This study has revealed some important insights into Australian osteopaths’ attitudes, skills and utilisation of evidence-based practice, as well as the barriers and enablers of EBP uptake among this professional group. Australian osteopaths were generally supportive of EBP, but largely reported low levels of EBP uptake in clinical practice. Further, despite most respondents completing some form of EBP-related training, perceived EBP skill levels were generally modest. Understanding the implications of these and other identified barriers and enablers of evidence-based practice uptake is a logical next step of this research, and consequently, is the focus of this discussion.
Encouragingly, respondents reported positive attitudes to the role of EBP in osteopathic practice. They also reported moderate-to-high levels of self-perceived skill in the identification of clinical questions and knowledge gaps in practice, as well as appraising and applying evidence from research to their clinical practice. These findings were similar to the perceived EBP skill level reported by UK osteopaths . Interestingly, respondents in the current study judged their skills in the relatively high-level tasks of ‘critical appraisal’ and ‘evidence synthesis’ to be of similar level as the more fundamental skill of ‘using findings from systematic reviews’. Notwithstanding, it should be emphasised that these surveys reported self-perceived skill in EBP and did not measure the actual skill level of respondents. It is possible that respondents who lack comprehensive knowledge of EBP could have over-estimated their skill level .
The lowest perceived skill levels relating to EBP were reported for the conduct of clinical research and/or systematic reviews. Given that this survey was distributed to practicing osteopaths, most without academic or research affiliations, it should be expected that they use research findings rather than produce them. Again, our findings are similar to recent studies, where Malaysian physiotherapists , US chiropractors  and UK osteopaths  were found to be confident in information appraisal, but lacked research skills. The small percentage of osteopaths reporting high-level skill in conducting clinical research or systematic reviews was also similar to previous studies of US and Canadian chiropractors where less than 5 % of respondents reported a high level of skill in these areas [31, 32]. Although allied health professionals should not necessarily be responsible for conducting research or literature reviews , we would expect that osteopaths should be able to search for and apply findings from systematic reviews and evidence-based guidelines to their daily practice. This ability is unlikely to represent a major barrier to EBP uptake amongst Australian osteopaths, with respondents reporting moderate to moderate-high level skills in these areas.
Use of EBP
Despite the favourable view of EBP and moderately-high level of perceived skills in EBP, the majority of respondents reported low levels of engagement in evidence-based practice activities (i.e. they participated in these activities no more than five times in the previous month). Surprisingly, over a quarter of respondents reported that they never used an online database to search for practice-related literature or used this literature to change clinical practice over the last month. Similarly, about 20% of respondents reported that they never read or reviewed clinical research findings related to practice in the previous month. Instead, only around 15 % of respondents regularly reviewed clinical research findings, searched online databases or used professional literature to assist in daily clinical decision-making. Adding to this, nearly 60% of respondents reported very small/small proportions of their clinical practice to be based on EBP.
Most respondents relied upon traditional knowledge, clinical practice guidelines and fellow professionals to inform their clinical decision making. What is not clear is whether this dependency on traditional knowledge in Australian osteopathic practice is largely a ‘capacity’ issue (i.e. insufficient scientific evidence in the field, lack of time or sufficient skill to engage in EBP), a more entrenched ‘cultural’ issue (i.e. widespread disinterest in research, perception that the effectiveness of osteopathy is not amenable to scientific testing), or a product of both of these factors, or something entirely different . Regardless of the reason, keeping up-to-date with current research, not in place of but as a complement to other relevant strategies, must be considered an important aspect of clinical practice in contemporary osteopathy. Thus, strategies and initiatives to increase EBP engagement in osteopathy practice may be important topics for future research.
Although the findings of the current study, and those of our recent UK study  indicate that Australian and UK osteopaths engage in EBP activities to a similar extent, the level of engagement in EBP appears to be somewhat lower than other manual therapy professions. In analogous studies involving chiropractors in the US  and Canada  (both of which used EBASE), approximately one-third of chiropractors reported reviewing professional literature / clinical research findings related to their practice, and using online search engines to search for practice-related literature, more than 11 times in the previous month . By contrast, less than one-fifth of Australian and UK osteopaths engaged in the same activities to the same extent .
A possible explanation for the relatively low frequency of EBP activity among Australian and UK osteopaths may relate to the presentation of patients with a consistent range of symptoms and disorders that do not require frequent searching of evidence. However, if that were the case, one might expect chiropractors, and possibly physical therapists, to see a similar patient population. Yet, both chiropractors [31, 32] and physical therapists  report relatively higher levels of engagement in EBP activities. In one study of US physical therapists, 66% of respondents reported consulting research material and 52% having used a medical database, four to ten times weekly to make clinical practice decisions . While a heterogeneous patient population might represent a probable reason for the differences in EBP utilisation between osteopaths and other manual therapists, other factors are equally possible, including differences in the level of research/EBP training, culture and opportunities for engagement .
Barriers to EBP uptake
Given the positive attitude to evidence-based practice, but the low level of EBP utilisation among respondents, an examination of the barriers to EBP uptake should be revealing. However, participants perceived 11 of the 13 listed barriers to EBP as being only a minor barrier or not a barrier to EBP at all. The only factors identified as moderate or major barriers to EBP uptake were lack of clinical evidence in osteopathy and lack of time.
It is true that there is a lack of osteopathy-specific clinical research for both common and uncommon conditions treated by osteopaths; and while clinical evidence for osteopathic manipulative therapy is now emerging, methodological rigour is often lacking . However, there is still much research in related disciplinary areas (e.g. physiotherapy, occupational therapy, chiropractic) that may be used to inform osteopathy practice [47, 48]. Thus, it is possible that the perceived ‘lack of clinical evidence’ was identified as a barrier to EBP uptake due to a poor understanding of the nature and activities of EBP. This level of understanding may stem from insufficient training in EBP, with the majority of respondents reporting some training in evidence-based practice, which was typically undertaken as a minor component of a professional study program. Although there have been calls to improve the development of EBP skills in osteopathy programs , it is likely the training offered over the last two decades has been variable and inadequate - particularly programs delivered more than 10 years ago.
Lack of time is not only a major barrier to EBP uptake reported by osteopaths , but also by nurses [50, 51], physiotherapists [44, 52, 53], chiropractors [31, 32, 54, 55] and other clinicians [56, 57]. However, some academics have argued that time is merely an excuse for not changing practice, and that clinicians playing the ‘lack of time card’ simply do not value EBP . The same academics argue that these clinicians instead need some buy-in . Indeed, studies of practicing chiropractors in the US, Canada, Australia and the UK indicate that lack of incentive is a notable barrier to EBP uptake [31, 32, 54, 55]. What is not clear at this point in time however, is whether incentivisation effectively improves EBP uptake, which of course should be a focus of further enquiry.
Enablers of EBP uptake
Australian osteopaths agreed that research findings are useful for practice, and that EBP assists in clinical decision making and is necessary in the practice of osteopathy. The majority of respondents also identified themselves as having a moderate or moderate-high level of EBP skills. Despite this, the reported frequency of EBP activity was low. In the absence of many identified barriers to EBP beyond relevant evidence and time constraints, the perceived enablers of EBP may provide useful insights on how to promote greater uptake of EBP in osteopathy.
Two factors perceived by respondents as being particularly helpful in enabling EBP uptake in osteopathy practice were accessibility of evidence (i.e. access to the internet, databases and full-text articles in the workplace) and access to EBP training (particularly online EBP education materials). These enabling strategies were consistent with those reported by UK osteopaths  and Canadian chiropractors . However, internet connectivity in the workplace is now largely ubiquitous, and primary online medical databases, such as PubMed, PEDro and The Cochrane Library, are free to access (at least in Australia) and include many open access full-text articles. Further, 90% of registered Australian osteopaths are members of the main osteopathic professional body , which provides members with access to full-text articles through various databases and journals. It is therefore unlikely that further efforts to expand clinician access to online resources would greatly enhance EBP uptake. Instead, the Australian osteopathy profession should consider placing emphasis on continuing profession education in EBP as a more suitable approach to improve the adoption of EBP within the osteopathic workforce. At present, there are no requirements for registered osteopaths (at least in Australia) to undertake continuing education in EBP.
While it is not possible to accurately determine the response rate to this survey due to the nature of sampling/recruitment, the survey appeared to be completed by approximately 14.6% (332/2277) of Australian osteopaths. This not only exceeded the minimum sample size required for this study, but also the response rates for other EBP surveys involving complementary medicine disciplines, including Canadian chiropractors (8%) , UK osteopaths (7.2%) , US yoga therapists (7.1%)  and US chiropractors (2.2%) . Notwithstanding, there are some limitations to this study that are worth noting. As with any survey examining attitudes, it is possible that participants with an interest in EBP might have been more likely to participate in this study, which may have inadvertently introduced some degree of selection bias. In the event that selection bias was present, it is probable that participant attitudes to EBP may be generally more positive than that reported across the osteopathy profession, and that the level of engagement in EBP activities may be less frequent. However, as the demographic profile of participants closely approximated the age, sex, geographical distribution, type of practice setting and highest qualification of Australian osteopaths, it is probable that the study sample was broadly representative of the Australian osteopathy workforce . Other limitations inherent in the survey design include the reliance on self-reported information and recall bias. Additionally, perceived skill level can be tainted by cognitive bias, particularly among participants with low-level knowledge and skill, which may result in over-estimation of such knowledge and skill (referred to as the Dunning-Kruger effect) .
The above limitations, as well as the understandings gained from this study, highlight the need for further research in this field. For instance, there is a need to investigate the skill/competency level of osteopaths with regards to applying EBP, and to better understand the skills that are required for the successful integration of EBP into osteopathic practice. A related area of research is the development, implementation and evaluation of appropriate interventions that facilitate the uptake of EBP by the osteopathy workforce. Such work could be facilitated through improved collaboration between professional, educational and academic research bodies, as has already been demonstrated through the recent Osteopathy Research and Innovation Network (ORION) project .