Key results
Response rate and sample characteristics
The response rate for the study was 7.2%. While low, it was within the range (4–8%) of previous national surveys examining EBP use among complementary therapists [5, 8, 10]. However, the response rate was considerably lower than the 30% reported in the UK nationwide Osteopaths’ Opinions Survey in 2012 [50], possibly due to the relatively longer time required to complete the EBASE. Nonetheless, the demographic characteristics of our sample were similar to those of the UK osteopathy profession in terms of gender, age and geographical distribution, years of experience, typical practice setting and types of treatment provided [50, 51]. This suggests that our survey sample was broadly representative of osteopaths in the UK.
EBP attitudes
Positive attitudes of UK osteopaths towards EBP support results of previous surveys of CAM professions, including US/Canadian chiropractors [4, 5, 8], western medical herbalists [9], yoga therapists [10], Australian naturopaths and TCM/acupuncture practitioners [6]. Similarly, positive attitudes toward EBP have been reported among physiotherapists [52] and occupational therapists [53].
Thirty-seven per cent of the respondents disagreed that patients’ treatment preferences should be taken into account in EBP, compared with 21–24% of chiropractors [5, 8], and 22% of yoga therapists [10] in North America. This finding suggests UK osteopaths have a limited understanding of EBP and patient-centred care, particularly the awareness of the role of patient’s perspectives among the three main elements of EBP decision-making, alongside best available evidence and the clinician’s expertise [1, 54]. Notwithstanding, most participants agreed or strongly agreed that EBP incorporates clinical expertise into account in clinical decision-making; a view shared by other health professions, especially chiropractors [4, 5, 55]. The implications of these findings to clinical practice require further investigation.
EBP skills
Overall, participants reported moderate levels of perceived skill in EBP, with the highest levels reported for items relating to problem identification and evidence acquisition. This suggests that osteopaths perceive themselves as sufficiently skilled in the first two stages of the EBP process, i.e. asking a searchable question and acquiring the right evidence [56]. The findings also indicate that UK osteopaths are moderately skilful in critically appraising, synthesising and applying research evidence to clinical practice, i.e. the final three stages of the EBP process [56]. An implication of these findings may be that clinician training in EBP should focus more on developing skills related to the appraisal and application stages of the EBP process. Indeed, an Australian longitudinal study showed research training for student nurses improved perceived skill level in the latter stages of the EBP process [55].
Participants reported lower levels of skill in using findings from systematic reviews compared to findings from other types of clinical research, which is consistent with previous surveys among chiropractors [4]. The use and interpretability of systematic reviews may be challenging in health professions [57], and given that such studies and meta-analyses represent the highest level of evidence, it is essential that osteopaths gain sufficient skills to utilise such results.
EBP use, barriers and facilitators
Although most participants engaged in various EBP-related activities one month preceding the survey, albeit infrequently, almost one-quarter of respondents reported never engaging in EBP activities in the preceding month. This moderately-low level of engagement in EBP-related activities are attributed to several factors, where for example participants cite a lack of time. Participants further reported a perceived lack of clinical evidence in osteopathy as a barrier to EBP uptake; a possible demotivator for practicing osteopaths [58, 59]. Participants indicated that access to the internet at work, online medical databases, full-text journal articles, and online education materials would be very helpful in facilitating EBP uptake. Thus it is likely that inadequate access to these services may significantly affect osteopaths’ ability to engage in EBP [13].
Further, the nature of osteopathic practice in the UK may not impose high-level engagement in EBP-related activities. Perhaps patients seeking care from UK osteopaths present with such a consistent range of symptoms and disorders that osteopaths do not feel the need to engage in EBP activities at a high-level? Such hypothesis may also help explain similar levels of EBP activity within the chiropractic profession [4, 5]. However, the level of engagement in EBP activities of US physical therapists has been reported as higher than that of our cohort, with one study showing 66% of respondents consulting research material and 52% having used a medical database, four to 10 times weekly to make clinical practice decisions [60]. Thus, future research should determine ideal levels of EBP activity for practicing osteopaths, and whether that might vary between different clinical settings and scopes of practice (e.g. Europe vs. US), and further, whether different levels of EBP activity translate into poorer or improved patient outcomes.
EBP education
While osteopathic degree courses in the UK provide at least 1000 h of clinical training [51], the extent to which EBP training is embedded within these courses is less clear. The majority (58–81%) of responding UK osteopaths reported some level of training in EBP such as critical thinking/analysis. Most UK osteopaths reported they had undertaken EBP training as a component of a study program, rather than through seminars or short courses.
Almost one-third of participants had been in clinical practice over 16 years. Recognising that Sacket’s EBP model [1] started gaining recognition among healthcare professionals in early 2000, it is probable that some respondents may have received little to no EBP training. Indeed, our analyses showed that the more years in practice, the lower the osteopaths’ EBP attitude and use scores. Similarly, lower EBP use and skill scores correlated with a greater number of years since receiving their highest qualification. Given the current push for EBP in healthcare, and that osteopathic education institutions are facing increasing scrutiny to prepare students to practise osteopathy in a safe and effective manner, effective EBP training and continuing education programs are needed. Notably, our results, which concur with survey findings among yoga therapists [10], suggest that providing opportunities and incentives for clinicians to engage in teaching and research may help to improve EBP uptake.
Limitations
The low response rate (7.2%) was surprising given that the pilot testing of EBASE did not identify the survey to be too long or time-consuming. However, post-hoc exploratory analysis of the response rates point to possible response fatigue, as several respondents dropped out before completing the survey. However, difficulties completing more complex questions, such as ranking multiple items, is another possible limitation suggested by most drop-outs occurring from question 38 onwards. Other possible explanations for our response rates may be that clinicians were too time-poor to complete the survey (noting that lack of time was a moderate to major barrier to EBP uptake), were generally uninterested in EBP (noting that most osteopaths engaged in EBP activities at a moderately low level), or were not incentivised to participate. Additional study limitations intrinsic to the survey design include recall bias and self-selection bias. Nonetheless, this was the first national survey to comprehensively explore EBP among osteopaths in the UK; the findings of which may be used to inform future research and EBP educational activities for this target group of healthcare providers. The online survey tool automatically restricted attempts to respond to the survey more than once by the use of cookies per device. While it may have been possible to answer the survey multiple times using different devices, the screening of duplicate ISP entries did not reveal any matching demographic data to suggest that any participants completed the survey more than once [61].