Physiotherapists’ perceptions of challenges facing evidence-based practice and the importance of environmental empowerment in fall prevention in the municipality – a qualitative study

The study was designed using a qualitative phenomenological approach. The materiel consists of 18 in-depth interviews with physiotherapists in four different districts in Oslo, Norway. A qualitative phenomenological approach offers an opportunity for in-depth information about a phenomenon about which little may be known [40]. A phenomenological perspective explores how human beings perceive the world and transform those experiences into consciousness [41].

Participants were recruited by the first author of this paper through leaders and contacts who attended an informational meeting regarding this study (e.g. aim, reasons for doing the research, personal goals). Subsequently, a response was given to the first author about potential participants who were contacted by either email or telephone. Furthermore, the researchers had no relationship with the participants. We used a purposeful sample to achieve a heterogeneity within the physiotherapist groups, which represented a broad spectrum of health professionals with different experiences and from different contexts to strengthen the validity of the study [40]. We sought a maximum variation in the sample in terms of socio-economic status of the district in which they were employed, gender, age and years of experience. Participants were included if they met two criteria: (i) they had knowledge and experience in practicing fall-prevention interventions, and (ii) they were employed at the municipality health care service. Based on the recommendation from Creswell and Poth [42] regarding inclusion of participants until the researcher assesses the number of informants as a sufficient sample (15 ± 10), data collection continued until the researchers were satisfied that rich detail of the participants’ experiences had been captured. Recruitment was considered complete when saturation was achieved. Data saturation means that no new information or themes are discovered in the empirical data, which indicates that the data collection may finish. At this point, the researcher can be reasonably assured that further data collection will not enhance or change the findings of a study [43].. Furthermore, we used the concept “information power” to guide adequate sample size for qualitative studies. Information power indicates that the more information the sample holds, relevant to the actual study, the lower amount of participants is needed and depends on 1) the aim of the study, 2) sample specificity, 3) use of established theory, 4) quality of dialogue, and 5) analysis strategy [44]. All the participants delivered detailed descriptions, and data were deemed to be rich enough to elaborate a general structure. In total, 18 physiotherapists, seven men and eleven women, from four different districts from the Oslo municipality participated in the study. No participants withdrew from the study. The physiotherapists ranged in age from 27 to 60 years (median 36 years) and had worked as a physiotherapist from 1 to 36 years (median 7 years). Table 1 presents information about the participants’ age, gender, years of experience as physiotherapists, years of experience in the primary healthcare service, additional education and position and/or unit.

The first author (HW) conducted all the interviews. Prior to the interviews, the participants received a thematic interview guide; this was a conscious decision of the research team, as the more-or-less prepared answers ensured completeness. The interview guide consisted of a series of open-ended questions created for this study by the researchers (See Additional file 1). The interview guide was tested in a pilot interview for comprehensibility. Furthermore, prompts were used in all interviews to ensure that all participants were prompted in a similar manner. Prior to the interview, participants completed a paper questionnaire with general information about themselves as physiotherapists, such as years of education, additional education, workplace, etc. Participants were asked to describe current practices and their experiences of EBP in fall prevention, their understanding of how to work EBP, success factors for implementing EBP, the necessary requirements for practising EBP, and the balance between the various elements of EBP. To facilitate a discussion, the illustration of the EBP model devised by Haynes et al. [45] was used during the interviews. The interviews were conducted between May and November 2019 and took place at the physiotherapist’s workplace. All interviews were conducted face to face by the first author and participant. All participants were interviewed only once. The interviews lasted about 45–60 min and took place at the physiotherapist’s workplace. To support the participants’ narratives, audiotape and field notes were used during the interviews. There was no modification of the procedures in response to evolving study findings.

The participants’ perceptions of the interviewer, including her professional role, can influence the interaction, and hence the information that is revealed [46]. In this study, the participants were informed about the researcher’s professional background as a physiotherapist and PhD student. This may have been important in the sense that the informants fail to give detailed descriptions, because they assume that someone as a physiotherapist already has some knowledge of the field of practice.. To avoid this, the participants were asked to describe in detail all the descriptions of clinical practice and any challenges with EBP. On the other hand, the researcher’s professional background and the fact that there was no close relationship between her and the participants may have contributed to they being able to tell something they would not otherwise tell. Challenges experience with EBP practice are of importance for the interdisciplinary team so, hopefully, our results are transferable to other healthcare professional practices. However, if the interviewer has been a nurse or a medical doctor they will have asked other follow up questions and received other answers.

The interviews were audio recorded and then transcribed verbatim by an independent person. Since the transcripts were not sent to the participants, the first author who performed the interviews reviewed the transcripts for accuracy. A qualitative software programme, HyperRESEARCH™, was used to organise data. The first author was primarily responsible for the analysis of the data, but all authors were involved and contributed to the analysis. Thematic analysis with an inductive approach was conducted to analyse the data [47]. During the analysis, data were systematically examined to identify repeated patterns of meaning. This process was composed of Braun and Clarke [47] six-step method: (1) familiarizing the self with the data, (2) generating initial codes, (3) searching for themes, (4) reviewing the identified themes, (5) defining and naming the themes, and (6) preparing the report. Coding at the latent level produced themes that cohered tightly around environmental empowerment and revealed four sub-themes and one main theme that influence implementation of EBP. An example of the process of transforming a quotation into initial code, sub-theme and main theme is shown in Table 2.

The participants did not provide feedback on the findings. Therefore, to ensure trustworthiness, the categorisation was discussed within the research team until consensus was reached. Furthermore, the methods and results (including quotations) were described in detail, according to recommendations for consolidating criteria to report qualitative interviews (i.e., COREQ) [48]. All the authors are females, professionally trained educators and health professionals who have a background in physiotherapy and nursing. At the time of the study, all researchers were employed at Oslo Metropolitan University. Except for the first author who is a PhD student, all researchers have long experience with qualitative research.

The study was approved by the Norwegian Ethics Committee for medical and health research ethics (2018/2227/REC south-east C). Verbal information about the study was provided to the participants, and oral and written informed consents were obtained from all participants before data collection. The participants were guaranteed confidentiality and reassured that their participation was voluntary and that they could withdraw from the study at any time without needing to state their reasons. All information was treated confidentially, and personal information was anonymized. Unidentified data is personal information where the name, birth number and other directly personal identifiers have been removed and replaced by a link key / lists of codes, so that the information cannot be immediately linked to the participant. Connection keys / lists of codes were stored separately from the personal data. Anonymized data are information that cannot be used to identify individuals in the data material, neither directly through names, personal ID numbers or other unique characteristics or indirectly via background variables, nor through a list of names / connection key or encryption formula or code. Furthermore, data material was stored on a password-protected data to prevent unauthorized access to information.

Features of research-based knowledge were reported to represent difficulties because of the attributes related to the research articles. Tension between research-based knowledge and clinical practice were reported to depend on the feature of the research-based knowledge; for example, ease-of-use, relevancy and applicability in practice are understood as the readability of research articles, formulations and style of the recommendations, including their complexity. In addition, the scientific validity of research and the relevance and applicability in practice therefore need further critical reflection and time to understand.

According to all of our participants, it is crucial for EBP implementation that research is presented in an understandable way. Clinical guidelines were said to provide a concrete and precise description of desired performance; by giving detailed advice on what to do in a given situation and to whom in which patient group and so on helps healthcare professionals determine which factors or conditions should be taken into account. In contrast, several participants described a tension between research-based knowledge and the usability and intelligibility of the research described in publications, such as scientific articles. They expressed that the layout of research articles was too detailed and not relevant to them as clinicians. Some of the research was described as unattractive, ‘untidy’ and ‘twisty’. Comprehensive figures, tables and abbreviations make some articles almost impossible to read and understand. Some of the participants also expressed that professional terminology and language can hinder and reduce their understanding of the research, especially when the professional terminology and literature are written in English. Research written in their native, mother-tongue language was preferred over English literature. One participant expressed frustration about the presentation of the research articles as follows:

I don’t know how many times I [have] started to read a lot of research papers and not finished them because of [the] complexity of the language they use. (Physiotherapist No. 5)

A majority of the participants preferred concrete, simple and clear recommendations. The content of research articles was considered by the participants to be of various levels of relevance. Advanced and detailed descriptions of the method were considered less relevant to clinical practice and appeared to be a challenge for the clinicians:

I don’t know in how many research articles I had to jump right to the results and just gave up because of the way it was written [ … ] It might just be natural that one always skips the method section and those kinds of things, which may not have the same great relevance, but I may read myself a little wild sometimes when intervention is also presented in an article. The way intervention is presented can be very, very unclear and maybe a little incomprehensible, and that’s the essence of what I want to get out of an article, as well as the results, of course. If the intervention part is presented in a cumbersome and bad way, then I really get nothing out of it. (Physiotherapist No. 5)

Most of the physiotherapists expressed satisfaction with the transferability of research in fall prevention and experienced limited tension between research-based knowledge, professional knowledge and patient needs and values. Their recommendations were based on evidence representing relevant aspects of daily practice. Nevertheless, some mentioned that there are some limitations in the methodology used in research. Research was regarded as a small part of a larger whole and not directly transferable to clinical practice in the municipality. In addition, they expressed that clinical trials are often performed in ‘ideal settings’ with various exercise equipment that is not available for home-based community dwellings.

[T] he research is done in ideal environments and circumstances where you have the equipment you need [ … ] [T] here are some practical things that make it difficult to transfer it directly [ … ] I definitely feel that there is a gap there between research and practice. (Physiotherapist No. 3)

Several of the participants also expressed concern about having access to research, which they considered to be a challenge in a busy workday. Comprehensive database search strategies are given lower priority than clinical practice and the encounter with the patient; to overcome this barrier, research must be as accessible as possible and almost ‘served’ to them. The large amount of research and lack of time to search for relevant literature, as well as diverse research results, can also confuse the clinician as to which studies they can rely on. In addition to the need for evidence, EBP requires that professionals are trained and endowed with the necessary skills to search after and critically use evidence. In addition to all of this, some of the research was perceived as vague and not specific enough to meet challenges in clinical practice, as one of the physiotherapists stated:

[I] t is a challenge that there is so much research, you don’t know if what you’re reading is the answer to everything, or the answer to one thing. There may be many other articles that say something different, so I think that can be a challenge. (Physiotherapist No. 9)

Research and clinical recommendations demand that the working environment facilitates the acquisition of new competence (i.e., knowledge, skills). However, research and clinical recommendations and can only be followed when the physiotherapist has specific knowledge and skills. One physiotherapist acknowledged the challenges regarding competence and use of research:

[T] he basic education we have as a health professional is very superficial and you do not learn enough about how to acquire research-based knowledge as a clinician. (Physiotherapist No. 11)

Tension between research-based knowledge and the individual patient was reported by several participants, who stated the importance of prioritising the individual patient. Some of the participants stated that evidence-based practitioners adopt a process of lifelong learning that involves possibilities for continually posing specific questions of direct clinical importance to clients, searching objectively and efficiently for the best current evidence related to each question and taking appropriate action guided by evidence:

Sometimes it’s really hard to use research—the patient doesn’t fit in a [mould.] I think the starting point is to try to understand the individual [ … ] The knowledge I have is pretty much general and you can quickly start something that is not feasible in accordance with the patient. I think that’s where the professional judgement appears [ … ] Everything is interwoven, general knowledge of strength and balance will always be present, but after all, it has to be adapted to the individual [ … ] So, practice means to move constantly between different types of knowledge. (Physiotherapist No. 2)

A majority of the participants stated that evidence can certainly inform policy, but sound policy requires understanding, values and deliberation with respect to practice. They also suggested that policy can be built on other sources of enlightenment, such as clinicians’ experiences. However, the physiotherapists acknowledged the importance of ‘evidence-based policy’ and associated it with the discourse of ‘what works’. It is important to consider the ways in which institutional mechanisms and government structures translate findings into policy, or not. Financial considerations and lack of personal contact with politicians that leads to mistrust of politicians are some of the factors that were highlighted as being important for evidence-based policy and further EBP.

A tension between therapists using EBP and the management conditions given by persons representing policy was evident in our participants’ statements. Policy provides preconditions for clinical practice; the participants emphasised the impact of power and budget struggles for implementing of EBP. Money is power, and power provides opportunities for influencing fall prevention interventions and programmes. Contextual influences on the roles and processes that support EBP were apparent at the policy level. According to our participants, the influence of formal regulatory schemes seemed to be important for the managers’ decisions regarding EBP implementation. However, politicians and clinicians’ understanding of fall prevention and physiotherapy seemed to be viewed as a ‘culture clash’. One physiotherapist shared her frustration over the politicians and leaders’ lack of understanding and insight into physiotherapists’ competence:

I have tried to say that strength and balance training are what research shows are the most effective intervention to prevent falls and fractures [ … ] [A] nyway, we are told that we should go out and sprinkle [ … ] So, we need to have bags with sand in the cars and we distribute crampons and things like that and that is great, but most of the accidents happen at home. (Physiotherapist No. 17)

All physiotherapists were aware of the importance of early intervention to prevent falls and the negative development of physical impairment in the elderly. In addition, long-term prevention of falls is economically profitable. However, according to our participants’ perceptions, this knowledge did not appear to be widespread among politicians. Interventions without visible financial gain were therefore gradually abolished.

Previously, fall prevention groups have started with a quite high intensity training exercises, but you do not see the economic gain after one year and then they are not prioritized which means that they eventually end. (Physiotherapist No. 15)

Furthermore, one of the physiotherapists expressed his frustration and annoyance regarding politicians’ lack of knowledge and understanding of the financial benefits of fall prevention:

[W] hat bothers me the most is that those who really need to understand the research, such as politicians and management don’t quite see it [ … ] [F] all prevention is not as high a priority when it is not a spontaneous economic gain. (Physiotherapist No. 15)

Participants expressed a lack of cooperation with management and politicians. However, numbers and finances seemed to be of interest, as one of the participants mentioned:

[T] hey are very fond of numbers, so when they see that a hip fracture costs [ … ] NOK 350 000 for the district during the first year, they are very interested in preventing hip fractures. (Physiotherapist No. 6)

Regarding preconditions to strategically implement EBP, the physiotherapist emphasised the role of management in terms of facilitating prerequisites, as well as creating a positive culture towards EBP. Several physiotherapists expressed a philosophy and culture of continuous quality improvement, which clearly influenced the approach for EBP implementation. The professional environment and common meeting point in the form of professional meetings were described as something the physiotherapists need to survive and overcome as a professional. Knowledge-sharing in a stimulating and engaging academic environment was described as a social process. Physiotherapists interact in constructing meaning. Development and changes in knowledge, behaviour and work routines are the sum of what the ‘team members’ learn and reflect in practice. A majority of the participants suggested that during job training, it is important to establish a context that facilitates building the capacity to perform EBP.

A strong professional environment is crucial for EBP implementation and is described as a centre of power where both human and professional resources are alternately affected. The physiotherapists expressed that they are inspired and motivated by each other through professional fellowship and discussions. Academic discussions and collaboration provide professional development, and engaged employees are more creative, productive and willing to go the extra mile. One participant expressed how a motivating collegiate environment stimulates service innovation and professional culture:

If you have a bunch of physiotherapists who only do what is strictly necessary, I think it may not be as expedient in terms of the professional and what you can accomplish as a team at the department level. But if you have a department that is motivated and wants to do a good job and wants to go the extra mile, which I feel we do here, most of us, then I think that you achieve more. (Physiotherapist No. 4)

Another participant described the importance of the academic work environment for motivation as follows:

The work environment is really alpha and omega for keeping up the motivation and for wanting to develop oneself and the health service and that you have colleagues who are supportive and open to suggestions. (Physiotherapist No. 6)

The physiotherapists emphasised that the composition and diversity of different professional groups may enrich EBP in fall prevention; however, this can also act as a detriment to the physiotherapists’ core competence. Without a professional community and competent leadership, the physiotherapists’ centres of power seemed ‘empty’. One said:

I miss a professional powerhouse, I don’t think I want an exclusivity, but I think you are a little dependent on someone talking together about professional knowledge, research or experience. (Physiotherapist No. 2)

The physiotherapists described how the organisation has a common responsibility for professional development. Research and knowledge distributed by mail, professional meetings and collegial guidance were frequently used approaches. Although most physiotherapists expressed motivation and commitment, one participant described a lack of motivation and interest in fall prevention and research:

[I] t may just be commitment or motivation to do it, because I wasn’t very keen to read research and stuff like that, so that might be my problem, but I know I should. (Physiotherapist No. 13)

Leadership were reported to be associated with EBP-enhancing environments. Several of the participants talked about appropriate staffing, effective decision-making, meaningful recognition, skilled communication and true collaboration. They suggested that it was important that the leader and politician were approachable and trustworthy, as well as good communicators, open-minded, knowledgeable, visible, transparent and responsive to the needs of the staff. One physiotherapist expressed frustration and shared her feelings about how the leader of another profession lacked understanding and support for physiotherapists:

[T] here is no leader in the leadership team that says that this is important that the physical therapists do [ … ] [T] he head of the department wants us to continue with groups, but they are nurses [ … ] [T] hey think that the physiotherapists are always busy with these groups, why should they keep doing that? Why can’t they help us? (Physiotherapist No. 17)

Factors belonging to this category were reported to be lack of facilitation and organisation for professional development, including time, capacity and resources to make changes. The physiotherapists described the importance of research for clinical practice, and most of them also expressed an interest in and motivation for professional development. Nevertheless, the physiotherapists described a continuous negotiation process between professional development and daily activities. The participants described tension between professional development and daily routines, and they highlighted dilemmas between prioritising working tasks and finding time for reading research for their own professional development. Self-study and reading professional literature were described as real-time and given less priority.

[I] t can be a bit difficult even if it is possible, in practice it can be a little difficult to prioritize it while you are at work because you often feels there are other things you should do, even though you may not feel that there are other things that are more important, but if you have an application for someone waiting for a walker, then the person is waiting for you and then you have to do it. (Physiotherapist No. 3)

Participants expressed tension between professional development and economic resources. Despite strong motivation to stay academically up-to-date, the everyday working life imposes limitations. Support and facilitation for competence development seemed low. A minority of the participants expressed that courses and other academic activities are not recognised by management, so course fees and other costs are therefore not covered. One participant described how lack of support from the workplace seemed like a barrier to their professional development:

The course must be 100% relevant for the job and it should not cost too much [ … ] [Y] ou might have to take leave without pay, pay the tuition fees and take free that day [ … ] [T] his feels quite difficult [ … ] First you have to lose money, then you have to pay for the course, suddenly it becomes very expensive. (Physiotherapist No.12)

Several of the physiotherapists expressed a strong inner motivation for physiotherapy and that they spent their free time on professional development. One participant said:

[Y] ou may have a strong desire to be updated, but you do not have time in a busy day. I spend a lot of time to keep [ … ] updated, but I do it at home and people are not expected to spend time in the evenings and weekends, to sit and read or go to classes and pay from their own pockets. (Physiotherapist No. 11)

However, several participants expressed the need for leadership from the management regarding professional development and facilitation. Research updates as a mandatory task was highlighted as a suggestion for getting more current research into use.

EBP was reported to require changing existing routines and habits and leaving what is seen as common practice towards the target group. Promoting organisational innovation, resources and a risk-taking climate builds the organisation’s absorptive capacity. The physiotherapists discussed several factors that are important for the changing culture in organisations. Research and changes might provoke negative reactions among colleagues because the updates are not compatible with their views, position or tasks.

The participants also expressed that their organisation’s readiness for evidence-based fall prevention depended on the individual’s interest and motivation for new knowledge and willingness to make changes, as well as the organisation’s resources, such as time and capacity. Although most of the participants acknowledged that a professional academic environment dedicated to development and research promotes EBP, a minority of the physiotherapists emphasised tension between colleagues, which was created by the composition and the positioning of personalities within the team, and which were described as preconditions for changing the culture within an organisation. The following quote is from a participant who described how hierarchy and long-working seniors can act as a barrier when implementing new knowledge:

I think it has quite a lot to say, what kind of personalities work together in a place [ … ] especially if it’s a bit like a hierarchy [ … ] [I] f you have a person who has worked for many years and has a lot of experience and further education behind them, then it can be a little difficult to try to change that person’s practice [ … ] [Y] ou really get into routines and maybe not everyone is equally open to new things and then it’s a bit scary as a recent graduate [to] question how things are done. (Physiotherapist No. 14)

Furthermore, management was identified as a key factor in establishing a change in organisational culture. Openness to change and reflexive practice regarding the relationship between research-based knowledge, professional knowledge and the patient’s need were highlighted as being crucial features for the organisation. One participant described tension between EBP and willingness to change, as well as the ability to take chances:

[F] irst and foremost, you have to have a leader who leads [ … ] [T] he leader has to be open for change, and maybe lead how to present it [ … ] I don’t know how to create a good culture for it, but the employee has to find it fun being able to change the way you work and maybe see that things are done more efficiently. Be willing to throw things up in the air and take a look it again. (Physiotherapist No. 8)

One participant pondered the gap between research and practice and raised a possible idea for clinicians who do not feel the need for professional development or improvement; in doing so, he also took a critical look at his own professional practice, which seemed to be influenced by tension between EBP, routines and long clinical experience:

You already have the recipes for most of the issues you encounter, and based on the experience and motivation, you assume what fails the patient and if the patient is motivated, then you start without feeling being good enough to be up to date on what recent research shows [ … ] I have been working here for eight years now, so I’m starting to feel that I need to be a little attentive [ … ] so that the workplace routines will not define me (or my clinical practice). (Physiotherapist No.12)

During the interviews, several participants suggested that a possible strategy to address good managerial and clinical relations would be to redistribute healthcare resources wherever and whenever possible and to consider task-shifting of roles when appropriate. Strategic long-term planning and budgeting to provide necessary resources should also be assessed. Further, they mentioned that leadership seemed to have several implications for EBP implementation. The participants described leaders’ tasks as providing personal recognition and support and enabling vision, motivation and facilitation, as well as setting the direction of EBP service. In order to achieve successful implementation, research and professional development must be ‘anchored’ in management. Provisions and mandatory tasks from the leadership are perceived as facilitators for research, as one of the participants stated:

[I] t depends if management actively advocates that this should be part of our way of working, our culture and devoting time and resources to actually being able to become smarter. (Physiotherapist No. 11)

The participants agreed upon the idea that different leaders, different levels of service and different professions also involve different understandings of physical therapy with respect to more discussion on topics such as research-based knowledge, professional knowledge and the patient’s need. The participants expressed that some leaders lacked insight into the physiotherapists’ clinical practice, and that leaders need to understand their team members in terms of their needs and encourage them in their professional development. Our participants expressed a desire for increased knowledge among the leaders about physiotherapy and physiotherapists’ tasks. One of the participants said:

[T] here is a pretty big gap further up in the system of the head of department [ … ] [T] hey may not see what we do or the utility of what we do, and there are things that we feel are very obvious and are very important, but I feel that they are not up to that mindset [ … ] [S] o yes, to the top management, I feel there is a big gap. (Physiotherapist No. 8)

A majority of the participants also mentioned the importance of transparency and open communication between leaders and employees. They referred to extensive two-way communication and transfer-of-information being the key factors for success when performing EBP. One participant expressed the importance of having a leader from the same profession:

[W] e have a leader who is a physiotherapist, he is very clever [and] he understands what we are talking about when it is related to physiotherapy. He has a lot of opinions and knowledge. I think it is only advantageous for us to have a leader who is a physiotherapist. (Physiotherapist No. 4)

The strengths of this study are as follows. First, the interview participants were from different districts with different socioeconomic statuses; and second, the participants varied in gender, age and years of experience. Thus, we were able to achieve an in-depth understanding of the barriers to EBP implementation from various points of view and thereby increase the transferability of the findings. There were also a few limitations in this study, such as only physiotherapists’ perspectives being included in this study. To gain a better understanding of the underlying process and the tension between the macro-, meso- and micro-levels, it would have been beneficial to include leaders and politicians in this study. We therefore recommend future studies to explore the relationship between these levels in order to bridge the EBP gap.