Evidence-based that is woven throughout all of

Evidence-based practice (EBP) is a
common thread that is woven throughout all of modern medicine.  Various definitions have been put forward by
relevant governing bodies, agencies, and in the research to describe EBP and it
is no different in the field of rehabilitation science.   The American Physical Therapy Association
(APTA) defines EBP as “the integration of best available research, clinical
expertise, and patient values and circumstances related to patient and client
management, practice management, and health policy decision-making” (Gardner,
n.d.). The American Occupational Therapy Association (AOTA)
and the American Academy of Physical Medicine and Rehabilitation (AAPM&R)
both hold similar definitions as well; emphasizing research, clinical
expertise, and the role of the patient in guiding appropriate provision of
healthcare (“Evidence-Based
Medicine,” n.d., “Evidence-Based Practice; Research – AOTA,” n.d.). 
The EBP process includes presenting a clinically relevant question,
searching for the best evidence in the literature, evaluating the quality of
the evidence, applying the evidence as appropriate and evaluating the entire
process (Harding,
Porter, Horne-Thompson, Donley, & Taylor, 2014; Sackett DL, Rosenberg WM,
Gray JA, Haynes RB, 1996).

EBP is well recognized as a key to
the success of the medical profession and for the best interests of patients;
however, there are a multitude of barriers that exist that prevent this
unquestionably valuable pillar of medicine from being as effective as it could
be.  A comprehensive review of barriers
to EBP was completed in February 2006 by the National Institute of Clinical
Studies in Australia and they divided common barriers into six primary categories:
intervention, patient, professional, organizational situation, economic and
political situation, and social situation (Buchan,
2006).  Many research
articles already exist describing the various barriers to EBP; however, very
few of them go beyond basic surveys to dissect underlying causes of such
barriers.  The aim of this paper is to
discuss the economic/financial and political (and disciplinary/practice)
situations that exist, as these appear to be playing an ever-growing barrier in
EBP, but are not as well supported currently in the literature.  We will pay particular attention to three situations
in which these economic implications manifest including: clinicians citing a
lack of time for EBP and more systemic limitations stemming from reimbursement
and disciplinary/practice act issues.  We
will elucidate these further through examination of several cases examples and
conclude with a few suggestions for future improvement.

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THE “LACK
OF TIME” BARRIER

A 2003 study by Jette et al. surveyed
488 physical therapists and found that the most common barriers to EBP were “insufficient
time, lack of applicability to patient population, unique needs of patients,
inability to understand statistics, lack of search skills, lack of informational
resources, lack of collegial support, inability to critically appraise, and
lack of interest”; with lack of time being the number one barrier (Jette
et al., 2003, p. 800). 
A study in 2014 by Bernhardsson et al. conducted in physical therapists
in Sweden found that, in general, EBP continues to be viewed favorably (96%
considering EBP important); however, less than 50% of clinicians actually
utilized the available EBP guidelines that were available (Bernhardsson,
Johansson, Berg, & Larsson, 2014). 
Those that were more likely to utilize or be able to locate the EBP
guidelines or view them favorably were those that had practiced less than five
years and had a postgraduate degree (Bernhardsson
et al., 2014). 
These results suggest that more recent advancements in medical education
training have focused on EBP and have helped to address the critical appraisal
and lack of search skill issues such that these are less apparent barriers to
EBP moving forward.  Additionally,
practice organizations such as the APTA have made a concerted effort to provide
summative EBP that is easy to access from a clinician standpoint; providing
much easier to digest methods of obtaining EBP than what was previously
available just a few years ago (Gardner,
n.d.).

A study by Harding et al. in 2014
found that 90% of clinicians surveyed had a “positive attitude” towards EBP (Harding
et al., 2014). 
Further analysis of the survey respondents found that the primary
barrier to EBP was lack of time with three subcategories as the causes cited
for lack of time: “attitudes and expectation of clinicians and managers, lack
of resources resulting in too many tasks to complete in the time available, and
lack of skills leading to inefficiencies in the implementation of EBP” (Harding
et al., 2014, p. 227). 
The first two primary barriers to “lack of time” seem to stem from a financial
source, not necessarily from the clinicians themselves, but rather how
clinicians’ time is accounted for when they are in the clinic, with the
emphasis being on the bottom line and productivity. 

In the Harding study they quote one physical
therapist as stating: “It’s just like you do all your professional development
stuff out of hours and I think subconsciously I put it (EBP) in with that”(Harding et al.,
2014, p. 229).  Another
physical therapist surveyed in the study states: “You just feel bad, like if
somebody walked past you sitting on a computer looking up something (EBP) you
kind of think… “Oh, I probably shouldn’t be seen doing this” (Harding et al.,
2014, p. 227).  This has
been this author’s experience as well. 
In a standard 40-hour work week, a clinician is generally expected to be
“fully productive” that is, seeing a full patient caseload and documenting at
“point of care/service”, therefore not allowing any time in a given workweek to
have dedicated to EBP.  If one is to
pursue EBP in the research it is reserved for time outside of work or the
occasions when a therapist has a cancellation; although that time is often
filled with getting caught up on documentation and completing discharge notes.