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http://informahealthcare.com/ptp
ISSN: 0959-3985 (print), 1532-5040 (electronic)
Physiother Theory Pract, Early Online: 1–9
! 2013 Informa Healthcare USA, Inc. DOI: 10.3109/09593985.2013.814185
REPORT
Applying self-determination theory for improved understanding
of physiotherapists’ rationale for using research in clinical practice:
a qualitative study in Sweden
Petra Dannapfel, MSc (PhD candidate), Anneli Peolsson, PT, Christian Sta ˚hl, MSc, Birgitta O¨berg, PT, and Per
Nilsen, MSc
Department of Medical and Health Sciences, Linko ¨ping University, Linko ¨ping, Sweden
Abstract
Physiotherapists are generally positive to evidence-based practice (EBP) and the use of research
in clinical practice, yet many still base clinical decisions on knowledge obtained during their
initial education and/or personal experience. Our aim was to explore motivations behind
physiotherapists’ use of research in clinical practice. Self-Determination Theory was applied to
identify the different types of motivation for use of research. This theory posits that all
behaviours lie along a continuum of relative autonomy, reflecting the extent to which a person
endorses their actions. Eleven focus group interviews were conducted, involving 45
physiotherapists in various settings in Sweden. Data were analysed using qualitative content
analysis and the findings compared with Self-Determination Theory using a deductive
approach. Motivations underlying physiotherapists use of research in clinical practice were
identified. Most physiotherapists expressed autonomous forms of motivation for research use,
but some exhibited more controlled motivation. Several implications about how more
evidence-based physiotherapy can be achieved are discussed, including the potential to tailor
educational programs on EBP to better account for differences in motivation among
participants, using autonomously motivated physiotherapists as change agents and creating
favourable conditions to encourage autonomous motivation by way of feelings of competence,
autonomy and a sense of relatedness.
Keywords
Physiotherapy, research use,
self-determination theory
History
Received 14 October 2012
Revised 5 April 2013
Accepted 15 April 2013
Published online 30 July 2013
Introduction
Physiotherapists generally hold favourable attitudes towards
evidence-based practice (EBP), which has been defined as ‘‘an
approach to health care wherein health professionals use the best
available evidence from systematic research, integrating it with
clinical expertise to make clinical decisions for individual
patients’’ (McKibbon, 1998). Numerous studies have demonstrated that physiotherapists believe it is important that practice is
based on the most up-to-date evidence available (Barnard and
Wiles, 2001; Grimmer-Somers et al, 2007; Heiwe et al, 2011; Iles
and Davidson, 2006; Kamwendo, 2002; Nilsaga ˚rd and Lohse,
2010; Stevenson, Phil, Lewis, and Hay, 2004). However, it has
also been shown that these attitudes are not fully reflected in
clinical practice, as many physiotherapists continue to base
practice decisions on knowledge obtained during their initial
education and/or personal experience, rather than findings from
research (Bridges, Bierema, and Valentine, 2007; Filbay, Hayes,
and Holland, 2012; Heiwe et al, 2011; Mikhail, Korner-Bitensky,
Rossignol, and Dumas, 2005; Overmeer, Linton, and Boersma,
2004). Hence, evidence-based physiotherapy may still be something of a misnomer.
The difficulty with converting favourable attitudes into
increased research use in physiotherapy practice has typically
been explained with reference to numerous barriers to EBP,
including time restrictions; limited access to research studies;
poor confidence in skills to identify and critically appraise
research; inadequate support from colleagues, managers and other
health professionals; as well as a paucity of research in some areas
of physiotherapy (Barnard and Wiles, 2001; Baxter, 2003; Fruth
et al, 2010; Grimmer-Somers et al, 2007; Hannes, Staes,
Goedhuys, and Aertgeerts, 2009; Herbert, Sherrington, Maher,
and Moseley, 2001; Iles and Davidson, 2006; Jette et al, 2003;
Kamwendo, 2002; Nilsaga ˚rd and Lohse, 2010; Palfreyman, Tod,
and Doyle, 2003; Stevenson, Phil, Lewis, and Hay, 2004).
The disparity between attitudes and practice could also be due
to social desirability bias, which may serve to produce more
positive accounts of EBP than is actually the case (Jette et al,
2003). In addition, relatively low response rates in many surveys
undertaken to measure attitudes to EBP imply that those
who answer are the ones most positive about EBP (Iles and
Davidson, 2006).
The move towards more evidence-based physiotherapy practice has become a ‘‘pressing issue’’ in physiotherapy (Iles and
Davidson, 2006), which is ‘‘driven by the profession’s collective
need to validate its position in health care’’ (Taylor and Copeland,
2006). However, individual clinicians may see it differently as
they struggle with expectations to keep abreast of rapidly
increasing amounts of research. Studies have documented reluctance to change well-established practices and scepticism towards
some elements of EBP among physiotherapists, including the
usefulness of randomized controlled trials to provide clinically
Address correspondence to Petra Dannapfel, Department of Medical and
Health Sciences, Linko ¨ping University, Linko ¨ping, Sweden. E-mail:
petra.dannapfel@liu.se
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Page 2
appropriate evidence and the low priority of qualitative research
in the evidence-based hierarchy of evidence (Abrandt Dahlgren,
2002; Bithell, 2000; Grimmer, Bialocerkowski, Kumar, and
Milanese, 2004; Grisogno, 2000; Jones et al, 2006; Wiart and
Burwash, 2007). Developing a more research-informed physiotherapy practice requires learning new skills to identify and
appraise research, reflect on its applicability and integrate it into
clinical practice; these activities are additional to the physiotherapists’ role in treating patients. It has been suggested that
experienced health care practitioners who learn how to apply EBP
must implicitly accept the role of student or novice, something
that many practitioners feel uncomfortable with (Quinn, 2000).
Thus, physiotherapists may lack conviction to use research to
inform their clinical practice despite being in favour of the key
principles of EBP.
Previous research has shown that physiotherapists generally
believe that EBP can improve the quality of patient care (Akinbo,
Odebiyi, Okunola, and Aderoba, 2009; Barnard and Wiles, 2001;
Heiwe et al, 2011; Jette et al, 2003; Nilsaga ˚rd and Lohse, 2010;
Salbach et al, 2007); is helpful for making decisions about patient
care (Akinbo, Odebiyi, Okunola, and Aderoba, 2009; Heiwe et al,
2011; Jette et al, 2003; Salbach et al, 2007); and can enhance the
status of the physiotherapy profession (Barnard and Wiles, 2001;
Hannes, Staes, Goedhuys, and Aertgeerts, 2009). Physiotherapists
have also expressed that their reimbursement rate can increase
with incorporation of EBP into their clinical practice (Akinbo,
Odebiyi, Okunola, and Aderoba, 2009; Heiwe et al, 2011; Jette
et al, 2003) and that EBP can yield improved relationships with
other health professions as well as better working conditions
(Barnard and Wiles, 2001). However, the reasons for research use
or commitment to EBP have not been the primary focus of interest
in these studies. Hence, we currently lack insight into the various
reasons behind physiotherapists’ integration of research findings
into their practice.
Based on focus group interviews with physiotherapists
in Sweden, the aim of this study was to explore the motivation
behind physiotherapists’ use of research in their clinical practice.
Motivation, energizing mechanisms that activate behaviour
and give it direction (Kleinginna and Kleinginna, 1981), is the
most proximate determinant of behavioural enactment in many
social-cognitive theories (Conner and Norman, 2005), suggesting
that it can better predict behaviour than attitudes. We applied
the Self-Determination Theory to identify and distinguish
between different types of motivation for the use of research
in clinical practice. This theory posits that all behaviours lie
along a continuum of relative autonomy, reflecting the extent to
which a person endorses what he or she is doing (Deci and Ryan,
1985). While research use is a more narrow concept than
evidence-based practice, knowledge about different reasons for
using research is important for designing and implementing
interventions aimed at attaining a more evidence-based physiotherapy practice.
Theoretical framework
Self-Determination Theory is a theory of motivation that posits
that all behaviours (such as use of research) lie along a continuum
of relative autonomy (i.e. self-determination), reflecting the
extent to which a person endorses what he or she is doing. The
theory was initially developed by Deci and Ryan (1985) and has
been elaborated and refined by other researchers over the years.
The theory has been applied to various health-related behaviours
(e.g. glycaemic control, diabetes, exercise, weight loss and
smoking cessation) and clinical behaviours of health care
practitioners (e.g. counselling on smoking by physicians)
(Norman and Conner, 2005).
At one end of the self-determination continuum is behaviour
that is intrinsically motivated and performed for its inherent
satisfaction (e.g. for the fun, interest or challenge it offers). At the
other end is amotivation, which refers to a lack of intention to
perform the behaviour. In between intrinsically motivated behaviours and amotivation lie behaviours that are characterized as
extrinsic, meaning that they are performed to obtain certain
outcomes in contrast to intrinsic behaviours, which are performed
for their own sake. Four types of extrinsically motivated
behaviours are distinguished in Self-Determination Theory,
defined in terms of the degree to which the regulation of an
extrinsically motivated activity has been internalized: (1) integrated (behaviours consistent with a person’s values and needs,
performed because they represent what the person stands for);
(2) identified (behaviours experienced as beneficial to a person’s
development, but not necessarily performed with enjoyment);
(3) introjected (behaviours performed to avoid negative feelings
such as guilt or shame); and (4) externally regulated (behaviours
performed to satisfy an external demand or reward contingency)
(Ryan and Deci, 2000).
Introjected and external regulations are referred to as
controlled motivation, whereas intrinsic, integrated and identified
types of motivation are labelled autonomous motivation.
A considerable body of research exists that shows that more
autonomously motivated behaviours are more stable, performed
with greater care and quality and accompanied by more positive
experiences (Ryan and Deci, 2000).
Methods
Study setting
Swedish health care is publicly funded (i.e. residents are insured
by the state, with equal access for the entire population and fees
regulated by law). The provision of health care services in Sweden
is primarily the responsibility of the 21 county councils throughout Sweden (National Board of Health and Welfare, 2010).
There are approximately 21000 registered physiotherapists in
Sweden (National Board of Health and Welfare, 2010). They are
employed by county councils (public sector) or they are selfemployed as entrepreneurs (private sector). Physiotherapists in
Sweden have a great deal of professional autonomy and authority
to act independently. They are entitled to choose and use any
assessment and physiotherapy treatment technique authorized by
the National Board of Health and Welfare that they find suitable
for the individual patient. Patients do not need a referral from a
physician or another health care provider to consult a physiotherapist. The patient can choose a physiotherapist both from the
private and public sectors; the charge is usually the same, albeit
depending on whether the self-employed entrepreneurs are
contracted to a county council or not. The study was approved
by the ethical committee of Linko ¨ping University.
Study design and participants
A qualitative method with focus group interviews was used. The
purpose of focus groups is to examine how opinions, attitudes and
ideas on a certain subject are expressed in a group. The group
dynamic of focus groups can be used to facilitate the participants’
discussion and reflection, thus generating deeper insights. By
building on one another’s responses, participants can come up
with ideas or perspectives they might not have thought of in an
individual interview (Barbour and Kitzinger, 2001).
Data were collected by means of 11 focus group interviews
involving 45 physiotherapists from 5 county councils in Sweden
from March to June 2011. Focus group participants were recruited
through managers and other key persons in different clinical
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settings in Sweden via an e-mail that briefly described the study.
The request was sent to a number of hospitals, primary care
centres and private physiotherapy clinics. All who answered
positively were asked to invite physiotherapists in their department to participate in the study. They were encouraged to invite
whole teams of physiotherapists to avoid bias due to selection of
specific physiotherapists who might be particularly enthusiastic
about research. Each focus group consisted of physiotherapists
from the same workplace, but they did not necessarily work as
part of the same team although they shared the same management.
Seven of the 11 groups of physiotherapists worked in a rural
setting and four in urban settings. Six of the groups consisted of
physiotherapists working in hospital settings, three groups worked
in primary care settings and two groups were self-employed.
A heterogeneous sample of the physiotherapist groups was
sought by means of a purposeful selection approach (Patton,
2002). Variety was achieved using a strategic sample with regard
to four aspects: (1) clinical context; (2) geographic location of the
physiotherapists; (3) the number of years in practice; and
(4) educational level. The objective was to recruit physiotherapists
that represented a broad spectrum of experiences, thus enhancing
the validity of the study.
Thirty-three of the 45 physiotherapists were female. The mean
age was 41 years (range 22–62 years; standard deviation (SD)
11.5) and their average length of work practice was 13 years
(range 1–37 years; SD 9.2). The participants had an average of
3 years of basic education (range 2–5 years; SD 0.5) and two had
a master’s degree. All had participated in courses beyond their
basic training; 82% had participated in non-academic courses and
64% had participated in academic courses. Thirty-six physiotherapists worked full-time, while nine were employed part-time.
Data collection
The study applied an inductive approach, using an interview guide
consisting of open-ended questions. The guide was developed by
the authors of the study and was scrutinized in a seminar with
10 physiotherapists most of whom combined research with
physiotherapy practice. The seminar aimed to trial the interview
guide; no major revisions in the interview guide were made
afterwards. In addition, a pilot focus group comprised of four
physiotherapists who participated in the seminar was conducted
before carrying out the interviews; this pilot focus group interview
was not included in the study.
Each interview started with an open question asking the
physiotherapists to describe their work. The interview was then
based on two overarching questions: (1) ‘‘Registered physiotherapists are supposed to work in accordance with ‘scientific
evidence and trusted experience’ – how is this expressed in
your daily practice?’’ and (2) ‘‘What are your reasons for using
research in your clinical practice?’’ We considered research use in
a broad sense, encompassing both direct (instrumental) use in
terms of changing clinical practice based on research findings and
indirect (conceptual) use, meaning that research influenced
physiotherapists’ thinking (understanding, knowledge and attitudes) concerning clinical practice issues (Estabrooks, 1999).
The focus group interviews were conducted during regular
working hours to facilitate participation. Each focus group
interview lasted between 90 and 110 minutes. Before the
interview, the participants filled in a questionnaire with background questions concerning their sex, age, years of education,
years since education, years working as a physiotherapist and the
extent to which they had participated in continuing professional
education.
Informed consent was obtained by information to the participants that participation was confidential and voluntary, and that
they could withdraw at any time during the interview.
Two researchers attended all focus groups except for one interview.
The first author of this study acted as moderator, leading
the interviews and asking follow-up questions. The second
researcher took field notes and made observations. In the interview
performed by the first author alone, she both acted as moderator
and took field notes. In general, discussions in the groups were
fluent and little steering from the moderator was needed.
The groups and participants differed concerning their interest in
research and perceived skills to critically appraise research results.
Data analysis
Interviews were recorded with a dictaphone and transcribed
verbatim by the first author. The first author and the last author
translated the quotes from Swedish to English. The data were
analysed as a whole using qualitative content analysis, a technique
for analysis of texts grounded in empirical data with an
explorative and descriptive character (Krippendorff, 2004). As a
first step, all authors read all transcripts to obtain an understanding of the whole. The transcripts were then coded by the first
author using conventional content analysis, which entails a
structured analysis process to code and categorize the data
(Hsieh and Shannon, 2005).
The next step in the process was to highlight words in the text
that captured various key statements and thoughts in relation to
the study aim (Hsieh and Shannon, 2005). The researchers
approached the text several times. During this process, codes that
reflected more than one key statement or thought developed; the
codes were then aggregated into clusters based on similarity of the
content and their relation to each other (Hsieh and Shannon,
2005). After re-examination, the initial clusters were merged into
categories.
The categories were given labels that provided an overall
description of their content (Hsieh and Shannon, 2005). The
categories were cross-examined to ascertain that they were
defined in such a way that they were internally as homogeneous
as possible and externally as heterogeneous as possible
(Krippendorff, 2004). All authors discussed the contents of the
categories using triangulating analysis (i.e. the authors independently analysed the same data and compared their findings).
In the next step, the findings concerning the contents of the
categories were compared and contrasted with the SelfDetermination Theory using a deductive approach. The categories
were then mapped onto the different types of motivation specified
in the theory, as described in the next section. Discussion about
this mapping process continued until no inconsistencies existed
and a shared understanding was reached to prevent researcher bias
and strengthen the internal validity (Patton, 2002). Representative
quotations were identified to report the findings. Quotations were
then translated from Swedish to English. We selected two or three
quotations for most types of motivation.
Results
We identified 10 different categories concerning reasons for
research use by the physiotherapists, which could be mapped onto
the six forms of motivation described in the Self-Determination
Theory (Table 1). Some physiotherapists provided statements that
showed that their research use was intrinsically motivated, driven
by a genuine curiosity and willingness to learn. They described
using research in their clinical practice for its own sake because
they felt it was interesting and satisfying in itself, as opposed to
using research to obtain external goals. They were ‘‘pretty
hungry’’ and had a ‘‘huge interest’’ in research, which they
considered to be ‘‘fun’’. For them, research use was an
opportunity rather than an obligation.
DOI: 10.3109/09593985.2013.814185
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Table 1. Different types of motivation underlying research use categorized according to the Self-Determination
Theory (SDT).
Type of motivation
according to
Self-Determination
Theory
Explanation of the type of motivation with regard to research use
Categories identified in the data:
rationale for research use in
clinical practiceQuotations
Intrinsic
motivation
Research use is perceived to be
interesting and satisfying in
itself
Research use is driven by a genuine curiosity and willingness to
learn
‘‘We are pretty hungry. I feel that I know quite a
lot, but I want to learn a lot more. The only
question is where to begin’’.
‘‘You really have to use all your spare time and
evenings. There is no money or rewards
involved, I do it because it’s so fun’’.
‘‘Some of us take a huge interest in this’’.
Research use enables provision of
best possible care for the patient
‘‘We cannot continue to treat patients with
ineffective methods’’.
‘‘We want to treat our patients in the same way.
They should get the same tests and treatment
regardless of whether they consult with me or
anyone else. It [using research] is a kind of
quality assurance’’.
’’We want to know more to be able to do a good
job for the patient. We look for knowledge’’.
Integrated Research use is important as it is
perceived to be congruent with
one’s other values and needs
Research use enables personal and
professional development
‘‘It’s important to keep track of the developments. You can’t stand still. But it would also
be very boring otherwise [if we did not keep
track]’’.
‘‘I think it’s in everyone’s interest that we work
on the basis of evidence. We do that in our
team. But it’s up to me; it’s my interest that is
the motivator’’.
Research use enables enhanced
confidence in the professional
role
‘‘A lot of what we do is described in new
research. It’s not always new [knowledge]
compared to how we work’’.
‘‘Research often seems to confirm that what
we’re doing is right’’.
‘‘It has been shown that the [treatment approach]
was no good. It’s clear that activity is better
for your back than to lie down. You might
think that this is common sense. That’s why
it’s good to reconsider what you do all the
time, how you look at things’’.
Research use facilitates improved
status for physiotherapists
‘‘It’s very important to show that we’re needed.
It’s up to us to demonstrate that what we do is
valuable, to show that we’re needed’’.
‘‘I think it is necessary that we develop the status
of our profession and its legitimacy through
research and that people conduct research and
do dissertations and such, because there is so
much more competition. We must be able to
stand our ground’’.
’’It’s important that we do research here, do our
own studies, to strengthen the profession and
to defend what we practice’’.
Identified Research use is perceived to be
beneficial to achieve personally
valued goals
Research use facilitates career
advancement
‘‘It [using research] is part of the requirements
when you’re recruited. It has become a
requirement. You don’t apply for a job unless
you are interested in using research to guide
your practice’’.
‘‘Several of us participate in the physiotherapist
[educational] program, giving lectures and
training the students in more hands-on skills.
We have also been involved in the examination of students and discussed how the
students should be appraised’’.
‘‘I am involved in a research project conducted at
the department of physiotherapy at the university, where they are performing an international neck study. I’m working for six
weeks with patients who have had neck
surgery’’.
(continued)
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Other physiotherapists depicted their use of research in terms
that suggested that it was regulated by integration, meaning that
they perceived research use as important because it was connected
to other important values and needs. Physiotherapists believed
that research use ensured that patients received the best possible
care. They said that they wanted ‘‘to do a good job for the
patient’’ and ‘‘to treat all [their] patients the same way’’, arguing
that research use provided ‘‘a kind of quality assurance’’.
Research use facilitated their personal growth and professional
development. They believed it was everyone’s responsibility to
‘‘keep track of the developments’’ in the field. Furthermore,
research use contributed to an improved confidence in their
professional role because research often seemed to confirm that
what they were doing was correct and that their practice was in
line with current research findings.
For some physiotherapists, the use of research in their clinical
practice was based on identified motivation. They identified the
personal value of research use and considered it to be beneficial to
achieve desired goals. They expressed a belief that research use
could facilitate improved status of the physiotherapy profession,
arguing that they had to ‘‘be able to stand [their] ground’’,
‘‘defend what [they] practice’’ and ‘‘demonstrate that [they are]
needed’’. The physiotherapists also recognized that research use
was helpful for their own career and development. They talked
about the necessity of being familiar with research when applying
for new jobs and engaging in education and research projects to
Table 1. Continued
Type of motivation
according to
Self-Determination
Theory
Explanation of the type of motivation with regard to research use
Categories identified in the data:
rationale for research use in
clinical practiceQuotations
Research use facilitates collaboration with other health
professionals
‘‘You have to constantly change since research in
surgery does. They can use different materials. We think in different ways, but we have
to keep pace with the changes in surgery’’.
‘‘Implementing something new, as suggested by
physiotherapists, depends on how complicated
it is to implement it and if they [physicians]
believe it’s a good thing. You have to have
them ‘on board’, on your side’’.
‘‘We need to have the rheumatologists with us
and you need nurses in the clinic, too.
Otherwise treatment will only be about
medication despite evidence from physiotherapy and such’’.
Introjected Research use is associated with a
feeling of pressure and is performed to avoid negative
feelings
Research is expected by patients’’Patients are becoming more informed. When a
patient says, ‘I’ve read about this’, you want to
be able to respond. You need knowledge from
research to be able to reply to all the questions
and opinions’’.
‘‘People more and more questionwhat we do and
they ask many questions’’.
‘‘I had a patient who suffered from a rare
disease. A lot of reading and learning is
necessary to understand the disease and the
prognosis. We had a lot of questions and so
did he [the patient]’’.
Externally
regulated
Research use is associated with an
external demand or externally
imposed reward contingency
Research use is requested by
leaders and authorities
‘‘Research takes time and that’s a disadvantage. I
always feel ‘directed’ because I wouldn’t do
the same [as described in research] if the
patient came to me. But it’s like, ‘OK, I have
to do these exercises and we have to talk about
this and do that’’’.
‘‘Our immediate manager is a paramedic, then
there is the manager of the clinic and there are
also other people who put pressure on us [to
use research results]’’.
‘‘The county council requires evidence for what
we’re doing, that applies not only to our clinic
but to all health care provided in the whole
county council. You need to have proof for
what you’re doing so that it’s not just
humbug’’.
Amotivation There is a lack of intention to
engage in research use
Research use is not a valued
activity
‘‘I think it’s very nice that there are people who
think we should look for new research and
such. But all of us aren’t interested. I think it’s
plain boring to read research, if I may say so.
Even if we would have three hours set aside
every week to read research, not everyone
would do it. Because some are like me and
think it’s boring’’.
DOI: 10.3109/09593985.2013.814185
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advance their career. Research use further served the function of
facilitating collaboration with other health professionals, allowing
the physiotherapists to have more leverage in discussions and
decisions regarding treatment of some patients. Working with
other health professionals required the physiotherapists to keep up
with advances in other fields such as surgery.
Research use was characterized by introjected regulation for
other physiotherapists. They used research because they felt it was
expected by patients. These physiotherapists had partially taken in
the behaviour and imposed pressure on themselves to use
research, partially to avoid negative feelings such as inadequacy
or worry. Patient expectations were expressed with statements
about the necessity of being ‘‘able to answer questions and
respond to [patient] opinions’’, which is needed because patients
are ‘‘becoming more informed’’ and tend to ‘‘question what
[they] do’’ and ‘‘ask many questions’’.
There were also physiotherapists who used research in their
clinical practice somewhat reluctantly because they felt it was
required or even demanded by leaders and authorities, which
meant that research use for them was externally regulated. They
felt they were under pressure to validate their work by using
research, but they did so primarily to satisfy external demands
from ‘‘above’’ (i.e. managers, county councils and health
authorities).
Amotivation in relation to regulations was expressed by one
physiotherapist. This person did not believe that the effort of
keeping up to date with research would yield a desired outcome.
The person was simply uninterested, considering research to be
‘‘boring’’.
Discussion
We identified six different types of motivation, according to the
Self-Determination Theory. The results suggest that physiotherapists differ with regard to their rationale for using research. This
key finding provides some insight into why some physiotherapists
are reluctant to use research and continue to use assessment and
treatment techniques with limited or no evidence of effectiveness,
alongside approaches with strong or moderate evidence of
effectiveness (Bridges, Bierema, and Valentine, 2007; Filbay,
Hayes, and Holland, 2012; Heiwe et al, 2011; Mikhail, KornerBitensky, Rossignol, and Dumas, 2005; Overmeer, Linton, and
Boersma, 2004).
Some physiotherapists exhibited more controlled forms
of motivation to use research, providing statements that suggested
that they sometimes used research because they felt it
was expectedby patients (introjected
requested by leaders and authorities (externally regulated motivation). Controlled motivation is likely associated with a certain
resistanceto engageinEBP-related
searching the scientific literature, appraising research studies
and assessing the strength of evidence, resulting in a clinical
practice that is experience-based rather than evidence-based.
Numerous previous studies have documented poor confidence in
skills to identify and critically appraise research among physiotherapists (Barnard and Wiles, 2001; Dannapfel, Peolsson, and
Nilsen, 2013; Fruth et al, 2010; Grimmer-Somers et al, 2007;
Hannes, Staes, Goedhuys, and Aertgeerts, 2009; Iles and
Davidson, 2006; Jette et al, 2003; Kamwendo, 2002; Nilsaga ˚rd
and Lohse, 2010; Palfreyman, Tod, and Doyle, 2003; Stevenson,
Phil, Lewis, and Hay, 2004).
Despite the existence of controlled motivation for research use,
we found that autonomous forms of motivation were most
common, with seven themes relating to intrinsic, integrated and
identifiedtypesof motivation
Physiotherapists in Sweden have a great deal of professional
motivation)and/or
activities suchas
for the use of research.
independence, which creates favourable conditions for more
autonomous motivation to use research findings in clinical
practice. In contrast, Hannes, Staes, Goedhuys, and Aertgeerts
(2009) describe how the limited autonomy of physiotherapists in
Belgium inhibits autonomous motivation to use research,
concluding that ‘‘intrinsic motivation to update knowledge is
low to absent’’ among physiotherapists. Patients in countries like
Sweden, the United Kingdom, the Netherlands, Canada, Australia,
New Zealand and many states in the United States do not need
referrals from physicians to see physiotherapists, whereas physiotherapists in Belgium are bound to prescriptions from physicians
(Hannes, Staes, Goedhuys, and Aertgeerts, 2009).
Several of the reasons for research use we identified are
consistent with those mentioned in previous research, including
using research and/or committing to EBP to: achieve improved
quality of patient care (Akinbo, Odebiyi, Okunola, and Aderoba,
2009; Barnard and Wiles, 2001; Heiwe et al, 2011; Jette et al,
2003; Nilsaga ˚rd and Lohse, 2010; Salbach et al, 2007); make
better decisions about patient care (Akinbo, Odebiyi, Okunola,
and Aderoba, 2009; Heiwe et al, 2011; Jette et al, 2003; Salbach
et al, 2007); and achieve improved status for the physiotherapy
profession (Barnard and Wiles, 2001; Hannes, Staes, Goedhuys,
and Aertgeerts, 2009). A study by Barnard and Wiles (2001) also
observed that physiotherapists believed that EBP can yield
improved relationships with other health professions, which is
also in line with our finding that research use can facilitate
collaboration withotherhealth
reimbursement rate has also been mentioned as a rationale for
research use (Akinbo, Odebiyi, Okunola, and Aderoba, 2009;
Heiwe et al, 2011; Jette et al, 2003). However, no physiotherapist
in our study brought up this particular type of externally regulated
motivation for research use, although career development and
improved status for the physiotherapy profession were mentioned
and might be seen as serving similar purposes in a longer-term
perspective.
Our study also revealed motivations for research use that have
not been addressed in previous research (i.e. intrinsic motivation
that comes from the sense of satisfaction one gets from using
research for its own sake, integrated motivation associated with
the use of research for personal and professional development,
andforenhancedconfidence
Autonomous forms of motivation for research use may be
considered a bottom-up approach to attaining a more evidencebased physiotherapy. The research–practice relationship is typically described in top-down ‘‘producer-push’’ terms, with a flow of
knowledge from the research community into the practice arena
and with authorities promoting the use of this research.
In contrast, ‘‘user-pull’’ conceptualizations view research use as
a process driven by health care professionals’ own motivation to
learn and develop (Nutley, Walter, and Davies, 2007). More
traditional top-down initiatives are more likely to yield more
externally regulated motivation, as shown in the responses from
physiotherapists who associated research use with external
demands from leaders and authorities. EBP in physiotherapy in
Sweden is actively promoted by the county councils and the
Swedish Association of Registered Physiotherapists (a professional body and a trade union). The socialization of physiotherapists into learning EBP skills (including finding and reading
research studies, critically appraising evidence and integrating
new findings into clinical practice) as part of their education may
also be viewed as a top-down approach to achieving a more
evidence-based physiotherapy practice, underscoring the importance of providing a clear rationale for the use of research.
Critics of the evidence-based movement have complained that
there is insufficient empirical evidence of the effectiveness
of implementing a more evidence-based health care practice
professionals.Increased
intheprofessionalrole).
6P. Dannapfel et al.
Physiother Theory Pract, Early Online: 1–9
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Page 7
(Trinder, 2000). However, a few physiotherapy studies (Fritz,
Cleland, and Brennan, 2007; Rutten et al, 2010) have shown that
the use of clinical guidelines can yield better treatment outcomes
although there is still relatively limited research concerning the
links between EBP and patient outcomes. Ultimately, widespread
implementation of EBP in physiotherapy requires that top-down
advocacy is complemented with bottom-up initiatives and actions
derived from physiotherapists’ autonomous motivation to use
research in their everyday clinical practice.
Overall, this study identified more autonomous forms of
motivation for research use than have been described in previous
research. One reason for this might be the time factor, as the
earliest research on EBP in physiotherapy dates to the late 1990s.
Although the need for a more research-informed physiotherapy
practice was recognized decades ago, the issue did not receive
high visibility until the emergence of the EBP movement in the
1990s. Since the late 1990s, professional physiotherapy organizationshave increasinglyidentified
(Ada, Butler, Scianni, and Texeira-Salmela, 2009; GrimmerSomers, 2007; Herbert, Sherrington, Maher, and Moseley, 2001;
Morris, 2003; Sherrington, Moseley, Herbert, and Maher, 2001;
Sundelin, 2010; Turner, 2001). Hence, EBP is considerably more
established today than when the early studies on EBP barriers and
facilitators in physiotherapy were conducted, contributing to a
progression towards more autonomous motivation for research
use among most physiotherapists. The EBP-related content of
physiotherapists’ basic and continuing education has increased
considerably over time (Hurst, 2010).
The study results point to several interesting implications on
how more evidence-based physiotherapy can be achieved. The
Self-DeterminationTheory incorporates
Cognitive Evaluation Theory, which outlines factors that may
hinder or facilitate different types of motivation, and may form
the basis of interventions to encourage more autonomous
motivation. This theory posits that more autonomous forms of
motivation can be fostered by feelings of competence, autonomy
and a sense of relatedness (Deci and Ryan, 1985; Ryan and Deci,
2000). Research has provided strong evidence for links between
autonomous motivation and the satisfaction of the need for
competence and autonomy and, to a lesser extent, for relatedness
(Norman and Conner, 2005).
The first condition, competence, is facilitated when individuals
are supported to develop clear and realistic expectations about
what the behaviour (i.e. using research in clinical practice) could
do for them, helped to formulate realistically achievable goals,
encouraged to believe that they are capable of engaging in the
appropriate behaviours and provided with positive feedback
regarding progress (Ryan and Deci, 2000). It would be feasible
to incorporate these aspects into physiotherapists’ basic and
continuing education to foster feelings of competence. Autonomy
support, the second condition, is associated with developing
a personally meaningful rationale for engaging in a behaviour,
providing opportunities for participation and acknowledging
negative feelings associated with engaging in difficult tasks
(Ryan and Deci, 2000). These aspects must be recognized in
education on EBP because seeking out, appraising and applying
research findings in busy practice settings present considerable
challenges for many health care professionals. Meanwhile, a
sense of relatedness, the third condition, is concerned with the
extent to which individuals perceive that significant others are
genuinely interested in them and their well-being, understand the
difficulties they are facing and can be trusted to provide
psychological and emotional resources that can be drawn on for
support (Ryan and Deci, 2000). These aspects underscore the
importance of the context in which research is used. A previous
study by Dannapfel, Peolsson, and Nilsen (2013) highlighted the
EBPasa priority
a sub-theory,the
importance of colleagues, leaders and organizational culture as
well as social and professional networks to support physiotherapists’ research use. Active management support and engagement
is important to create legitimacy for implementation to achieve
practice changes because clinicians cannot change clinical
practice alone, without supportive conditions (Eldridge and
Soutch, 1998; Kerssens-Van Drongelen, De Weerd-Nederhof,
and Fisscher, 1996).
The fact that physiotherapists had different motivations for
using research and committing to EBP implies that it may be
advantageous to tailor education in EBP-related issues to different
types of motivation. Tailoring intervention content to clients’
readiness to change is a key principle of counselling based on the
Stages of Change Model, which describes individuals’ progression through different stages (pre-contemplation, contemplation,
preparation, action and maintenance) to achieve successful
behaviour change (Prochaska, DiClemente, and Norcross, 1992).
However, it is important to emphasize that education does not
constitute a magic bullet to achieve a more evidence-based health
care practice. In general, the effects of most educational programs
to change clinical behaviour tend to be small, but there are
indications that education that is interactive and personal (e.g.
small-scale meetings and outreach visits) is more effective than
passive education (e.g. written material and large-scale meetings)
(Wensing and Grol, 2005).
Physiotherapists who exhibit more autonomous motivation
could potentially function as change agents for a more evidencebased physiotherapy practice. Individuals learn in many ways
other than by formal education and the importance of peer
learning in physiotherapy has been highlighted in previous
research (Grimmer-Somers et al, 2007). The lack of peer support
and perceived isolation from colleagues have been noted as
obstacles to the use of research (Grimmer-Somers et al, 2007;
Nilsaga ˚rd and Lohse, 2010; Salbach et al, 2007). The use of social
influence offers a promising approach to modifying clinical
behaviours and achieving a more research-informed practice
(Nutley, Walter, and Davies, 2007).
This study has some shortcomings that must be considered
when interpreting the findings. The study was set in Sweden and
the transferability of the findings beyond the context of the
Swedish health care system might be limited. Swedish physiotherapists are highly autonomous, as previously described.
The focus groups may not have been fully representative of
different types of physiotherapists in Sweden despite the fact that
a heterogeneous purposeful sample was sought. It may be
considered a strength of the study that there was considerable
intrapersonal coherence concerning what types of motivation the
participants expressed. No physiotherapist provided statements
that belonged to more than two adjacent types of motivation
(e.g. integrated and identified) on the self-determination continuum and no one expressed both autonomous (intrinsic,
integrated and identified) and controlled (introjected and external
regulation) motivations.
In conclusion, we identified a broad range of motivations
underlying physiotherapists’ use of research in their clinical
practice. Most physiotherapists expressed autonomous forms of
motivation for research use, but there were also physiotherapists
who exhibited controlled motivation or completely lacked interest
in research. The study points to several implications with regard
to how more evidence-based physiotherapy can be achieved,
including the tailoring of educational programs on EBP to account
for differences in motivation among the participants, using
autonomously motivated physiotherapists as change agents and
creating favourable conditions that encourage autonomous motivation by way of feelings of competence, autonomy and a sense of
relatedness.
DOI: 10.3109/09593985.2013.814185
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Page 8
Declaration of interest
The author(s) declare no potential conflicts of interest with respect
to the research, authorship and/or publication of this article.
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