Copyright Sociological Research Online, 2001

 

Rose Wiles and Sue Barnard (2001) 'Physiotherapists and Evidence Based Practice: An Opportunity or Threat to the Profession?'
Sociological Research Online, vol. 6, no. 1, <http://www.socresonline.org.uk/6/1/wiles.html>

To cite articles published in Sociological Research Online, please reference the above information and include paragraph numbers if necessary

Received: 6/3/2001      Accepted: 10/5/2001      Published:

Abstract

The profession of physiotherapy in the UK is undergoing a period of change. Prominent among these aspects of change is the movement to evidence based practice (EBP). EBP is a central element of policy in the National Health Service (NHS). It is being implemented in physiotherapy as a means of securing contracts with purchasers but also as a means of contesting challenges from alternative practitioners and health professionals to the areas of work that physiotherapists view as their territory. Using data collected from a qualitative study of 56 physiotherapists of different grades working in different sectors of the NHS, this paper explores physiotherapists' views of EBP and the impact that they expect it to have on professional boundaries and on the status and practice of physiotherapy. The study indicated that physiotherapists' views may differ according to their position in the profession. Senior physiotherapists appeared to view the development of EBP as a threat to the profession which would decrease professional autonomy and the status of the profession. In contrast, junior and superintendent physiotherapists appeared to view EBP as an opportunity for strengthening the profession. The impact EBP will have on the profession of physiotherapy and its relationships with a range of health professionals is as yet unknown as are the responses that physiotherapists are likely to have to this development. This study identifies the areas in which conflicts are likely to be played out. A focus for future research analysing the impact of EBP is suggested.

Keywords:
Evidence Based Practice; Health Care Professions; Medical Sociology; Physiotherapists; Professional Boundaries

Introduction

1.1
The profession of physiotherapy in the UK is undergoing a period of change as a result of a number of pressures from different health professional groups. In addition, wider organisational change to the National Health Service (NHS) imposed by the Labour Government is pushing the profession to change established working practices in a number of ways as a means of improving standards within the NHS (Department of Health, 1998). Challenges to the work traditionally undertaken by physiotherapists from different professional groups within the NHS and from alternative practitioners have resulted in physiotherapists feeling under threat. In order to meet this threat physiotherapists have been encouraged to 'prove' the effectiveness of their interventions by gaining scientific evidence through a process known as evidence based practice (EBP). EBP is also a central element of the Government's proposals for modernising the NHS. This paper will explore physiotherapists' views about EBP and the impact they expect it to have on professional boundaries and on the status and practice of physiotherapy. In order to set this study in context, the paper will begin by reviewing the history of physiotherapy, the threats posed by other professional groups and the background to the development of EBP.

1.2
The history of physiotherapy, like that of nursing and other professions allied to medicine has been one of a struggle to attain and maintain professional status (Walby & Greenwell, 1994). In the United Kingdom this history is a relatively short one. The profession grew out of the practice of massage in the late 1890s and from an attempt to distinguish medical massage from various massage establishments in operation at that time which were widely regarded as immoral; its proponents aimed to establish it as an 'honourable profession for British women' (Thornton, 1994). It gradually incorporated various therapies other than massage and the title physiotherapy was adopted in 1943 in order to emphasise the use of a wide range of physical therapies. Physiotherapy continues to be a female dominated profession although, as with nursing, the numbers of men entering physiotherapy training is slowly increasing.

1.3
By 1993 all physiotherapy pre-registration education and training had moved from a hospital based apprenticeship model to degree level courses in higher education establishments. Physiotherapy in the UK has become increasingly specialised and physiotherapists work in a variety of specialisms. The areas in which the largest numbers of physiotherapists are employed are neurological rehabilitation and the treatment of musculoskeletal conditions. Most physiotherapists in the UK work in the NHS. However, a growing number of physiotherapists work in private practice in the UK, not all of whom have completed physiotherapy training validated by the Chartered Society of Physiotherapy (CSP). Recent CSP membership surveys show that there are around 25,000 physiotherapists registered with the CSP. Of these, 91% are female (Bainbridge, 1997; CSP, 1998). The precise number of physiotherapists working privately is not known. The title physiotherapist is not protected enabling individuals without recognised physiotherapy training to set themselves up in practice.

1.4
Like alternative therapies, physiotherapy has a popular image with the general public, particularly in relation to the recovery of physical function following the onset of a range of disabling conditions (Partridge, 1994; Sheppard, 1994). Patients with stroke in particular view physiotherapy as effective, have high expectations of it and appear to want it to be made more widely available over prolonged periods of time (Partridge, 1994; Pound, Bury, Gompertz & Ebrahim, 1994). They also appear to value the process of receiving treatment from physiotherapists (Anderson, 1992; Pound et al, 1994). While evidence about the effectiveness of physiotherapy treatments is limited (Ashburn, Partridge, DeSouza, 1993) what research there is indicates that the process of receiving physiotherapy treatment has a number of benefits to people's health and general well-being.

1.5
Sociologists have paid little attention to the position of physiotherapists and allied professionals such as occupational therapists, speech and language therapists and podiatrists in the health care division of labour (Borthwick, 2000). Physiotherapists and allied professions may be viewed as occupying the 'middle ground' in the health care hierarchy between doctors on the one hand and unqualified staff on the other, in a similar position to nurses (Miles, 1991:125). However, as Walby & Greenwell (1994) among others have noted, relationships between professional groups in the health care hierarchy are complex and subject to change according to time and context. In the secondary care setting, physiotherapists are attached to a number of wards according to their speciality and work with patients on those wards as they see fit. They are also referred patients by medical and nursing staff for particular treatments which, in the case of referral by medical staff, may be 'prescribed'. The level of autonomy physiotherapists have in their work with patients varies according to the level of teamwork existing on the wards, the attitudes of other staff, particularly doctors, and physiotherapists' status within particular specialities. Physiotherapists have enjoyed varying degrees of success in their struggles with other 'middle range' occupations as they have sought to establish and maintain boundaries in all the areas of health care in which they work. Within rehabilitation wards or units, physiotherapists tend to have a higher status than in areas such as intensive care or surgical wards where nurses tend to have higher status than physiotherapists. On wards or units with a rehabilitation focus, physiotherapists instruct nurses on rehabilitation practices to be used in providing day-to-day care on the ward to individual patients (Chamberlain, 1988). In such cases, nurses work under the direction of physiotherapists in relation to this aspect of their work on the ward. This tends not to occur in other specialities.

1.6
The professions allied to medicine have posed little challenge to medical dominance in the health care division of labour in the way that nurses and alternative therapies have (Gabe, Kelleher & Williams, 1994). This may be because the work that they do is largely separate from the work undertaken by doctors. Alternatively it may be because these professions do not have the clout in terms of numbers or status to make a successful challenge to the medical profession. Physiotherapists comprise a much smaller proportion of the NHS workforce than do nurses and, compared with nursing, physiotherapy is a much newer profession. While the growth of physiotherapy (as with other professions allied to medicine) may have resulted in some loss of absolute power for medical professionals as they have become increasingly reliant on the expertise of other health professionals (Stacey, 1988), this does not appear to have resulted in the contesting of boundaries between the two groups.

1.7
Physiotherapy's engagement with the medical profession to date has been a struggle to achieve status in the eyes of the medical profession in order that they may be treated as practitioners in their own right rather than as technicians who do doctors' bidding. There are some parallels to be drawn with the attempts nursing has made to achieve the status of independent professionals rather than doctors' handmaidens (Pashley and Henry, 1990). Nursing's professionalisation project has resulted in a blurring of roles between (some) doctors and nurses as nurses have taken on more 'treatment' roles with the development of nurse practitioner and nurse consultant posts in preference to the more traditional 'caring' nurse roles (Annandale, 1998: 243). Physiotherapists' attempts to develop their professional status have centred around adherence to a broadly medical model and EBP can be seen as part of this strategy. However, it appears doctors view physiotherapists as having less status than themselves and, in some contexts, they expect to be able to prescribe the treatments physiotherapists should provide. The fact that physiotherapy, like nursing, is a female dominated profession may be one factor encouraging both the power of the medical profession to prescribe the work physiotherapists do and the lack of power of physiotherapists to challenge it.

1.8
The extent to which physiotherapists have struggled with other 'middle range' occupations in order to maintain boundaries in all the areas of health care in which they work is varied. In areas where the work they undertake is distinct from the work undertaken by other health professionals, such as neurological rehabilitation for example, there is little dispute with other professions over boundaries. However, in other areas where the boundaries between the activities they carry out and the activities carried out by other health professionals are blurred then there is scope for conflict.

1.9
Alternative medicine has traditionally posed a significant threat to physiotherapy. Alternative medicine is defined here, following Saks (1992), as therapies which do not receive support (in the broadest sense) from the British medical establishment. Such therapies have gained enormously in popularity over the last 25 years (Sharma, 1992; Saks, 1994) and it is estimated that as many as one in four people may consult various types of alternative practitioners (BMA, 1993). While the medical establishment has traditionally been hostile to alternative medicine it has more recently sought to incorporate it within medicine so that it can exert some control over its influence (Fairfoot, 1987). Physiotherapists have also sought to incorporate some aspects of alternative therapies into their work and some who have completed recognised courses are registered with the CSP to provide reflex therapy and acupuncture in conjunction with other treatments for defined conditions. The acceptability and growing popularity of alternative therapies has accentuated boundary disputes between physiotherapy and alternative practitioners (particularly osteopaths and chiropractors). Both groups have used various strategies to challenge the other's claim to territory. In the case of NHS physiotherapy a central strategy has been to prove the efficacy of their practice through scientific evidence.

1.10
One of the strategies that officials working at CSP's Head Office have sought to develop among CSP members in order to protect and enhance the profession vis--vis other professional groups has been to develop a specific knowledge base through physiotherapy research (Sackley, 1994). The aim of this is to produce evidence about the effectiveness of physiotherapy interventions and thereby to prove that the skills and practice of physiotherapy, rather than those of other practitioners, are the most effective means of managing specific areas of health care. Physiotherapy research is in its infancy (Robertson, 1995) and the CSP has developed a number of ways of encouraging and supporting research in the profession. This activity is viewed as a priority by the CSP (CSP, 1995; 1996(a); 1996(b)). The CSP's mission in this area has been strengthened by Governmental policy in relation to EBP and clinical governance in the NHS.

1.11
EBP is a central part of NHS policy and various Department of Health Reports have stressed that services which are purchased from health care providers must be based on research evidence of effectiveness (Department of Health 1996a, 1996b, 1998). EBP has been defined as comprising the integration of the best available clinical research evidence with clinical experience (Sackett, Rosenberg, Muir-Gray, Haynes & Scott Richardson, 1996). Thus, EBP is not seen as simply using techniques or treatments that are prescribed by research evidence but rather drawing on research evidence and what a health professional finds clinically to reach a decision about treatment for individual patients. The best research evidence used to inform practice is identified by Sackett as being evidence of effectiveness from randomised controlled trials. Other methodologies, such as qualitative research are identified as having lower status.

1.12
The movement to EBP began with the medical profession and it has been argued that this movement arose in response to the need for rationing of health care (Harrison, 1997). Harrison argues that EBP is a 'neat solution' to the problem of rationing which has appeal to the Government, the medical profession and patients. The movement to EBP can also be seen as a Governmental attempt to exert some control over medical practitioners. However, it is argued that doctors have a number of means at their disposal to resist such control (Hunter, 1991; Grimley-Evans, 1995; Jacobson, Edwards, Granier & Butler, 1997).

1.13
The movement towards EBP has filtered down to the professions allied to medicine, such as physiotherapy. This has occurred partly as a result of the Government's proposals for modernising the NHS and because purchasers are demanding evidence of effectiveness before purchasing services for all areas of health care (Department of Health, 1996a,1996b). At the same time this movement has been one that the CSP and some individual members of the physiotherapy profession have embraced as a means of contesting the challenges from alternative practitioners to the areas of work they perceive as being their territory (Bury, 1996; McQuarrie, 1997). It has been noted that developments such as EBP which have a considerable impact on a profession are not necessarily experienced or viewed in the same way by all members of a profession (Freidson, 1994; Annandale, 1998:240). While EBP may be seen by the knowledge and managerial elite within the profession as the most appropriate way forward for safeguarding the future of the profession and contesting challenges from other health 'tribes', the rank and file who are expected to put such strategies into action in their day-to-day work frequently have a different view.

1.14
This paper will draw on qualitative data collected from 56 physiotherapists of different grades who worked within a range of different NHS treatment settings within one Region in the South of England. It will explore physiotherapists' views of EBP and the impact they perceived it would have on professional boundaries and on the status and practice of physiotherapy.

Method

2.1
The data reported here were collected as part of a NHS funded study which aimed to explore physiotherapists' attitudes to EBP and the factors which either encourage or discourage physiotherapists developing a culture of EBP. The study was located within a NHS policy agenda in which the development of EBP is seen as essential to ensure competitiveness in gaining contracts from purchasers.

2.2
Focus groups and individual or group interviews were conducted with 56 physiotherapists of different grades from a range of NHS treatment settings in part of one NHS Region in the South of England. The NHS treatment settings in the area comprised hospitals with links to universities (n=2), district general hospitals (n=11) and community and domiciliary settings (n=13). Managers of physiotherapists working at each of these district general hospitals and community settings were asked to arrange for one member of staff of each grade to attend focus groups. Managers of physiotherapists working at the university hospitals were asked to identify three members of staff of each grade. The intention was to conduct nine focus groups each comprising 6-9 individuals. In the event, five focus groups, five group interviews (with two or three participants) and four individual interviews were conducted with the sample. Group or individual interviews were conducted where there were insufficient numbers of participants to conduct focus groups. We viewed it as necessary to have a minimum of four participants in order to conduct focus groups (Kitzinger 1995). Fewer than this and it becomes very difficult to generate discussion among group participants and the group tends to revert to a group interview format with the participants addressing questions raised by the researcher rather than discussing issues with each other.

2.3
The focus groups and group interviews were organised to ensure homogeneity among participants. Each focus group or group interview was conducted with staff of the same grade (i.e. either: junior; senior or superintendent physiotherapists) and sector of work (i.e. either: community; district general hospitals or university hospitals) but from different geographical areas of the Region. The focus groups or interviews were conducted in hospital seminar rooms at various locations. A total of 56 physiotherapists participated in the study. Seven of these participants were male. As Table 1 shows, the sample comprised 14 junior grades, 23 senior grades and 19 superintendent grades.


Table 1: Study Participants

Juniors

Seniors
Super-
intendents

Total
University
Hospitals

5

5

4

14
District
General
Hospitals

8

9

9

26
Community
Settings

1

9

6

16

Total

14

23

19

56

2.4
The following issues were explored in the focus groups or interviews: understandings of EBP; EBP activities being carried out by individuals and departments; factors perceived as encouraging and discouraging EBP; and, perceptions of the implications of EBP for the future of physiotherapy. As is usual in focus group research, the topics were introduced to the group by one researcher and the discussion within the group was observed by a second researcher in order that the interpersonal communication within the groups, which may encourage or inhibit the expression of particular views, could form part of the analysis (Kitzinger, 1995). Observation was not conducted for the group or individual interviews where the small numbers participating meant that focus group style discussions were not possible. In the interviews the aim was for the interviewer to explore participants' views of the research topics through active questioning and probing of responses rather than for the participants to discuss the topics with minimal intervention from the researcher. The focus groups lasted an average of one hour and the interviews lasted an average of forty minutes. All focus groups and interviews were audio-taped.

2.5
Typed transcripts were made of the tape recordings of the focus groups and interviews. Typed notes were also made of the observations of interpersonal communication within the focus groups. Interview and focus group transcripts were analysed separately. A thematic analysis was conducted on each set of transcripts. This involved examining the transcripts for emergent themes in relation to the issues explored in the focus groups and interviews outlined above. In order to enhance the validity of the themes and issues identified, initial coding of the data into themes was carried out independently by two researchers on the first two focus group and first two interview transcripts. The initial themes identified were pursued in further data collection and refined through further analysis. In addition, the observational notes of each focus group were used alongside the focus group transcripts in the process of analysis so that the potential influence of group processes on the views expressed could be explored.

2.6
Combining data collected by different qualitative research methods is not without problems. It has been noted that data collected from focus groups and interviews are likely to be dissimilar with one eliciting public accounts and the other eliciting private accounts of phenomena (Barbour, 1998). Consequently, data collected via different research methods often cannot be combined because the findings differ. In this study, 15 people were interviewed individually or in groups and the other 41 participated in focus groups. The data collected by interview compared with those collected by focus group were similar. Both focus groups and interviews appeared to elicit broadly 'public' accounts of EBP in relation to physiotherapy. This is unsurprising given that individuals participated in one-off focus groups or interviews, that these were conducted in a work setting and that one of the researchers was known to be a physiotherapist. Such factors mean that 'private' accounts of professional practice are less likely to be elicited regardless of the method of data collection.

Findings

The Need for EBP in Physiotherapy

3.1
The physiotherapists in the study were convinced of the need to develop EBP in physiotherapy. This need was seen to be determined largely by NHS policy in that purchasers were beginning to demand evidence for the services they purchased in all areas of the NHS, including physiotherapy. To this extent, physiotherapists felt they had little choice but rapidly to develop EBP in order to compete with other professions which laid claim to similar areas of expertise to their own and who, it was feared, may be gathering evidence quicker than they could. The physiotherapists had a sense that self esteem in the profession was low, that their profession was very much under threat and that the need to accumulate evidence was urgent. The need to develop EBP was therefore seen as a crucial undertaking to secure the future of the profession. Without it participants feared they would lose their tentative foothold on the areas in which they currently worked and be replaced by other professions who could lay claim to physiotherapy's traditional areas of expertise. Some participants felt that the profession was at a crisis point and that unless they could produce the evidence for the effectiveness of their therapies the profession was likely to lose credibility altogether and to die out. Participants were primarily concerned about the threat from alternative therapies, such as osteopathy and chiropractic. However, they also felt under threat from other professional groups such as specialist nurses in cases where they carried out similar work to them (in intensive care, for example) but where evidence of the contribution physiotherapists made to this area of work was limited. The following excerpts from focus groups illustrate this view. The first is from a focus group with superintendent physiotherapists:

P4: 'The need [for EBP] has come out of vying and jockeying for attention and we are being bombarded from different angles, from medical, chiropractic and osteopathic and everyone is coming out with their research and saying "we are bigger and better than everyone else"'

P1: 'If your services are being bought, then people want to know that they are buying good practice and good services don't they? We have to prove that in order to get the business'

(Superintendent physiotherapists, focus group 9)

3.2
Senior physiotherapists expressed similar views:

P3: 'It has to be the direction the profession moves in'

P1: 'Oh I would totally agree'

P3: 'I think otherwise our jobs are really and truly on the line, our profession is on the line unless we can actually say "yes this helps this particular type of condition in these circumstances"'

(Senior physiotherapists, focus group 7)

3.3
This excerpt from a focus group with junior physiotherapists illustrates their concerns about competition from nurses with specialist skills:

P3: 'I feel like even on ITU [intensive therapy unit] here, I mean the nurses are quite often on these ITU courses and they know more about patients than I do. They know more about ventilation and they're suctioning all the time and bagging and I'm going up twice a day to do what they're doing'

P6: 'We've got a really good senior who's just come in and has been doing lots of research and she can give the evidence and she can say "well this is what I found and we should be doing this" and now they're actually saying "OK" but then again with me I won't argue so strongly because I haven't seen it'

P4: 'If you've got the research behind you you're a lot more respected aren't you?'

P6: 'I think this is one of the problems in respiratory. Some people say "why have we got respiratory physios when some of the nurses are becoming so, you know?"... We do need to get the research evidence'

(Junior physiotherapists, focus group 3).

3.4
As well as a strategy for contesting professional boundaries with 'middle range' occupations, pursuing EBP was also seen as a means of gaining greater respect from doctors. Despite having a degree of professional autonomy, some physiotherapists noted that they were treated as technicians by doctors in that they were prescribed what treatment to provide to a patient. Having a greater evidence base was seen as something that would enhance physiotherapists' status in the eyes of the medical profession and thereby address this problem. The following excerpts illustrate this view. The first is from a junior physiotherapist who was interviewed individually:

'I think often on the wards, doctors tend to think, you know, oh we'll just tell the physio to go and do this type of thing and it becomes more of a technician's role and one of the doctors can be quite bad at that, and I think we just need to, you know, be a bit more assertive sometimes and I think if there is more evidence, more research in certain areas, we will be more assertive definitely in that area and probably gain more respect I think as physios'

(Junior physiotherapist, individual interview 2.1)

3.5
Participants in one of the focus groups put forward a similar view:

P4: 'I think it comes down to how the profession is respected ... I know that some medical staff really seriously criticise us because we haven't got enough research evidence and they perhaps would respect us better if we did'

P2: 'I think they probably would too'

P4: 'It would be much more of a powerful argument wouldn't it?'

(Senior physiotherapists, focus group 7)

3.6
Some physiotherapists noted that an additional advantage of developing an evidence base would be that it would enable them to provide patients with the opportunity to make informed choices about the treatments on offer and would reduce the risk of litigation. However, improving the status of physiotherapy in the eyes of patients, whether through EBP or any other means, was not identified as an important objective. While physiotherapists noted the threat to their profession from alternative therapies and saw gaining evidence in order to contest or maintain professional boundaries as one means of diverting this threat, they did not appear to view enhancing their status with patients through the accumulation of evidence as a means of achieving this goal. The physiotherapists in this study viewed scientific evidence of effectiveness as the means whereby the challenges made by these therapies could be contested. Claims of scientific effectiveness were not identified as a means of improving physiotherapy's popularity with the public. Indeed, this was not identified as a necessary goal for the profession.

The Impact of EBP

3.7
While all physiotherapists in the study identified the need for EBP in principle in order to contest claims made by alternative therapies, when they discussed how this might work in practice some participants were less convinced of its appropriateness. Junior physiotherapists, who were all recently qualified, appeared to be committed to the notion of EBP. This is unsurprising in that learning about EBP comprises a central part of physiotherapy undergraduate education and training which these physiotherapists had only recently completed. While some junior physiotherapists recognised the difficulties in implementing EBP in their day to day work, most did not view these as in conflict with good physiotherapy practice. Some superintendent physiotherapists recognised conflicts between EBP and their established and preferred ways of working but all respondents at this level appeared to be generally committed to EBP. This may have been because superintendents have a management role and EBP is central to the managerial agenda. Thus superintendents may have been unwilling to express publicly disapproval of EBP. In contrast, senior physiotherapists presented greater variation in their discussion and responses about EBP. Senior physiotherapists comprise the majority of physiotherapists working in the NHS. They have generally been trained to diploma level (rather than degree level) and been working as physiotherapists for three or more years. They are likely to have little training in research methods or evaluation. The senior physiotherapists in this study identified a conflict between what they understood EBP to be and their established ways of working to the extent that EBP was viewed as posing a threat which had the potential to weaken the profession. The conflicts that these physiotherapists identified have been categorised into three areas: physiotherapy knowledge and expertise; patient oriented practice; and, physiotherapists' status as independent practitioners. Each of these will be examined in turn.

EBP: a Threat to Physiotherapy Knowledge and Expertise

3.8
Participants were agreed that EBP is defined as practice based on evidence rather than on tradition or unsubstantiated belief about what is effective. More in-depth analysis of physiotherapists' views about how this should work in practice revealed that while most physiotherapists viewed evidence to be a mix of both research evidence and evidence from clinical experience, in practice it appeared that evidence from clinical experience was viewed as superior to research evidence. For example, physiotherapists noted that they would not change to a treatment for which there was research evidence if the current treatment they were using was effective, even if this was not indicated by research evidence. They noted that they would change their practice to take into account research evidence only if the treatment that they were currently using was not working. However, for this to happen they noted that they would want a substantial body of evidence before changing their practice and that this would need to be linked to evidence from clinical practice in some way, for example, being presented on a course with the research and clinical evidence. Finally, they noted that even if there was a substantial body of knowledge about the effectiveness of a treatment, they would not continue to use it if it did not appear to work in practice. So while they paid lip service to defining EBP as practice based on research evidence, in the reality of their day to day work, their own clinical practice appeared to be viewed as a more salient source of evidence than research evidence.

3.9
Some senior physiotherapists expressed this notion of clinical evidence being superior to research evidence very strongly and saw research evidence as having a very limited role in practice. These respondents noted that physiotherapists gain 'evidence' of effectiveness through their day to day practice with patients and that research tells them only what they already know from practice. It was noted by some of these participants that the movement to EBP as opposed to practice based evidence resulted in a devaluation of physiotherapy knowledge and expertise and low self esteem in the profession. The following excerpt from one of the focus groups with senior physiotherapists illustrates this point:

P1: 'Whatever we write down in our notes is gonna be evidence towards your goals, your aims, in looking towards evidence based practice'

P6: 'It doesn't have to be research'

P4: 'No'

P1: 'A lot of emphasis has been put on research recently ... and we look at it [research evidence] and we go "hah, that doesn't fit into any kind of clinical form" and they're just proving that it doesn't work but we know it does 'cos we've seen it on our patients. So I think from the research point of view we sort of seem to be disproving ourselves, yet we know it works'

P4: 'And from the outside looking in the purchasers are going to be looking at the research and they may base what they want on the research which might not necessarily be you know what you felt helped, like you were saying'

(Senior physiotherapists, focus group 6)

3.10
One factor encouraging participants to view clinical evidence as superior to research evidence was the recognition that the way that physiotherapists carry out treatments and the ways patients respond to treatments vary. It was noted that even though there may be research evidence for the effectiveness of a certain treatment, individual physiotherapists may not achieve a good outcome using that treatment because they lack the expertise to put it into practice. Similarly, in terms of patients, it was noted that outcomes are dependent on the patients' willingness to adopt changes to their lifestyles or to comply with a self directed exercise programme suggested by a physiotherapist. So again physiotherapists felt that, even though there may be evidence for the effectiveness of a certain treatment, patients may not make the recovery expected because they do not or can not follow the advice given by a physiotherapist. Some senior physiotherapists saw these difficulties as reasons for basing practice primarily on their clinical experience of what will be most effective for an individual patient and not on research evidence. One senior physiotherapist for example said:

'Those guidelines, if you just followed that you'd manipulate every patient in the first six weeks and we all know that not every patient responds well to manip[ulation] and there's a lot of other factors again so you can't just follow evidence based practice.'

(Senior physiotherapist, focus group 7).

EBP: a Threat to Patient Oriented Practice

3.11
EBP is viewed in the literature as having benefits for patients by improving patient care and enhancing patient choice. Improvements in patient care are seen as arising from using only those treatments proven to be effective and discarding those that are ineffective. Patient choice is seen as being enhanced through the provision of evidence about the outcomes associated with the various treatment options thereby enabling patients to make an informed choice about the treatment they would prefer to opt for with the knowledge of what the likely outcome of the treatment will be. However, EBP does not necessarily increase patient choice in that it may result in the range of options available to a patient being severely limited. Furthermore, the options that patients want to choose because they believe them to be beneficial may be removed from the possible treatments available because there is no proof of their effectiveness. Thus EBP is not necessarily patient centred practice in that patients' knowledge and experience of their condition plays only a limited role in decisions about treatment. While EBP does allow patients to make choices, the choices that it is possible to make are limited by available evidence.

3.12
Senior physiotherapists in this study noted the importance of respecting patients' wishes and knowledge and providing care that takes patients' preferences into account. This was viewed as a central element of physiotherapy practice that additionally made physiotherapy a popular treatment with patients. Some physiotherapists felt that EBP limited the extent to which they could adopt such patient oriented approaches. The participants noted that there is a placebo element involved in physiotherapy in that treatments for which there is no evidence are sometimes effective in terms of patient outcome because the patient believes they will be. They also noted that patients' responses to treatments are individual and that what is effective for one patient with a particular condition might not be for another patient with a similar condition. Both these factors were put forward by some senior physiotherapists as reasons for using treatments based on patients' preferences and experiences of what is effective. Such treatments may have no evidence base but might nevertheless be effective for individual patients. This excerpt from one focus group illustrates these views:

P6: 'There's quite a lot of placebo in our work and if a patient's convinced such and such is gonna help them 'cos that's what they had twenty years ago and you've got no definite reason for not doing it then we all know with some patients it's easier just to do what they want and they're going to get better, than do what you think is best that they don't think is gonna help them'

P2: 'It's part of the skill of dealing with the patient isn't it?'

Res: 'so you wouldn't want to see physio going down a road where that couldn't happen?'

P6: 'No'

P1: 'We'd be out of a job'

P2: 'Well you could hand it to a physio assistant and say you do this with that patient and almost walk away couldn't you?'

P1: 'We would become technicians'

P6: 'Physios wouldn't do it, we're not like that'

(Senior physiotherapists, focus group 6).

3.13
These physiotherapists feared that EBP would mean that only those treatments proven to be effective could be used. They feared that this would mean that they would lose important treatments from their repertoire which may be effective for some patients regardless of the available evidence of their effectiveness. Furthermore, they feared the loss of these treatments would result in a poor or non-existent service for those patients who did not respond to evidence based treatments. Participants felt that these treatments might be discarded on the basis of evidence that proved at a later date to be flawed.

EBP: a Threat to Physiotherapists' Status as Independent Practitioners

3.14
The third area in which EBP was viewed as a threat concerns physiotherapists' status as independent practitioners. The movement towards EBP was viewed by some more senior grades of physiotherapist as a threat to what they called the 'human element' of their work. These physiotherapists feared that EBP might mean that they would not be able to continue working in ways in which patients were assessed as individuals and in which the treatment provided was identified as appropriate for that individual. These physiotherapists feared that EBP would mean that only those treatments proven to be effective could be used and that, if such practices had to be adopted in a uniform way, then physiotherapists would become technicians who followed particular set procedures for specific conditions and were unable to use their experience and act as independent practitioners. This was a situation they wanted to avoid at all costs.

3.15
These physiotherapists noted how hard the profession had fought, and continued to fight, to achieve their status of independent practitioners from that of a technician who was told what to do by doctors. EBP was viewed as being a backward step which would encourage other health professionals to view physiotherapists as technicians. This excerpt from one of the focus groups illustrates these views:

P1: 'my biggest worry is if everything does become evidence based we're going to go back to the old technician thing.'

P3: 'You are straitened, you are blinkered then, you would lose your flexibility, your autonomy as a practitioner'

P1: 'Which we've fought so hard for really haven't we?'

P3: 'It's full circle isn't it?'

(Senior physiotherapists, focus group 7).

Discussion

4.1
Some caution needs to be exercised in drawing the conclusion from this study that senior physiotherapists have different understandings of, and attitudes to, EBP than do lower and higher grade physiotherapists. The senior physiotherapists who participated in this study did so through focus groups or group interviews and there may have been group processes at work that influenced the particular views expressed in these groups. One influence, for example, may be the impact of dominant group members on the views expressed with groups. Furthermore, the sample size of each physiotherapist grade is relatively small which makes comparisons between groups problematic. However, while further research is necessary to explore some of these findings further, this study has nevertheless highlighted some important issues.

4.2
This study indicates that physiotherapists view the movement to EBP as necessary for the survival of the profession. However, two contrasting ways of interpreting the impact that EBP might have on the profession were identified. Physiotherapists' views appeared to differ according to their position in the profession. Senior physiotherapists tended to view the development of EBP as a threat to the profession while junior and superintendent physiotherapists tended to view EBP as an opportunity for strengthening the profession. Thus, junior and superintendent physiotherapists viewed EBP as a positive move that would strengthen the profession's position within the health care division of labour through the accumulation of scientific evidence which will prove the effectiveness of physiotherapy interventions. A contrasting position was identified by senior physiotherapists who expressed various reservations regarding what the impact of EBP would be on physiotherapists' autonomy, physiotherapy knowledge and expertise and on patient choice.

4.3
In relation to devaluing physiotherapy knowledge and expertise, senior physiotherapists feared that EBP might result in their being unable to use clinical experience in deciding the most appropriate treatment for individual patients. Yet senior physiotherapists viewed the experience gained through clinical practice with patients to be crucial in determining the most effective treatment for an individual. Such experience is used to identify the most effective treatment based on a physiotherapist's assessment of their ability and competence at delivering a specific intervention and an individual's likely response to that intervention and to advice regarding subsequent self-care. EBP is currently defined as practice which involves the integration of research evidence with clinical expertise. Thus, physiotherapists should continue to be able to use their expertise in identifying appropriate evidence based treatment for patients. In part, senior physiotherapists' fears may have resulted from a lack of understanding of what EBP should comprise. However, EBP does have the potential to change the role that clinical expertise and experience has by stressing the importance of integrating it with research evidence in identifying appropriate treatments. The fears expressed by the senior physiotherapists reflect concerns about the potential impact this may have on practice.

4.4
The perceived threat to the use of clinical judgement in deciding what treatment is appropriate for an individual was linked to fears about loss of autonomy. These physiotherapists feared that EBP might result in their becoming technicians who used set procedures or techniques for specific conditions. Thus, physiotherapists feared that pursuing EBP might result in a strengthening of the doctor:physiotherapist hierarchy rather than a reduction of it because doctors would be able to instruct physiotherapists to use set procedures for specific conditions. In addition, such a development could be seen as threatening physiotherapists' position and status in relation to other 'middle range' health professions.

4.5
In relation to patient choice, physiotherapists in this study were concerned that EBP may limit the extent to which physiotherapists could work with patients in reaching decisions about the appropriate treatment for an individual. EBP encourages the focus of practice to be on outcomes. The success of treatments is viewed as being related to the extent to which a treatment results in physical recovery. While recovery may be the most important outcome that people hope to achieve through physiotherapy (Wiles, Pain, Buckland & McLellan, 1998), physiotherapy is also valued for the feelings of well being and self worth it can give a patient (Pound et al, 1994) and these factors are viewed as having an impact on outcome. It was feared that EBP might limit opportunities for patients to be involved in treatment decisions and result in patients being provided with only a limited number of treatments for limited periods of time which would be likely to impact on the effectiveness of the treatment physiotherapists could provide.

4.6
The different views expressed by senior physiotherapists on the one hand and by junior and superintendent physiotherapists on the other about the impact of EBP on the status of the profession held can be seen as relating to contrasting understandings about the nature of the work that physiotherapists do. On the one hand are those physiotherapists who characterise physiotherapy as closely aligned to the medical model of care where physiotherapy interventions are seen as resulting in specific outcomes which can be measured. These physiotherapists consequently view obtaining scientific evidence of the effectiveness of physiotherapy interventions as possible and as a means that will assist in establishing a secure basis within the health care division of labour. On the other hand are those physiotherapists (which in this study was those with extensive 'front line' experience with patients) who characterise the work they do as broadly intuitive and based on trial and error and clinical experience of what works with individual patients. Within this characterisation, the process of care as well as the specific intervention is seen as important. Such a model is viewed as not amenable to scientific proof (i.e. randomised controlled trials) because of the difficulties in standardising physiotherapy treatments and outcomes and because of the difficulties in examining the effects of the process of receiving physiotherapy. One might characterise this model of care as being more closely aligned with the alternative therapies where scientific evidence of effectiveness has been difficult to obtain but where there is substantial anecdotal evidence of effectiveness from both patients and practitioners and where the popularity of alternative therapies is seen as 'evidence' of their effectiveness. As they stand these two models are not readily compatible but the pursuit of EBP is likely to push physiotherapists towards seeking some resolution of these contrasting models of care.

Conclusion

5.1
The development of EBP in physiotherapy is in its early stages and just how this process will unfold and the impact it will have on the profession of physiotherapy and its relationships with a wide range of health professions is as yet unknown. It seems unlikely that the movement towards EBP will lose impetus at least in the immediate future given the central role it plays in Government health policy. While doctors may have some power to contest and challenge the effects of EBP, physiotherapists are in a relatively powerless position to challenge the march towards EBP at least in the foreseeable future.

5.2
The attitudes of physiotherapists to EBP and their responses to it are likely to be influenced by the impact EBP has on physiotherapy's professional standing and the autonomy physiotherapists maintain to conduct their work as they see fit. EBP may turn out not to be the straitjacket that senior physiotherapists feared and this group may be won over to EBP if their autonomy is maintained and their status in the health care division of labour does not deteriorate. Alternatively, junior and superintendent physiotherapists may not remain as committed to EBP if it is seen as weakening the professional standing of physiotherapy.

5.3
This study has identified some of the key issues to which researchers need to be sensitive in analysing the impact of EBP, namely the extent to which it: compromises physiotherapists' autonomy and scope for discretion; devalues physiotherapists' clinical experience; and, limits patient choice. In addition, the extent to which EBP contributes to a redefinition of boundaries between professions warrants further research. Such redefinition of boundaries may occur between conventional medicine and physiotherapy, alternative therapies and physiotherapy, and public and private physiotherapy.

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