Evidence Based Practice: Attitudes, Knowledge, Behaviors, and Perceived Barriers of Physical Therapist

Key Words: Evidence Based Practice, Physical Therapy, APTA membership

Michael P. Beavin, Jason D. Copelin, John G. Hardy, Dr. Nancy Urbscheit

AbstractBackground

“Evidence based practice (EBP) is the integration of the best research evidence with clinical experience and patient values.”1 The four domains of EBP include: attitudes, knowledge, behaviors, and barriers. A survey was obtained from “Measuring evidence–based practice in physical therapy: translation, adaptation, further development, validation, and reliability test of a questionnaire.” The survey was modified to assess specific interests of the researchers and adapted for a North American audience. To our knowledge, no study has assessed the domains of EBP using a validated survey in the United States in the past decade.

Objective

Describe the attitudes, knowledge, behaviors, and perceived barriers of Kentucky licensed physical therapists as they relate to EBP and determine the influence APTA membership, education level, and primary work setting has on these domains.

Major Findings

Physical Therapists in Kentucky report generally positive attitudes towards EBP. The majority of respondents agreed the use of evidence based guidelines is necessary, it facilitates their work, and helps ensure the highest quality of patient care. The majority of participants reported reading 2-5 articles a month and using EBGs “quite often” or “very often.” Lack of time, guidelines too general/specific, and guidelines taking too long to read were the most frequently reported barriers to the implementation of EBP.

Clinicians with doctoral degrees reported a higher level of confidence in their knowledge about EBP than bachelor’s or master’s educated clinicians. The vast majority of bachelor’s educated clinicians did not believe EBP was necessary in daily practice. Results indicate APTA-membership may play a positive role in EBP behaviors in that members reported searching for research more frequently than non-members. Members were also more likely to believe EBP does not create unreasonable demands in their daily work than non-members. Participants working in skilled-nursing facilities reported significantly less access to evidence-based guidelines at work than all other settings. These findings may suggest the lack of an organizational framework that supports EBP in the work place.

Introduction

“Evidence based practice (EBP) is the integration of the best research evidence with clinical experience and patient values.”1 Evidence based guidelines have been shown to improve quality of care and patient outcome.1,9,14 Though research has demonstrated the benefits of EBP many clinicians do not implement current research into practice. Shuster et al. reported that approximately 30%-40% of patients do not receive care supported by current evidence.1 Though the American Physical Therapy Association (APTA) promotes the use of current research in practice many authors argue our profession is in its “infancy” in regards to EBP.11

Four domains of EBP have been identified: attitudes, knowledge, behavior, and barriers.1,4 Past research has assessed these four domains in an effort to identify strategies to facilitate the development of EBP in physical therapy.1,3,4 Barriers such as lack of time, difficulty interpreting and applying research, and lack of access have been frequently reported in the literature.1,4,6,10 Instruments used to measure these domains should contain similar levels of validity and reliability as the clinical research EBP necessitates. Bernhardsson et al. modified and empirically validated a questionnaire created by Jette and colleagues to evaluate the four domains of EBP. The questionnaire was found to have acceptable levels of face validity, content validity, and test-retest reliability.1

To our knowledge, the four domains of EBP have not been evaluated in the U.S. using a validated questionnaire in the last decade. An updated assessment of these domains is needed to analyze the current state of EBP and foster its development in our profession. The purpose of this study is to describe the attitudes, knowledge, behaviors, and perceived barriers of physical therapists as they relate to EBP. Proposed solutions to identified barriers will then be made available to participants and interested parties through various electronic communication outlets.

Methods

Survey:

A survey was obtained from “Measuring evidence –based practice in physical therapy: translation, adaptation, further development, validation, and reliability test of a questionnaire.” The survey was modified to assess specific interests of this study and adapted for a North American audience. Refer to table 1A for specific modifications made to the survey.

Subjects:

The only inclusion criterion was each subject must be a licensed physical therapist in the state of Kentucky. Subjects were recruited via email, with a description of the survey being sent to 63 CCCE’s (Center Coordinator of Clinical Education) of various clinical sites affiliated with Bellarmine University. Emails were sent out on two separate occasions with instructions for the CCCE’s to distribute the survey to all interested clinicians in their work place. A disclaimer was attached to the recruitment email to disregard the survey if it had been previously completed. Subjects were a mix of APTA and non-APTA members. Additionally, APTA members were targeted through a KPTA newsletter advertisement on two separate occasions. The subjects are described in Table 1B.

Procedure:

The survey was generated and tracked using Survey Monkey. Information regarding demographic and practice data was collected in questions 2-11. Attitudes toward, use of, and perceived benefits and limitations of EBP were addressed in questions 12-22. Questions 23-34

TABLE 1A

Modified:

6. Do you have a physical therapy specialist certificate? (ex: Orthopedic Certified Specialist)

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

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

19. I know how to access relevant databases for evidence based research articles

Added:

35. Are you a member of the APTA?

36. The APTA resources: PTNow.org, Hooked on Evidence, PTJ podcast, etc. are useful for accessing evidence based research?

Removed:

Question 30. For which diagnoses would you benefit the most from having evidence-based guidelines? State up to 5 diagnoses.

assessed attitudes towards the use of clinical practice guidelines. Lastly, APTA membership and perceptions about its resources were addressed in questions 35-37. Most item responses concerning attitudes toward EBP, as well as attitudes towards clinical practice guidelines were addressed using a standard 5-point Likert scale. Response options ranged from Strongly Agree to Strongly Disagree. Some yes/no and other open ended questions were also included. The survey and a list of relevant definitions used are available in the index.

Data Analysis:

Data was analyzed using Survey Monkey’s “analyze results” feature. This allowed the researchers to look at question summaries, data trends, and individual responses. All questions were analyzed using this process. Further analysis was performed on two questions of each domain of EBP. Questions were selected for further analysis based on how well they reflect the domain and specific interests of the researchers. The questions selected and their associated domains are listed: questions 12 and 13 for attitudes, questions 19 and 21 for knowledge, questions 27 and 33 for barriers, questions 18 and 28 for behaviors.

Researchers further grouped responses by APTA membership, clinician’s education level, and the setting in which the clinician works. Through survey monkeys “compare data” feature we were able to look at relationships between two different variables. These variables were manually converted to Microsoft Excel and were then calculated as percentages. APTA membership was divided into members and non-members. In a similar way, Education level was compared to each of the previous 8 questions. Researchers wanted to see if a relationship existed between a clinician’s education level, and their responses towards the four domains of EBP. Lastly, clinician’s primary work setting was compared to each of the previous questions. Researchers wanted to investigate the impact work setting has on EBP.

ResultsKnowledge:

Knowledge of EBP was assessed in this study by analyzing the responses from questions 21 and 19 in conjunction with membership, education level, and work setting.

In Regards to membership, an analysis of question 19 showed the vast majority of respondents felt they knew how to access relevant data bases whether they were APTA members or not. Our study found that 83.33% of APTA members and 76.19% of Non-Members either strongly agreed or agreed that they knew how to access data bases for EBP. Question 21 analyzed the confidence level of members vs. non-members in their ability to find relevant research in their field of study. The survey results revealed that 85.42% of Members and 76.19% of Non-Members either strongly agreed or agreed that they felt confident in finding information to answer their clinical questions.

Question 19: I know how to access relevant databases for evidence based research articles

**Yes represents respondents who reported to being APTA members and no represents Non-Members

Question 21: I feel Confident in my ability to find relevant research to answer my clinical questions.

**Yes represents respondents who reported to being APTA members and no represents Non-Members

Next, descriptive statistics from questions 19 and 21 of the survey were used to assess therapists’ knowledge in regards to their education level. Of the total 92 responses 57 were from therapists educated at the Doctoral Degree level, 15 at a Master’s Degree level, and 20 at a Bachelor Degree level. 92% of the respondents educated at a Doctoral level, 87% of the respondents educated at a Master’s Degree level, and 80% of respondents educated at a Bachelor’s Degree level responded with strongly agree or agree when asked if they knew how to access relevant databases for evidence based research articles. Question 21 was applied to analyze the descriptive statistics in regard to education level and the therapists’ confidence in finding information to answer clinical questions. 83% of Doctoral respondents, 73% of Master’s respondents, and 65% of Bachelor’s respondents stated they strongly agreed or agreed they felt confident in their ability to find relevant resources to answer their clinical questions.

Question 19: I know how to access relevant databases for evidence based research articles

**Chart represents respondents’ education level in response to question 19.

Question 21: I feel Confident in my ability to find relevant research to answer my clinical questions.

**Chart represents respondents’ education level in response to question 21.

Finally, descriptive statistics were analyzed to describe therapist work setting in regards to their knowledge of evidence based practice. The survey respondents included practitioners from the acute hospital, acute rehab hospital, sub-acute hospital, skilled nursing facility, privately owned practice, facility based out-patient, school system, and University settings. Of the 92 total respondents, 8 worked in an acute care hospital, 8 in an acute rehab hospital, 0 in a sub-acute care hospital, 3 in a skilled nursing facility, 26 in a privately owned out-patient facility, 38 in a facility based out-patient center, 5 in home health care, 1 in the school system, and 3 from the University education system .When the practitioners from various settings were asked if they knew how to access relevant data bases for evidence based research articles (Question 19) 87.5% of acute care, 75% of acute rehab, 33.3% of skilled nursing facility, 84.6% of privately owned out-patient, 81.6% of facility based out-patient, 60% of Home Health Care, 100% of school system, and 100% of University respondents selected either agree or strongly agree. When the respondents were asked if they felt confident in their ability to find relevant research related to their topics (Question 21) 87.5% of acute care, 87.5% of sub-acute rehab, 0% of Skilled Nursing Facility, 76.9% of privately owned out-patient facility, 89.5% of facility based out-patient, 60% of Home Health Care, 100% of School system, and 100% of University system respondents selected either agree or strongly agree.

Question 19: I know how to access relevant databases for evidence based research articles

** Chart represents respondents’ work setting in response to question 19.

Question 21: I feel Confident in my ability to find relevant research to answer my clinical

questions.

** Chart represents respondents’ work setting in response to question 21.

Attitudes:

Attitudes of EBP were assessed in this study by analyzing the responses from questions 12 and 13 in conjunction with membership, education level, and work setting.

There were a total of 90 respondents who described themselves as either Members of the APTA or Non-Members. Of the 90 respondents 48 stated they were members and 42 stated they were Non-Members. All of the respondents were asked whether they consider it necessary to apply EBP in the daily practice of physical therapy (Question 12). Of the APTA members 87.5% either strongly agreed or agreed it was necessary to apply EBP. 88% of the Non-Members also agreed or strongly agreed it was necessary to apply EBP in the daily practice of physical therapy. Of the 48 APTA members , 83.3% either strongly disagreed or disagreed that applying EBP created an unreasonable demand in their daily work. 78.6% of the 42 Non-APTA members also strongly disagreed or disagreed that applying EBP created an unreasonable demand in their daily work.

Descriptive statistics from questions 12 and 13 were used to analyze the attitudes of therapists in regards to their education level. There were a total of 92 respondents. Of the 92 respondents, 20 stated they had received a Bachelor’s degree, 15 a Master’s Degree, and 57 a Doctoral Degree. 80% of those who had received a Bachelor’s degree, 92.9% who received a Master’s Degree, and 91% of those who have received a Doctoral degree either agreed or

strongly agreed that EBP was necessary to use in daily practice. 60% of Respondents with a Bachelor’s Degree, 92.9% with a Master’s Degree, and 86% with a Doctoral Degree strongly disagreed or disagreed that applying EBP created an unreasonable demand in their daily work.

Question 12: I consider it necessary to apply EBP in the daily practice of Physical Therapy.

**Chart represents respondent education level and attitude of EBP.

Question 13: I think it creates an unreasonable demand to apply EBP in my daily work

**Chart represents respondent education level and attitude of EBP.

Questions 12 and 13 were again used to analyze the descriptive statistics of respondent work setting and their attitudes of EBP. There were a total of 92 respondents who answered the questions. Of those 92 respondents. The breakdown of the number of respondents is the same as

what is listed in the work setting paragraph regarding knowledge of EBP.87.5% of acute Care respondents, 52.3% of acute rehab, 100% of Skilled nursing facility, 92.3% of privately owned out-patient clinic, 89.4% of facility based out-patient, 100% of school system, and 100% of University system respondents selected either agree or strongly agree that it necessary to apply EBP in the daily practice of physical therapy (Question 12).

Question 12: I consider it necessary to apply EBP in the daily practice of Physical Therapy.

Chart represents the respondents’ work setting and attitude of EBP.

When asked if applying EBP created an unreasonable demand in their daily work, 87.5% of acute care respondents, 75% of acute rehab, 12.5% of Skilled nursing facility, 84.6% of out-patient private practice, 84.2% of facility based out-patient, 100% of the school system, and 66.6% of University system respondents selected either disagree or strongly disagree (Question 13).

Question 13: I think it creates an unreasonable demand to apply EBP in my daily work

**Chart represents respondent’s work setting and attitude of EBP.

Behaviors:

To represent the respondents’ behaviors in regards to EBP, Questions 18 and 28 were selected. Question 18 asked the respondents how many times they used data bases to search for evidence based literature per month. Question 28 was a statement that said, “I use evidence-based guidelines in my work”.

APTA Membership was then applied to assess the descriptive statistics between membership and the respondents’ behaviors. In regards to question 28, 41.67% of APTA members stated they searched <1 time per month, 45.83% of members searched 2-5 times, 4.17% searched 6-10 times, 2.08% searched 11-15 times, and 6.25% searched >16 times per month. Next, Non-members’ behaviors were assessed in regards to question 18. 71.43% of non-members stated they searched <1 time per month, 28.57% stated they searched 2-5 times, and 0% stated they searched data bases for evidence based evidence greater than 6 times per month.

Question 18: Number of times I use PubMed or other databases to search literature that is relevant to my work, during a typical month.

**Yes represents respondents who reported to being APTA members and no represents Non-Members

In regards to using evidence-based guidelines in their work, 70.83% of APTA members stated they used EBP very often or quite often. While 42.85% of Non-APTA members stated they used EBP very often or quite often.

Question 28: I use evidence based guidelines in my work.

**Yes represents respondents who reported to being APTA members and no represents Non-Members

Next, behaviors based on education level were assessed with descriptive statistics using questions 18 and 28. The breakdown of the total respondents is listed in the table below. 71% of respondents with a bachelor’s degree reported searching <1 time per month, 24% reported searching 2-5 times per month, and 5% reported searching >16 times per month. Of those with a Master’s degree, 87% reported searching <1 time per month and 13% reported searching 2-5 times. 42% of those with a Doctoral degree reported searching <1 time per month, 49% reported searching 2-5 times per month, 4% reported searching 6-10 times, 2% reported searching 11-16 times, and 4% reported searching >16 times per month.

Question: 18: Number of times I use PubMed or other databases to search literature that is relevant to my work, during a typical month.

**Chart represents respondents’ education level and number of times they search for evidence per month

When responding to using EBP in their daily practice, 5% of those with a Bachelor’s degree stated they used it very seldom or seldom. While 45% stated they used it very often or often. 7% of those with a Master’s level degree reported using EBP very seldom or seldom. While 46% stated they used it very often or often. 4% of those with a Doctoral degree report using EBP very seldom or seldom. While 63% report using EBP very often or often. The remaining respondents of each degree level report using EBP sometimes.

Question 28: I use Evidence Based Guidelines in my work.

**Chart represents respondents’ education level and behavior of EBP.

Behaviors were then assessed within the work setting using descriptive statistics. The breakdown of the respondents of the workplace is listed in the knowledge section. 87.5% of respondents in the acute care reported searching for evidence via a database <1 time per month and the remaining 12.5% reported searching 2-5 times per month. 75% of the acute rehab respondents reported searching for evidence via a database <1 time per week and 25% reported searching 2-5 times per week. 66.6% of respondents in the skilled nursing facility reported searching for evidence <1 time per week and 33.3% reported searching 2-5 times per week. 42.3% of respondents working in a privately owned out-patient facility reported searching for data <1 time per month, 50% reported searching 2-5 times per month, 3.84% searching 6-10 times, and 3.84% reported searching 11-15 times. 52.63% of respondents in a facility based out-patient center reported searching <1 time per week, 42.1% reported searching 2-5 times, 2.6% reported searching 6-10 times, and 2.6% reported searching >16 times per month. 60% of home health respondents reported searching <1 time per month, 20% (1) 2-5 times, and 20% (1) reported searching > 16 times per month. There was a single respondent in the school system who reported searching <1 time per month. Finally, within the University system there were 3 respondents. 33.3% (1) of the university respondents reported searching for evidence <1 time per month, 33.3% (1) reported searching 2-5 times per month, and 33.3% (1) reported searching >16 times per month.

Question: 18: Number of times I use PubMed or other databases to search literature that is relevant to my work, during a typical month.

**Chart represents respondent work setting and behaviors of EBP.

Question 28 of the survey was used to analyze the use of evidence based practice among the clinicians. The following descriptive statistics represent the respondents’ survey answers by work setting. 37.5% of the acute hospital respondents reported using EBP very often or quite often while 12.5% reported using it very seldom or seldom. 25% of the acute rehab respondents

reported using EBP very often or quite often while 12.5% reported using it very seldom or seldom. Of the skilled nursing facility respondents 33.33% (1) reported using EBP very seldom while the remaining 66.6% (2) reported using it sometimes. 73% of privately owned out-patient respondents reported using EBP quite often or very often and the remaining 27% reported using it sometimes. 63.1% of out-patient facility based respondents reported using EBP very often or quite often while only 2.6% reported using it seldom. The remaining 34.2% reported using EBP sometimes. 60% (3) of home health care respondents reported using EBP very often or quite often while the remaining 40% (2) reported using it sometimes. The single school system respondent reported using EBP sometimes and university system respondent reported using EBP very often.

Question 28: I use evidence based guidelines in my work.

**Chart represents respondent work setting and behavior of EBP.

Barriers:

The perceived barriers to use of EBP were assessed in questions 27 and 33. Responses to these questions were analyzed and compared to each respondent’s membership status, education level, and primary work setting.

Question 27 assessed the availability of evidence-based guidelines (EBGs) in the clinician’s work place. The majority of respondents reported having fast and easy access in their workplace. 67% of members and 36% of non-members responded either agree (A) or strongly

agree (SA) to question 27. Question 33 asked clinicians to indicate the greatest barriers to using EBP. Lack of time and guidelines being too general/specific were the most frequently reported barriers. Most frequent barriers reported by members were: lack of time 69%, guidelines too general/specific 29%, guidelines take too long to read 25%, none or too few guidelines 25%. Non-members reported barriers as follows: Lack of time 71%, guidelines take too long to read 24%, guidelines too general/specific 24%, don’t know where to find guidelines 21%.

Question 27: I have fast and easy access to relevant evidence-based guidelines at my place of work.

**Yes represents respondents who reported to being APTA members and no represents Non-Members

Question 33: Mark the factors below that constitute the greatest barriers to using evidence-based guidelines. You can mark as many as you wish.

**Yes represents respondents who reported to being APTA members and no represents Non-Members

Participant responses to questions 27 and 33 were also compared to their highest education level achieved. 45% bachelors educated, 47% masters educated, and 55% doctoral educated participants responded SA or A to question 27. Similar results were obtained when analyzing question 33 by education level with lack of time being the most frequently reported barrier. Bachelors level reported lack of time 34%, takes too long to read 18%, and guidelines too general/specific 13%. Masters level responded lack of time 34%, guidelines too general/specific 18%, and guidelines too much or recipe 13%. Lastly, doctoral educated clinicians reported lack of time 34%, guidelines too general/specific 14%, and guidelines too much of a recipe 13%.

Question 27: I have fast and easy access to relevant evidence-based guidelines at my place of work.

**Chart represents respondent education level and access to EBP at work place.

Question 33: Mark the factors below that constitute the greatest barriers to using evidence-based guidelines. You can mark as many as you wish.

**Chart represents respondent education level and perceived barriers.

Descriptive statistics were analyzed to describe perceived barriers to use of EBP in regards to participants work setting. Participants from every setting except for three (school system, university, and SNF) listed lack of time as a primary barrier. Of the settings who didn’t list lack of time as a primary barrier the option “other,” too few guidelines exist, and guidelines are too general/specific were selected. Acute hospitals ranked lack of time 33%, too few guidelines 19%, and guidelines too general/specific 14% most frequently. Acute rehab reported the same top three barriers with percentage as 35%, 18%, and 18% respectively. Privately owned outpatient based clinicians indicated lack of time 37%, guidelines take too long to read 13%, and guidelines too much of a recipe 13% as primary barriers. Facility based outpatient participants ranked lack of time 35%, guidelines too general/specific 14, and guidelines take too long to read 13%. Home health based PTs rated lack of time 40%, guidelines too much of a recipe 20%, and an even mixture of remaining responses.

Question 27 was also analyzed comparing responses to primary work setting. Responses varied significantly from setting to setting. SNF is the only setting the majority of respondents (66%) disagreed with the statement made in question 27. 75% of acute hospital, 26% acute

rehab, 42% privately owned outpatient, 50% of facility based outpatient, 60% home health, and 100% university based PTs answered SA or A that they have fast and easy access in their work place.

Discussion

Our results indicate physical therapist generally hold EBP in positive regards. The majority of respondents agreed the use of evidence based guidelines is necessary, it facilitates their work, and helps ensure the highest quality of patient care. These results are consistent with work published by Jette and colleagues. The majority of participants reported reading 2-5 articles a month and using EBGs “quite often” or “very often.” These findings indicate improved behaviors in the use and implementation of EBP than reported in similar studies.3,4 Lack of time, guidelines too general/specific, and guidelines taking too long to read were the most frequently reported barriers to the implementation of EBP. Again these findings are consistent with previous literature and reiterate the need for creative solutions to address these persistent problems.2,3,4,14

Knowledge

With regards to knowledge, there were no meaningful differences between APTA and Non-APTA members. The majority of clinicians reported they knew how to access relevant databases and felt confident in finding information to clinical questions. The majority of respondents of all education levels believed they knew how to access relevant databases. PT’s with a doctoral degree were the most confident cohort in their ability to find relevant resources to clinical questions. This may reflect the increased exposure doctoral students have to the retrieval and appraisal of clinical research. Acute care responders were the most confident setting in their ability to find relevant resources to clinical questions. Conversely the majority of acute care responders use EBP “only sometimes”, and “<1 time per month.” The reasons for this disconnect between beliefs and behaviors are unclear.

Attitudes

Negligible difference were recognized between APTA members and non- APTA members’ attitudes towards the necessity of EBP in daily practice. APTA members were slightly more likely to believe EBP does not create unreasonable demands in their daily work than non- APTA members (83.3% and 78.6% respectively). Physical therapists with a doctorate or master’s degree were much more likely to agree that EBP was necessary and did not create unreasonable demands than physical therapists with a bachelor’s degree. Notably only 15% of physical therapists with a bachelor’s degree felt that EBP was necessary in daily practice, however 60% disagreed that it created unreasonable demands. This may suggest physical therapists with a bachelor’s degree do not value EBP in the same way as physical therapists with a higher degree (master’s or doctorate). With the exception of acute rehab, most workplace

settings believed applying EBP in daily practice is important and does not create unnecessary demands.

Behaviors

The majority of APTA members stated that they searched 2-5 times per month of EBP research, while the majority of non-members reported that they searched <1 time per month. This finding suggests membership plays a positive role in EBP behaviors. Physical therapists with a doctoral degree reported using EBP more often than therapists with either a Bachelor or Master’s degree. With the exception of home health, whose majority reported using EBP very often; most settings reported using EBP only sometimes. The relatively recent emphasis the PT profession has placed on EBP may account for differences between educational cohorts and work settings. More positive behaviors being associated with APTA members may further reflect the commitment of clinicians to EBP and the support of a professional organization that champions EBP.

Barriers

Lack of time, guidelines too general/specific, and guidelines take too long to read were the most frequently reported barriers to the implementation of EBP. Between members and non-members, all education levels, and most workplace settings, lack of time and guidelines too general/specific were the most common barriers. These barriers have been previously identified in the literature.

Though not frequently reported by this sample, lack of access has been identified by various researchers as a considerable barrier to EBP.4,12,15 Nearly half of all clinicians believed they did not have fast and easy access to relevant databases at work. These finding may reflect the lack of administrative support for EBP. Schreiber et al identified administrative emphasis on productivity as a barrier to EBP in the workplace. There is a growing need to establish organizational frameworks which support the implementation of evidence based care. Non-members were notably less likely to report fast and easy access at work than members. The electronic resources available through APTA membership may therefore be a viable option for clinicians seeking access to relevant research at work.

Limitations

Limitations to this study include: relatively small sample size, inclusion of only PTs licensed in Kentucky, and limited data analysis. Furthermore, significance of differences identified by researchers was not statistically validated. Further research addressing these limitations may produce more generalizable results.

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Appendix

I) EBP Survey:

A. The first part of the questionnaire is about personal/demographic information.1. Are you male or female?▫ Male ▫ Female

2. To which age group do you belong?▫ 20–29 years ▫ 30–39 years ▫ 40–49 years ▫ 50–59 years ▫ 60_ years

3. For how many years have you worked as a physical therapist in primary care?▫ _3 years ▫ 3–5 years ▫ 6–10 years ▫ 11–15 years ▫ 16–20 years ▫ _20 years

4. What is your highest degree in physical therapy?▫ _2.5 years of education▫ 2.5 years of education▫ 3 years of education/bachelor’s degree▫ Master’s degree (1 year)▫ Master’s degree (2 years)▫ PhD student▫ Doctoral degree

5. Do you have a physical therapy specialist certificate? (ex: Orthopedic Certified Specialist)▫ yes▫ no

5a. If yes, in which area? __________________________________

6. Which of the following best describes the facility at which you do most of your patient care?▫ Acute hospital▫ Acute Rehabilitation▫ Subacute Rehabilitation▫ Skilled Nursing Facility▫ Privately Owned Outpatient Clinic▫ Facility-based Outpatient Clinic▫ Home Care▫ School System▫ University▫ Other

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

▫Urban▫Suburban

8. How many physical therapists work at your main place of work?▫ _3 ▫ 3–5 ▫ 6–10 ▫ 11–15 ▫ _15

9. What portion of your total work time do you spend with patient care (including patient administration)?▫ _25% ▫ 26–50% ▫ 51–75% ▫ _75%

B. The following part is about attitudes toward, use of, and perceived benefits and limitations of EBP.Evidence-based practice is defined as integrating the best available external clinical evidence from systematicresearch with individual clinical experience and patient preferences.1Answer the questions by checking the response alternative you consider the most suitable.

10. I consider it necessary to apply EBP in the daily practice of physical therapy.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

11. I think it creates unreasonable demands to apply EBP in my daily work.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

12. I want to learn and improve the knowledge and skills necessary to apply EBP in my work.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

13. Strong evidence is lacking for most treatments that I use for my patients.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

14. EBP can help me make decisions in the choice of treatment.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

15. Number of scientific articles related to my clinical work that I read, during a typical month.▫ _1 article ▫ 2–5 articles ▫ 6–10 articles ▫ 11–15 articles ▫ 16_ articles

16. Number of times I use PubMed or other databases to search literature that is relevant to my clinical work, duringa typical month.▫ _1 time ▫ 2–5 times ▫ 6–10 times ▫ 11–15 times ▫ 16_ times

17. I know how to access relevant databases for evidence based research articles .▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

18. At my place of work the use of current research is encouraged.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

19. I feel confident in my ability to find relevant research to answer my clinical questions.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

20. I feel confident in my ability to treat my patients according to current evidence.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

C. The following part is about attitudes toward and use of clinical practice guidelines.Guidelines are “systematically developed recommendations with the purpose to facilitate for caregivers and patientsto make decisions about suitable treatment in specific situations.”2 In this survey, “guidelines” means “evidencebasedclinical practice guidelines for physical therapy.”

21. I consider it important that easily available evidence-based guidelines related to my work exist.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

22. I consider it important to use evidence-based guidelines in my work.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

23. I’m aware that evidence-based guidelines for diagnoses relevant to my work exist.▫ Yes ▫ Partially ▫ No

24. I know how and where to find evidence-based guidelines related to my work on the Internet.▫ Yes ▫ Partially ▫ No

25. I have fast and easy access to relevant evidence-based guidelines at my place of work.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

26. I use evidence-based guidelines in my work.▫ Very seldom or never ▫ Seldom ▫ Sometimes ▫ Quite often ▫ Very often

27. I can integrate the patients’ preferences with evidence-based guidelines.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

28. Evidence-based guidelines are important to facilitate my work.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

29. Evidence-based guidelines are important so that the patients receive the best possible treatment.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

30. Evidence-based guidelines are important so that patients receive equal treatment.▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

31. Mark the factors below that constitute the greatest barriers to using evidence-based guidelines. You can markas many as you wish.▫ Lack of time▫ None or too few guidelines exist for my patient groups▫ Don’t know where to find guidelines▫ Takes too long to read guidelines▫ Guidelines are too general and too unspecific▫ Guidelines are too much “recipe” and don’t let me decide what is most appropriate▫ Lack of support from my colleagues at my place of work▫ Lack of interest▫ Other

31a. If you answered “Other,” please state what.

_________________________________________________________________________________________

32. Are you a member of the APTA?▫ Yes▫ No

33. The APTA resources: Hooked on Evidence, PTJ podcast, etc. are useful for accessing evidence based research?▫ Strongly disagree ▫ Disagree ▫ Neutral ▫ Agree ▫ Strongly agree

34. Do you have any other comments on EBP, guidelines, and treatment methods?__________________________________________________________________________________________

II) Requirement Email:

Evidence Based Practice Survey *(Please disregard if already completed)*

Hello fellow Physical Therapists,

We are DPT students at Bellarmine University conducting an anonymous research survey concerning evidence based practice in physical therapy. We would like to invite you and your colleagues to participate. The purpose of this short survey (5-10 min) is to assess the attitudes, knowledge, behavior, and perceived barriers to implementation of EBP by physical therapists. Furthermore, we plan to assess the influence American Physical Therapy Association (APTA) membership and non-membership has on the implementation of EBP. We would like to thank you in advance for your efforts in facilitating the development of EBP and resulting growth of the physical therapy profession. We encourage you to forward this email to any licensed physical therapists in your work place, including both APTA and Non-APTA members.

EBP Survey:

https://www.surveymonkey.com/s/EBPandPT

 With kind regards,      

Michael Beavin, SPT Jason Copelin, SPT John Hardy, SPT

III) Definitions:

Evidence based practice was defined as integrating the best available external clinical evidence from systematic research with individual clinical experience and patient preferences.

Guidelines were defined as “systematically developed recommendations with the purpose to facilitate for caregivers and patients to make decisions about suitable treatment in specific situations.” In this survey, “guidelines” means “evidence-based clinical practice guidelines for physical therapy.”

V) Extra Data

The APTA resources: PTNow.org, Hooked on Evidence, PTJ podcast, etc. are useful for accessing evidence based research?

Answer Options Response Percent

Response Count

Strongly disagree 2.2% 2Disagree 0.0% 0Neutral 46.7% 42Agree 41.1% 37Strongly agree 10.0% 9

answered question 90skipped question 15

I have fast and easy access to relevant evidence-based guidelines at my place of work.

Answer Options Response Percent

Response Count

Strongly disagree 1.1% 1Disagree 21.1% 19Neutral 25.6% 23Agree 35.6% 32Strongly agree 16.7% 15

answered question 90skipped question 15

VI) EBP ResourcesThe following four categories are a collection of resources aimed at addressing barriers

to EBP identified by us and other researchers. The resources listed below were taken directly from public sites and are not the property or original work of the creators of this document. There are various other quality resources available regarding EBP that are not listed below.

1. Improving Access to Literature

Free Databaseso http://www.pedro.org.au/ o http://www.ncbi.nlm.nih.gov/pubmed o http://www.ncbi.nlm.nih.gov/pmc/ o http://scholar.google.com/ o http://eric.ed.gov/ o http://www.nlm.nih.gov/medlineplus/ o https://clinicaltrials.gov/ o http://toxnet.nlm.nih.gov/ o http://www.physiotherapychoices.org.au/ o http://www.pdq-evidence.org/ o http://www.evidence.nhs.uk/ o http://www.guideline.gov/

Databases requiring subscription o http://www.ebscohost.com/ o http://www.thecochranelibrary.com/view/0/index.html o http://www.ptnow.org/Default.aspx?navID=10737432269

Other Databaseso http://www.ptresearch.org/article/55/resources/researchers/online-evidence-based-

databases

2. Effective Literature Searching Search terms

o http://www.nlm.nih.gov/mesh/MBrowser.html Tips for effective literature searching

o http://www.idemployee.id.tue.nl/g.w.m.rauterberg/lecturenotes/literatur-search- tips-2004.pdf

o http://www.lib.berkeley.edu/PUBL/litsearch.html 3. Appraising literature

Appraisal Guidelineso http://guides.nyu.edu/content.php?pid=34319&sid=252135o http://www.hopkinsmedicine.org/gim/training/Osler/osler_JAMA_Steps.html

Appraisal Toolso http://www.cebm.net/critical-appraisal/

4. Understanding EBP (knowledge) Free EBP courses

o http://ebp.uga.edu/courses/

o http://www.med.unc.edu/www/google_search_results?q=evidence-based %20practice%20for%20physical%20therapist

Fee-Based EBP Courseso http://www.physicaltherapy.com/pt-ceus/course/fundamentals-evidence-based-

practice-1100-1100o