Nine favorable conditions at three system levels were identified: two conditions at the individual level, four at the workplace level, and three at the extra-organizational level. Conditions at the three levels appear to interact to influence the physiotherapists’ use of research. Hence, physiotherapists are involved in constructing their context, but are in turn influenced by the context, for example, the interpersonal relationships and organizational culture in which they are embedded . Understanding the process of research use in healthcare requires an interdependent, multi-level system perspective, which is echoed in many frameworks and models of implementation, including the Promoting Action on Research Implementation in Health Services (PARIHS) model [32, 33, 35], the Iowa Model of Evidence-Based Practice , the Knowledge-to-Action Framework  and the Consolidated Framework for Implementation Research .
We found that positive attitudes and motivation to use research, as well as research-related knowledge and skills, provided important individual-level conditions that were perceived as supportive to research use. These factors are likely interdependent, such that research-related knowledge and skills affect attitudes and motivation to use research and vice versa. Attitudes to research have emerged as the single most important factor shaping the use of research among nurses . Findings on determinants for allied health practitioners’ use of research are less consistent; only six studies of relatively weak quality were included in a recent systematic review . Although research has shown that physiotherapists in general are positive to a more EBP, converting these attitudes into changed practice has met with considerable difficulty. The physiotherapists in our study recognized that changing clinical practice is a process that takes time. Several studies have documented that many physiotherapists continue to base practice decisions on knowledge obtained during their initial education and/or personal experience, rather than findings from research [24, 45–48]. It has been shown that physiotherapists use treatment techniques with strong or moderate evidence of effectiveness alongside approaches for which evidence is limited or absent [24, 45, 46, 48–50].
The fact that we identified many conditions at the workplace and extra-organizational levels clearly points to the importance of accounting for this influence on the use of research by individual physiotherapists. However, interventions to achieve increased research use in various fields have predominantly targeted individual clinicians [28, 29, 51]. It is ultimately the individual healthcare professionals who decide whether or not to use research in their practice, which may provide an explanation for the individualized view of research use processes and why many interventions are directed at individuals. However, although research has increasingly recognized the relevance of the workplace or organizational level to research use, Nutley et al. believe that knowledge is still lacking on how research might be used at the organizational level and what types of interventions might facilitate increased organizational use of research.
At the workplace level, we identified leadership support, organizational culture, research-related resources, and knowledge exchange as four important conditions that supported the use of research by the physiotherapists, underscoring the significance of achieving an environment that is conducive to the translation of research into practice. Similar to the factors at the individual level, the factors at the organizational level must be considered highly interdependent. For example, a favorable organizational culture is strongly associated with effective leadership in organizations [52–54]. The organizational culture influences how successful leaders are at implementing changes [55, 56]. The culture is also related to opportunities for knowledge sharing, learning, reflection, and competence development activities in organizations . Learning, in turn, depends on the availability of some research-related resources, such as time and financial and personnel resources.
The physiotherapists in our study emphasized the importance of formal and informal leadership support for research use. They believed that, to a large extent, research use is a management responsibility, which is consistent with earlier research in various healthcare fields that has shown that healthcare professionals often consider research use to be as much an organizational as an individual responsibility [33, 58, 59]. Previous physiotherapy research has identified inadequate support from managers as a barrier to research use [19, 21, 22, 60]. Nilsagård and Lohse  have proposed that the level of EBP skills (including the ability to find and read research studies, critically appraise evidence, and integrate new findings into their practice) should be considered when recruiting future managers to ensure progression towards more evidence-based physiotherapy. Stevenson et al. argue that EBP-skilled opinion leaders, who are not necessarily managers, can be an important influence on other physiotherapists’ commitment to using research. Research in various fields, including healthcare, has shown that opinion leaders—i.e., individuals with specific influence on the attitudes, beliefs, and actions of their colleagues—can indeed be an important strategy to improve the use of research, although opinion leader support alone may not be sufficient to effect practice changes .
The physiotherapists believed that an organizational culture that provides opportunities for learning, reflection, and competence development activities facilitated research use. Achieving EBP is reliant on clinicians who acquire EBP skills, that is, the new skills required of today’s physiotherapists (and other healthcare professionals), emphasizing the importance of learning to develop a more EBP. A learning-oriented culture has often been highlighted as a prerequisite for achieving a more EBP in various healthcare fields [61, 62]. Similar to our findings, Barnard and Wiles  observed that physiotherapists working in university hospitals felt they were part of a research-oriented culture although this was dependent on support from leaders for implementing change and research use. Culture and context are recognized in many of the frameworks and models used in implementation research  and in theories concerning concepts such as organizational readiness for change  and implementation climate . There is an emerging recognition that findings from organizational and management research can inform implementation research to improve understanding of how the gap between healthcare research and practice can be narrowed [66–68].
Resources such as having access to research studies and sufficient financial and personnel resources and time were identified as important conditions for using research in clinical practice. These factors correspond well with previously identified barriers to physiotherapy research [17–22, 26, 27]. Lack of sufficient time has almost unanimously been reported as a major hindrance to a more EBP across different healthcare professions. The physiotherapists in our study believed that dedicated time to discuss research was needed. Various solutions have been proposed in the literature, but there appears to be consensus that time must be set aside to provide a formal, scheduled opportunity to meet and discuss relevant research-related matters and that meetings should focus on reflection on research findings and clinical guidelines rather than discussions based on experiential or anecdotal knowledge not linked to research [6, 21, 69]. However, Heiwe et al. have argued that more research is needed into various aspects of the lack of time concept before it is possible to reduce the impact of this factor on implementation of EBP. Limited time is certainly not unique to physiotherapy or healthcare in general, as there is a difficult trade-off between short-term production requirements and longer-term ambitions for learning and development in many work contexts .
The physiotherapists in our study stated that knowledge exchange with their physiotherapist peers and colleagues from other healthcare professions supported research use. The importance of peer learning in physiotherapy has been highlighted in previous research on physiotherapists  and the lack of peer support and perceived isolation from colleagues have been noted as obstacles to the use of research [21, 22, 71]. Physiotherapists typically face difficulties when choosing the optimal treatment taking into account the limited evidence base for many of the options, underscoring that peers and colleagues are very important for physiotherapists’ informal learning and their use of research to guide their practice. Knowledge exchange with patients was also found to be conducive to the physiotherapists’ use of research. Patients have been identified in previous research as a key source of knowledge for physiotherapists [26, 72]. Physiotherapists listen to the patients’ stories and attempt to understand the context of their life in determining treatment and they collaborate with patients to support regained function and enhance quality of life. Obviously, the holistic nature of much physiotherapy practice does not fit comfortably with the biomedical model of medicine, something that has contributed to considerable debate in the physiotherapy field. Herbert et al. succinctly summed up this discussion on physiotherapy when they titled an editorial ‘Evidence-based practice—imperfect but necessary.’
With regard to the extra-organizational level, we identified three conditions that the physiotherapists considered to be supportive of research use: evidence-based guidelines, participation in external meetings, networks, and conferences, as well as involvement in academic research and education. The system level can be seen as an outer context (i.e., factors external to the organization that are related to the wider social, economic, and political context within which organizations reside) that might influence research use via its impact on the workplace and its groups and individuals.
Evidence-based guidelines were seen as supportive to the physiotherapists’ use of research. Clinical practice guidelines are ‘systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances’ , a definition adopted by the European Region of the World Confederation for Physical Therapy . By making research findings available to healthcare professionals in a user-friendly format, guidelines are aimed at facilitating EBP. Although physiotherapy has followed the example of other healthcare fields and is producing many guidelines, it lags behind the medical profession in evaluating adherence to and effects of guidelines as well as the effectiveness of various strategies intended to increase their use [75, 76].
The physiotherapists believed that various external forums meetings, networks, and conferences were important for research use, which is congruent with research in other fields that has indicated the importance of both formal and informal networks . Recent research has pointed to the critical importance of to healthcare professionals of social networks for the adoption of new practices in healthcare [78, 79]. Parchman et al. argued that efforts to understand the research–practice gap have been hindered by a lack of recognition of the social networks within which healthcare professionals are embedded. Networks have increasingly emerged as a strategy by governments to facilitate the transfer of more research into clinical practice in healthcare .
Involvement in academic research and education was conducive to the physiotherapists’ use of research. Clinical practice and research were interconnected through interaction with colleagues with research experience and with external academic institutions. Our findings lend credence to strategies that have been proposed in various studies, including increased involvement by physiotherapists in research and joint initiatives between academia and healthcare professionals such that students are developing research competence and physiotherapists provide a working laboratory for inquiry [3, 69, 81, 82]. Strategies aimed at strengthening the link between researchers and healthcare professionals as a means to encourage use of research have shown promise in promoting both conceptual and instrumental research use . However, more research is needed to explore how physiotherapists can take part in the research cycle, from planning and conducting studies to the publication, dissemination and implementation of findings.
Several of our results—including the relevance of knowledge exchange with colleagues and patients, interaction with academic institutions, and participation in different external forums—indicate that physiotherapists learn about research through diverse routes. Personal contacts have been found to be an importance source of information about research for professionals in many fields [83, 84], and it has been shown that interaction and dialogue can significantly increase the chances that research will be used in various settings [77, 85, 86].
Our findings suggest that research use in physiotherapy is rarely a simple process of transferring findings from research to practice. It is a complex and dynamic social process that involves a great deal of interaction and knowledge exchange with various people, both internal and external to the workplace. The challenge, according to Greenhalgh et al.: , is to ‘expose the tensions, map the diversity and communicate the complexity’ to understand the process of using research. The view of research use as an interactive and interpretative social process, rather than as a result of straightforward adoption of research findings, implies that research use is associated with a degree of adaptation of the research itself. This raises the question of whether this process undermines the effectiveness demonstrated by the original research and the extent to which physiotherapy practice can be described as evidence-based. This is an important issue that warrants further investigation.
This study has some shortcomings that must be considered when interpreting the findings. The study was conducted in Sweden and the transferability of the findings beyond the context of the Swedish healthcare system might be limited. Swedish physiotherapists are highly autonomous because they do not depend on referrals from physicians or other healthcare providers, and they can use any physiotherapeutic treatment technique they find suitable. Furthermore, the focus groups may not have been fully representative of all types of physiotherapists in Sweden despite the fact that a heterogeneous purposeful sample was sought.
Research use was not defined by the researcher in the interview situations because the aim was to explore the physiotherapists’ viewpoint of research use. Hence, the physiotherapists had the interpretive prerogative on the meaning of research use because we relied on their subjective interpretation and understanding of research use. They discussed small and large changes due to research, from changes in their understanding and perspectives of issues in physiotherapy to more visible changes in their actual practice, that is, both conceptual and instrumental research use .