Barriers to the use of clinical practice guidelines: a qualitative study of Danish physiotherapists and chiropractors

Abstract

Purpose

Low back pain (LBP) is the leading cause of disability worldwide. Providing evidence-based practice (EBP) for patients with LBP is more cost-effective compared with non-EBP. To help health care professionals provide EBP, several clinical practice guidelines have been published. However, a relatively poor uptake of the guidelines has been identified across various countries. To enhance future implementation of EBP, the aim of this study was to explore barriers to using LBP guidelines in clinical practice.

Materials and methods

A qualitative constructivist grounded theory design was employed in order to gain an in-depth understanding of the barriers. Semi-structured interviews (+/− observations) of nine physiotherapists and nine chiropractors from primary care in the Central Denmark Region were conducted.

Results

Two key barriers were found to using guidelines in practice: (1) a scepticism due to doubts about validity and applicability of the guidelines, which emerged particularly among physiotherapists; and (2) a deep biomechanical professional identity, due to perceived role, interest, lack of skills, and patient preferences, which emerged particularly among chiropractors.

Conclusions

For guidelines to be better implemented in practice, these key barriers must be addressed in a tailored strategy. Furthermore, this study showed a difference in barriers between the two professions.

Implications for Rehabilitation

• It is important that physiotherapists and chiropractors reflect on what constitutes their core task and professional identity if the implementation of the biopsychosocial model is to be successful.

• To overcome the barrier of scepticism towards guidelines, the applicability of the guidelines could be improved by elaborating on how the recommendations could be individualised.

• It is important to incorporate the biopsychosocial model into the programs of educational institutions and provide training to improve those skills in physiotherapists and chiropractors.

Keywords:

• Implementation
• clinical practice guidelines
• barriers
• qualitative study
• physiotherapists
• chiropractors

Acknowledgements

The authors would like to thank the participating physiotherapists and chiropractors for sharing their thoughts and experiences, and allowing us to observe their practice. Likewise, we would like to thank the patients for allowing us to observe them during their treatments. Also, sincere thanks to the steering group of the project (Nils-Bo de Vos Andersen, Bo Albertsen, Henrik Frederiksen, and Jeppe Mølgaard Mathiasen) who helped to ensure that the project stayed on the right path. We appreciate their professional dialogue. Finally, we would like to thank our colleagues who have given important feedback on the analysis process.

Disclosure statement

The authors report there are no conflicts of interest to declare.

Additional information

Funding

This work was supported by the Fund for Research, Quality and Education in Physiotherapy Practice, Denmark (Fysioterapipraksisfonden); by the The Association of Danish Physiotherapists’ Foundation for Research, Education and Practice development, by the Department of public health, Aarhus University, Denmark and by Elective Surgery Centre, Silkeborg Regional Hospital, Denmark.