal skills to aim at producing more comprehensive and easy-to-access pre-appraised EBP material to inform ‘EBP users’, which could be seen as an additional strategy to ensure EBP in clinical practice [
1,
36].
Although 41% of the respondents in our study sample reported to have a diploma from vocational school to be their highest professional degree and hence did not necessarily receive a curricularly established EBP training, 28% favourably evaluated EBP (sum scores across dimension 1). This is in keeping with findings from previous international studies of a variety of healthcare professionals [
22,
26,
37,
38], which support the general positive attitude of healthcare professionals towards EBP. Yahui et al. [
22] and Jette et al. [
26] reported that physical therapists in Malaysia and the USA, respectively, had a positive attitude towards EBP and are inclined towards implementing evidence into their clinical practice. Philibert et al. [
37] also reported that American occupational therapists generally had a positive attitude regarding EBP although ratings regarding the usefulness of research to inform clinical practice were less favourable. In the study by Knops et al. [
38], Dutch surgeons and nurses also had a generally positive attitude towards EBP and were familiar with the EBP terminology, although more frequent staff meetings for the critical appraisal of research evidence was advocated.
Regression analysis—determinants
The most important influencing factor of EBP adherence found in this study was the time available for studying or reading scientific literature at work. According to our results, at least one hour for studying scientific literature at work significantly increases a healthcare professionals’ chance to improve his/her own estimate of the social pressure to perform an EBP conform behaviour. These findings are in line with results of previous studies of American occupational and physical therapists [
26,
37]. In the study by Jette et al. [
26], 46% of the respondents named insufficient time as the most important barrier to the use of EBP in practice. Philibert et al. [
37] reported time constraints to be the most important barrier for American occupational therapists to read scholarly journals. In 2006, [
39], the study results by Upton and Upton showed that healthcare professionals across 14 different professional groups, such as speech and language therapists and psychologists, reported lack of both, time and money as main barrier to the implementation of EBP. Hence, considerable attention needs to be paid to further develop a German healthcare infrastructure, which is committed to best practice [
1], requiring health policy action such as the implementation of a financial compensation system to offset the time invested for scientific literature at work [
40].
Based on our results, persons with a higher academic degree were more likely to adhere to EBP. Dawes et al. [
41] claimed that professions and their educational institutions need to incorporate the necessary knowledge, skills, and attitudes of EBP into their training and registration requirements. However, in Germany, currently only midwifery is legally established as a primary qualifying university degree course [
10] among allied healthcare professions, constituting the principal legal stipulations to provide students with a basic understanding and level of EBP capability upon graduation [
42]. As, for example, the German Training and Examination Regulations for Physical therapists (PhysTh-AprV) currently do not stipulate EBP training components, German physiotherapy education was stated not to meet the World Congress of Physiotherapy’s expectations regarding educational standards, which was considered a crucial issue to be addressed in the current debate on health policy [
43]. However, our study sample also comprised professions trained in higher education institutions, such as medicine, psychology, and sports sciences, but they only represented 7% of the total sample (
n = 63). The highest chances across all dimensions to adhere to EBP were shown to be associated with a postgraduate or higher academic degree, mirroring the fact that a mere university degree does not automatically implicate EBP adherence in clinical practice. These findings are in line with international requirements for medical training curricula which should enable their graduates’to have the ability to adapt to changing circumstances throughout their professional life’ [
44]. An early claim by Shin et al. [
45] supports the notion that in order to 'futureproof' healthcare graduates, they need to be trained in the necessary skills to support life-long learning through all the steps of EBP.
However, for those healthcare professionals who need to improve their EBP skills in clinical practice, the way with which to achieve this goal remains unclear. The design of effective training programmes, fostering not only healthcare professional’s attitudes and knowledge about EBP but also its implementation into clinical practice, is still matter to ongoing research [
46‐
48]. In a systematic review from 2016, Hecht et al. [
49] reported insufficient evidence as to whether currently available EBP trainings for healthcare professionals resulted in a meaningful change in EBP behaviour in clinical practice. However, in a recent study by Draaisma et al. [
50] the authors showed that healthcare professionals who were exposed to deliberate practice of EBP in a routine clinical setting, evaluated EBP as more useful and were more likely to use it in decision making than their peers who only followed a standard EBP workshop.
Participants who stated to have drafted or have been involved in at least one scientific publication or have hosted lectures and workshops on EBP, felt more able to enable EBP behaviour (dimension 3). Hosting lectures as well as drafting a scientific publication presupposes a thorough understanding of the complex construct of EBP as well as comprehensive skills regarding its teaching [
51]. However, both aspects may not directly mirror a person’s ability to adhere to EBP in clinical practice. Kaper et al. [
4] noted that the EBPI does not concern step 4 (application) and 5 (audit) of the EBP process but explicitly assesses attitude, behaviour, information processing, decision making, and department setting conditions via self-report. Hence, both these factors need to be further assessed as to whether they actually influence a person’s adherence to EBP in clinical practice by means of qualitative [
52] or mixed methods research approaches [
53,
54], going beyond the sole self-report of EBP adherence.
Study strengths and limitations
A major limitation of this study, as already published elsewhere [
14,
55], might have been the issue of sampling bias, mirrored by the above mentioned relatively low response rate of 13% (according to the number of accesses to the survey homepage). We strived to include a representative sample in the online survey by employing different media to bring the survey to the community of German healthcare professional’s attention. Yet, with respect to the total number of healthcare professionals working in Germany, the total number of participants (
n = 889) was relatively low [
14]. Currently, there are approximately 385,100 active physicians (in 2017) [
56], approximately 1,064,342 healthcare professionals who are subjected to social insurance contributions (in 2018) [
57] and approximately 192,000 physical therapists (in 2016) [
58] working in Germany [
14]. Therefore, we must presume that most healthcare professionals in Germany were not aware of the survey or decided not to participate, although we tried to distribute the information about the survey as broadly as possible [
14]. In particular, medical physicians and nurses were not sufficiently represented [
14]. A wider announcement of the survey among these professionals as well as the utilization of the Total Design Method provided by D.A. Dillman [
59] as well as incentives might have increased the rate of participation [
14,
55].
A further limitation was the sole online accessibility of the survey [
14,
55]. This fact might have inflated the participation of (younger) healthcare professionals and people familiar with the use of digital media and online contents. In contrast, it might have prevented (older) people from participation, who are not that familiar with online content or healthcare professionals working in institutions without internet access [
14]. However, the mean age of participants (37.4 years) in our study was lower than that of the total working population in Germany (43 years) [
14,
55,
60]. However, representative data for the age distributions of healthcare professionals working in Germany are not available. In addition, younger healthcare professionals may be distinct from older (more experienced) ones regarding their EPB adherence, as stated by Dysart et al. [
61], who reported greater reservation towards research evidence among more experienced occupational therapists compared to less experienced colleagues [
14,
55].
In addition, our study was conducted as a self-administered online survey, not as an actual audit of current clinical practice. This might not provide a complete realistic impression of EBP under routine clinical care conditions [
62].
Currently, there is no standardised instrument to assess the construct of EBP in its complexity, hampering the comparability of results across studies. In 2014, a systematic review by Fernándes-Dominguez et al. [
63] identified 24 instruments assessing EBP adherence as well as barriers and facilitators only among the professional group of physical therapists with all instruments judged to lack sufficient comprehensiveness regarding the validation procedure. We used a cross-culturally adapted German version of the EBPI, an instrument with evidence of sufficient reliability [
14] and construct validity [
4].
Despite these limitations, our study presents several strengths. This is the first survey to systematically assess self-reported adherence to EBP across healthcare professionals in Germany. In addition, we also explored a broad set of potential facilitators and barriers regarding EBP implementation into clinical practice, which constitutes a crucial component for implementing research evidence into routine clinical practice [
62].
Although our sample size did not arrive to be representative for the entire group of healthcare professionals in Germany, we reached 889 respondents across 9 professions, which is comparable to other international nationwide surveys [
39] across healthcare professionals [
14].
Regarding the univariate logistic regression analysis, we decided to draw influencing factors which were previously used [
4] in similar studies, which constitutes a sound methodological approach recommended for exploratory regression analysis [
15].
A further strength of this study was the use of the “snowball-principle”, which led to the involvement of many national journals, newspapers, professional societies, informal social media groups and other ways to distribute the survey nationwide to as many potential participants as possible [
14]. All healthcare professionals working in Germany were able to access our survey online without any preceding restrictions, such as a password [
14,
55].