- Email: [email protected]
A survey investigation of UK physiotherapists’ use of online search engines for continuing professional development
Physiotherapy 99 (2013) 201–206
A survey investigation of UK physiotherapists’ use of online search engines for continuing professional development Nicholas Harland ∗ , Benjamin T. Drew Musculoskeletal Physiotherapy Services, Friarage Hospital, Bullamoor Road, Northallerton DL6 1JG, UK
Abstract Objectives The purpose of this study was to discover the frequency and type of use of online resources for continuing professional development displayed by physiotherapists in the UK. Therapists’ skills, needs and frustrations using these resources were explored. With the relatively recent release and saturated use of the internet the potential presence of a skills gap between therapists at different stages of their career was also investigated. Design National online survey study. Setting The online survey was carried out using the international online service ‘Survey Monkey’. Participants 774 physiotherapists from students to band 8c completed the survey. Interventions The online survey was advertised through Frontline, the Interactive Chartered Society of Physiotherapy, Journal of Physiotherapy Pain Association and cascade email through research and other networks. Results Most physiotherapists reported using the internet for professional purposes daily (40%) or 2 to 4 times a week (37%), with only 8% of respondents using it less than once a week. Overall the results suggest band 6 and 7 physiotherapists had the least skills and most frustrations when using online search engines. Conclusions History and the nature of rapid technological advancement, specifically of the internet, appears to have created a generational skills gap within the largest group of the physiotherapy workforce band 6 and 7 therapists. Students, band 5 and band 8a therapists appear to most successfully use online resources and the reasons for this are explored. © 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Physiotherapist; Online; Internet; Education
Introduction The last restrictions on the presence of commercial traffic on the internet were removed in 1995. Since then the availability of personal computers and the number of people regularly using the internet has risen dramatically. Between 2006 and 2010 the number of individuals in the UK accessing the internet on a daily or almost daily basis is estimated to have doubled to almost 60% [1]. Currently approximately 2.1 billion people use the internet [2]. The use of computers and the internet within educational institutions began to proliferate from approximately 1995 [3] but it has only been since 2005 that over 50% of households in the UK have had ∗
Corresponding author. Tel.: +44 01609 763786; fax: +44 01609 766044. E-mail addresses: [email protected] (N. Harland), [email protected] (B.T. Drew).
internet access [4]. As a result, the time gap between individuals in higher education having limited access to online resources within their educational institutions and unlimited access at home could potentially be several years. Google’ the most prominent search engine currently channelling approximately 65% of all US internet searches was fully released in 1998 with its creators having a vision ‘to organize the world’s information and make it universally accessible and useful’ [5]. PubMed hosting Medline perhaps the largest and most used international repository of medical literature was also released in 1998. With these advents has come the opportunity for post registration health professionals to undertake continuing professional development (CPD) activities online, with the vast majority of medical journals now being released electronically and many medically relevant special interest groups and organisations maintaining active websites.
0031-9406/$ – see front matter © 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.physio.2012.12.006
202
N. Harland, B.T. Drew / Physiotherapy 99 (2013) 201–206
Due to the significant volume of medical information accessible online, however, finding the information required can be difficult [6]. This is a challenge for every medical professional opting to use online resources for CPD activities. To assist with this challenge a range of generic or focused online ‘search engines’ are available to use, with ‘Google’ fitting into the generic search engine category. An example of a specific medical information search engine, particularly pertinent to the UK population sampled, is ‘NHS Evidence’, provided by the National Institute for Health and Clinical Excellence (NICE). Although the internet has become rapidly embedded within society it remains a relatively new phenomena being less than 20 years, or one generation, old. On average those born into a time when the internet was commonly used have yet to have children. As a result the current adult population is, conceptually at least, still coming to terms with and learning how to use the internet, not having been brought up with it as children. The presence of this ‘generation gap’ can be seen within recent American survey results showing a 12% gap between 18 and 29 (93%) and 30 and 49 (81%) year olds using the internet [7]. From a professional education perspective it has been noted that current health care workers may be less skilled regarding internet use than health care students [8], although with this reference being 4 years old it may now be more correct to say that those in the early stages of their career may be more familiar than their more experienced counterparts. Despite the potential presence of a generational skills gap regarding internet use for CPD activities investigations into this possibility are almost entirely absent from the health literature with no studies of a UK Physiotherapy population identified. Aims and objectives The aim of the survey was to investigate UK Physiotherapists’ use of online resources for CPD activities. More specifically the aim was also to examine any skills gap regarding use of online CPD resources by respondents at different stages of their career. Aspects of usage investigated include both quantitative elements, such as frequency and type of use, in addition to more qualitative elements such as ‘frustrations’ when searching for information. Although multiple dedicated medical search engine sites exist, such as WebMD, PubMed and Bing Health, this survey also more specifically examined if respondents had heard of or used ‘NHS Evidence’ the service provided by NICE, a UK based resource. Method An online survey of UK Physiotherapists carried out using the online service, ‘Survey Monkey’ [9], was undertaken in 2011. Survey Monkey is an internationally available internet based resource for hosting internet surveys that allows users
to word their own questions and collect respondent data into a single database. The survey was advertised in: ‘Frontline’ the UK’s monthly national Physiotherapy news edition; through email alert by the Interactive Chartered Society of Physiotherapy (iCSP) online discussion and exchange site; and in issue no. 30 of the Journal of the Physiotherapy Pain Association. An additional e-mail request to complete the survey was circulated via regional research network distribution lists asking recipients to complete the survey and then cascade it through their own professional networks. The means of distributing the survey invitation were chosen to maximise the response rate through use of national paper and online distribution lists. Although not discussed in this paper a secondary aim of the channels of distribution chosen was to discover their effectiveness in generating survey responses. Specifically, though maintaining a relatively small distribution of approximately 650, an advert for the survey was placed in an edition of the Journal of the Physiotherapy Pain Association partly to evaluate the effectiveness of an article placed in a smaller special interest journal. The United Kingdom National Health Service (NHS) banding structure To interpret the following data some knowledge of the UK career structure is necessary. In the UK, a salary ‘banding’ system exists that relates to every non-medical job, e.g. excludes doctors and consultants, within the NHS. This banding ranges from band 1, the lowest paid worker, to band 9 the highest paid worker [10]. Band 8 pay is split into band 8a, b and c. Within physiotherapy a newly qualified therapist will start at band 5 and will rotate across different specialities to gain experience. Many band 6 physiotherapists are still often rotational but are seen as more specialist. Band 7 physiotherapists are often non-rotational specialising in a specific clinical area such as musculoskeletal out-patients or respiratory care [11]. In the UK due to a much lower availability of band 8a jobs, only 8% of therapists registering their work data with the Chartered Society holding band 8a roles [11], many physiotherapists will never progress past band 7 positions. Band 8a staff are more highly qualified and specialist staff who often also take on greater educational, research, managerial and/or leadership roles [12]. Only a very limited number of band 8b, 8c and band 9 positions exist in the UK. Although some data was collected from band 8b and 8c physiotherapists and from NHS managers as these respondents were very small in number, 6 managers for instance, their data is not discussed as results are unlikely to be representative. Although some data from students will be discussed data was only collected from (n = 20) students so again results may not be representative. Respondents A sample of 833 physiotherapists started the survey and 774 (93%) completed it. The largest group of respondents
N. Harland, B.T. Drew / Physiotherapy 99 (2013) 201–206
were band 6 (178/774, 23%) and band 7 (286/774, 37%) therapists. This demographic is moderately representative of the UK workforce, though the band 6 staff are slightly underrepresented, with band 6 and 7 physiotherapists making up a significantly greater proportion of the workforce [11]. Overall 10% of respondents were undertaking a health related MSc with 16% of band 8a (12/774), 8% (6/774) of band 7 and 12% (9/774) of band 6 being enrolled on an MSc program. The most common means by which respondents heard about the survey was through e-mail alert from the Interactive Chartered Society of Physiotherapy (iCSP) (418/774, 54%) and cascade e-mail from a colleague (330/774, 43%). The least common means were through the paper sources; ‘Frontline’ (5/774, 1%), and the Journal of the Physiotherapy Pain Association (17/774, 2%).
203
Information most commonly searched for The most common type of information searched for was ‘Evidence Based Recommendations or Guidelines’ with 89% (685/774) of respondents suggesting they most commonly search for this type of information. When split by NHS banding there is a steady increase across the bands of respondent’s commonly accessing this type of information from 80% (619/774) of students to 96% (743/774) at band 8a. Table 1 below shows the full range of responses by NHS band. Of the free text responses given in the ‘Other’ category searching for medical equipment was the most common response. Usefulness of sites used The survey asked respondents to report how useful they found the sites they usually use. Overall respondents were more than twice as likely to report they found sites ‘fairly useful’ (505/774, 65%) compared to ‘very useful’ (213/774, 28%). There was only a minimal difference across banding in this trend although band 8a therapists reported the highest ‘very useful’ figure at 31% (240/774). The highest reported figure of sites being ‘not very useful’ came from band 6 therapists at 5% (39/774).
Results Frequency of use The vast majority of physiotherapists reported to use the internet to search for information daily (312/774, 40%) or 2 to 4 times a week (286/774, 37%). Only 8% (60/774) of respondents use it less than once a week. Band 8a physiotherapists were most likely to use the internet daily (375/774, 48%) compared to band 6 physiotherapists who reported the lowest figure of 34% (266/774).
Ease of accessing information Respondents were asked; ‘How easy do you find accessing the information you are looking for’, a five point Likert scale ranging from ‘very easy’ to ‘very difficult’ was used. Overall the majority of respondents reported access to be ‘moderately easy’ (436/774, 56%) or ‘not easy or difficult’ (135/774, 18%). Table 2 shows the detailed results split by banding.
Sites most commonly used When asked which sources respondents ‘mostly frequently use’, with the survey allowing multiple answers, Google was the most used site (567/774, 73%). When split by NHS banding, Google remained the dominant site with lower bands, tending to use it more, band 5 (674/774, 87%) than higher bands, band 8a (498/774, 64%). Search engines accessed through a University login (194/774, 25%) and Hospital Library login (122/774, 16%) were the next most common sites used. ‘Other’ sites made up 11% (82/774) and the most common response in the free text response box available for this question was the Interactive Chartered Society of Physiotherapy (iCSP) site.
Most frequent frustrations When asked ‘Which of the following describe your frustrations when using the internet to search for health and medical information’ perhaps predictably the most frequent frustration expressed by all bands was being unable to access full content journals and articles (542/774, 70%). Getting irrelevant results (341/774, 44%) was reportedly more frustrating than not being able to find what was being looked for (204/774, 26%). Being unsure of the robustness of the
Table 1 Type of information searched for split by banding – all figures are integers.
Pathological diagnostic information Evidence based guidelines Individual articles Management information Patient information Information on medicines
Student
Band 5
Band 6
Band 7
Band 8a
60 80 70 5 5 30
72.9 84.3 72.9 1.4 28.6 17.1
68.2 87.2 75.9 5.6 33.3 20.5
66.6 88 72.4 13.3 40.9 17.9
66.7 96 80.2 29.4 44.4 22.2
204
N. Harland, B.T. Drew / Physiotherapy 99 (2013) 201–206
Table 2 How easy therapists found it to access the information they wanted, split by banding – all figures are integers.
Student Band 5 Band 6 Band 7 Band 8a
Very easy
Moderately easy
Not easy or difficult
Moderately difficult
Very difficult
35 5.7 9.2 10.1 7.7
45 68.6 55.9 53.9 69.2
15 20 16.9 20.1 15.4
0 4.3 13.8 11 0
0 1.4 0 1.3 0
Table 3 Most common frustrations when searching for information split by banding – all figures are integers.
I can’t find what I’m looking for I can’t narrow my search criteria I get lots of the same results I find it hard to save and return to a search I am not familiar enough with the site used I cannot access full content I get results that are not relevant I don’t know what key words to use I am unsure how robust the information is I have no particular frustrations
Student
Band 5
Band 6
Band 7
Band 8a
20 5 10 20 10 70 45 20 25 20
35.7 17.1 24.3 21.4 11.4 88.6 38.6 14.3 37.1 7.1
30.8 20 23.1 11.8 15.9 73.3 46.7 9.7 37.4 7.2
26.6 19.8 18.2 18.2 23.4 66.9 46.1 14.3 44.5 8.1
23.8 20.6 16.7 17.5 15.9 73 44.4 9.5 33.3 11.9
information found was also a significant frustration (298/774, 39%). Table 3 shows the more detailed results split by banding. Training to search the internet Respondents were asked if they had or wanted to receive training to help them search for information on the internet. Overall 30% (232/774) said they had no difficulties and did not feel they needed training. This percentage was highest in students (310/774, 40%) and band 8a staff (276/774, 36%). Overall, 24% (185/774) reported they would like training but did not know how to access it, band 6 and 7 therapists reported this more frequently than other grades. 24% (185/774) reported they had received formal training and it had helped them and 20% (156/774) said they had received informal training from a colleague that had helped. Band 8a staff were the most likely to have received formal training (234/774, 30%) while band 7 staff were most likely to have received informal training (201/774, 26%). NHS Evidence Results showed that 47% (361/774) of respondents had heard of NHS Evidence, and of these, 35% (126/361) had used it. When broken down, those most likely to have heard of NHS Evidence were students, band 5 staff and band 8a staff (216/361, 60%). Those most likely to have used it were also students, band 5 and band 8a staff. Discussion Rather than a detailed study of a specific aspect of physiotherapists’ use of online resources for CPD, the purpose
of the study was to explore the subject, using banding to contextualise results. The survey was therefore more inductive and hypothesis generating, rather than deductive or definitive. Hypotheses generated below are therefore inferred, requiring further deductive study to confirm or disprove. A comparatively short survey length was used to ensure a higher participation and subsequent completion rate [13]. At 93% the completion rate is deemed good in comparison to data from a survey company showing that for surveys of under 60 questions an average completion rate was 82% [14]. As no other examples of published online surveys directed at all physiotherapists were found, rather than surveys directed at a specific subset, it is difficult to comment on if results represent a ‘National Survey’ or if 774 complete respondents represents a large number. A recent online UK survey of physiotherapists treating frozen shoulder was found [15] that also advertised through iCSP and received 289 responses. Peer review literature search failed to uncover a survey of physiotherapists in any country with 774 respondents. The results of the survey potentially have implications for the ongoing training and development of working physiotherapists in the UK. The most striking trend the survey uncovers is a potential gap in the training and development of band 6 and 7 therapists regarding their use on online resources for CPD. This is important when these bands make up by far the greatest proportion of the working profession in the UK [11]. This trend can be seen to some degree regarding many of the survey questions. Band 6 and 7 respondents were the least likely to access the internet daily, were most likely to report sites being ‘not very useful’ and ‘moderately difficult’ to find information on, potentially implying a lack of skilled use rather than poor site design, and were most likely, though not by a large percentage, to report they would like training
N. Harland, B.T. Drew / Physiotherapy 99 (2013) 201–206
to use such sites but did not know how to access this. When asked about common frustrations using the internet they were also most likely to report being unable to find what they were looking for. The phenomenon described above can hypothetically be explained by historical examination of the learning culture of physiotherapists, affected directly by the availability of different types of learning resources to different generations of therapist [16–18]. Easy and convenient access to the internet during graduate or post graduate education is comparatively new being relatively unavailable 15 years ago. Though difficult to define exactly, saturated use of internet resources by students on and off campus has only been present for perhaps 10 years [19]. For further context it was only in 2006 that ‘relevancy ranking’ became an significant issue with the number of online search results increasing to unmanageable levels, requiring search engines to be re-designed to show the most relevant search results first [20]. It is therefore only over the last 5 to 6 years that the skills set needed to effectively search the internet for medical information has also had to expand [21]. When these time frames are applied to the employment hierarchy of physiotherapists a hypothesis can be generated. It is perhaps only the last 5 to 6 graduating years of physiotherapists that have been supported in developing more sophisticated internet search skills and knowledge of internet resources like NHS Evidence during their higher education [22,23]. Many of these therapists, particularly those qualifying in the last 2 to 3 years may have not been qualified long enough to have gained band 6 positions. This cohort’s familiarity with the internet is likely to be greater than that of the generations of therapists before them that dominantly occupy band 6 and 7 positions [24]. The results of this survey provide empirical data to support this argument, though generalisations have been made regarding the number of years it takes to progress between bands. When looking at the band 8a group that also appear to more frequently and more successfully use the internet for CPD other possible reasons can be identified for their apparent success. The likelihood of band 8a therapists having had to come to terms with formal educational internet use is very high when MSc courses or equivalent are present as an essential criteria in many band 8a job descriptions [12,25]. There is also significant competition for band 8a jobs with Chartered Society data showing band 8a’s only making up 8% of the workforce [11]. It is likely therefore that only the most qualified staff are likely to secure band 8a jobs. These factors potentially explain why this group also appears to more successfully use online resources, though again generalisations have necessarily been made regarding these points. It is perhaps justifiable to argue that the education and training gap tentatively identified in this survey is temporary and will reduce with each generation of newly qualified therapist. It is also likely that those current band 6 and 7 therapists may acquire improved online skills over time. It
205
may also be valid to argue, however, that there are generations of physiotherapist that would benefit from targeted training regarding the use of online resources [26] for continuing professional development. In addition many of this cohort will never become band 8a therapists and are therefore less likely to be more significantly exposed to further higher level or formal university based education. There could therefore perhaps be a large cohort of therapists with this relative skills gap within the profession for several decades to come. As an apparently unique example of a published online ‘National Survey’ aimed at all working UK Physiotherapists this study may also provide reference data for response rates, completion rates and distribution pathways for future online survey studies.
Limitations Many assumptions have been made in order to generate a hypothesis from the results of this survey. With a large number of respondents however the chances of significantly misleading results seems small. The survey only captures physiotherapists self-report answers to the questions framed and deeper investigation of the meaning of results in the context of the framing of the questions was outside the remit of this study. For instance, when asked how ‘useful’ respondents found sites this may as much be a measure of a therapists aptitude in critically analysing the information held as it is of their familiarity and skill with using the online format. Similarly when respondents were asked if they found what they were looking for this assumes the skill to recognise relevant sources when presented and could perhaps be independent of online skills. Many such questions remain unanswered and are beyond the remit of this paper to discuss. The purpose of the paper is to present the information gained in the hope it may stimulate debate and perhaps further study. Conflict of interest: None declared. Ethical approval: None required.
References [1] Office for National Statistics. Statistical bulletin: internet access 2010, Available at: http://www.ons.gov.uk/ons/rel/rdit2/internet-access —households-and-individuals/2010/index.html; 2010 [last accessed 02.02.12]. [2] Miniwatts Marketing Group. World internet users and population stats 2011, Available at: http://www.internetworldstats.com/stats.htm [last accessed 02.02.12]. [3] Hokanson B, Hooper S. Computers as cognitive media: examining the potential of computers in education. Comput Hum Behav 2000;16:537–52. [4] Office for National Statistics. Statistics bulletin: internet access households and individuals 2012, Available at http://www.ons.gov.uk/
206
[5]
[6]
[7]
[8]
[9] [10] [11]
[12]
[13]
[14] [15]
N. Harland, B.T. Drew / Physiotherapy 99 (2013) 201–206 ons/rel/rdit2/internet-access—households-and-individuals/2012/stbinternet-access–households-and-individuals–2012.html [last accessed 22.11.12]. Google. Corporate information: company overview, Available at http://www.google.com/about/corporate/company/ [last accessed 06.02.12]. Coumou HCH, Meijman FJ. How do primary care physicians seek answers to clinical questions? A literature review. J Med Libr Assoc 2006;94(1):55–60. Cullifer B. Web’s generation gap and internet stats. Web professionals.org 2010, Available at http://webprofessionals.org/websgeneration-gap-and-internet-stats/ Luke R, Solomon P, Baptiste S, Hall P, Orchard C, Rukholm E, et al. Online interprofessional health sciences education, from theory to practice. J Contin Educ Health Prof 2009;29:161–7. Survey Monkey, Available at: http://www. surveymonkey.com/ [last accessed 08.02.12]. Employers NHS. Agenda for change—NHS terms and conditions of service handbook. London: NHS Employers; 2005. Chartered Society of Physiotherapy. Physiotherapy workforce survey 2010, Available at http://www.csp.org.uk/sites/files/csp/secure/cfwi physiotherapy workforce review 2010.pdf [last accessed 05.02.12]. Green A, Perry J, Harrison K. The influence of a postgraduate clinical masters qualification in manual therapy on the careers of physiotherapists in the United Kingdom. Man Ther 2008;13: 139–47. Deutskens E, Ruyter KD, Wetzels M, Oosterveld P. Response rate and response quality of internet based surveys: an experimental study. Mark Lett 2004;15(1):21–36. Sleep D, Puleston J. The survey killer. Quirk’s Mark Res Rev 2008;22(11):54–8. Hanchard N, Goodchild L, Thompson J, O’Brian T, Davison D, Richardson C. A questionnaire survey of UK physiotherapists on the
[16] [17]
[18]
[19]
[20]
[21]
[22] [23]
[24]
[25]
[26]
diagnosis and management of contracted (frozen) shoulder. Physiotherapy 2011;97:115–25. Peacock S, Hooper J. E-learning in physiotherapy education. Physiotherapy 2007;93:218–28. Rappolt S, Tassone M. How rehabilitation therapists gather, evaluate and implement new knowledge. J Contin Educ Health Prof 2002;22(3):170–80. Ryan S, Bernard S, Freeman H, Patel D. The virtual university: the internet and resource-based learning. London: Kogan Page Limited; 2000. Jansen BJ, Molina PR. The effectiveness of Web search engine for retrieving relevant ecommerce links. Inf Process Manage 2006;42:1075–98. Casebeer L, Bennett N, Kristofco R, Carillo A, Centor R. Physician internet medical information seeking and on-line continuing education use patterns. J Contin Educ Health Prof 2002;22:33–42. Salbach NM, Jaglal SB, Korner-Bitensky N, Rappolt S, Davis D. Practitioner and organisational barriers to evidence-based practice of physical therapists for people with stroke. Phys Ther 2007;87:1284–303. Link T, Marz R. Computer literacy and attitudes towards e-learning among first year medical students. BMC Med Educ 2006;6:34. Brown T, Williams B, Jaberzadeh, Roller L, Palmero C, Mckenna L, et al. Predictors of attitudes to e-learning of Australian Health Science students. J Appl Res High Educ 2009;2(1):60–76. Boulos MNK, Maramba I, Wheeler S. Wikis, blogs and podcasts: a new generation of Web-based tools for virtual collaborative clinical practice and education. BMC Med Educ 2006;6:41. Sran MM, Murphys S. Postgraduate physiotherapy training: interest and perceived barriers to participation in a clinical masters degree programme. Physiother Can 2009;61(4):234–43. Rowe M, Frantz J, Bozalek V. Physiotherapy students’ use of online technology as part of their learning practices: a case study. S Afr J Physiother 2012;68(1):29–34.
Available online at www.sciencedirect.com
A survey investigation of UK physiotherapists’ use of online search engines for continuing professional development Nicholas Harland ∗ , Benjamin T. Drew Musculoskeletal Physiotherapy Services, Friarage Hospital, Bullamoor Road, Northallerton DL6 1JG, UK
Abstract Objectives The purpose of this study was to discover the frequency and type of use of online resources for continuing professional development displayed by physiotherapists in the UK. Therapists’ skills, needs and frustrations using these resources were explored. With the relatively recent release and saturated use of the internet the potential presence of a skills gap between therapists at different stages of their career was also investigated. Design National online survey study. Setting The online survey was carried out using the international online service ‘Survey Monkey’. Participants 774 physiotherapists from students to band 8c completed the survey. Interventions The online survey was advertised through Frontline, the Interactive Chartered Society of Physiotherapy, Journal of Physiotherapy Pain Association and cascade email through research and other networks. Results Most physiotherapists reported using the internet for professional purposes daily (40%) or 2 to 4 times a week (37%), with only 8% of respondents using it less than once a week. Overall the results suggest band 6 and 7 physiotherapists had the least skills and most frustrations when using online search engines. Conclusions History and the nature of rapid technological advancement, specifically of the internet, appears to have created a generational skills gap within the largest group of the physiotherapy workforce band 6 and 7 therapists. Students, band 5 and band 8a therapists appear to most successfully use online resources and the reasons for this are explored. © 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. Keywords: Physiotherapist; Online; Internet; Education
Introduction The last restrictions on the presence of commercial traffic on the internet were removed in 1995. Since then the availability of personal computers and the number of people regularly using the internet has risen dramatically. Between 2006 and 2010 the number of individuals in the UK accessing the internet on a daily or almost daily basis is estimated to have doubled to almost 60% [1]. Currently approximately 2.1 billion people use the internet [2]. The use of computers and the internet within educational institutions began to proliferate from approximately 1995 [3] but it has only been since 2005 that over 50% of households in the UK have had ∗
Corresponding author. Tel.: +44 01609 763786; fax: +44 01609 766044. E-mail addresses: [email protected] (N. Harland), [email protected] (B.T. Drew).
internet access [4]. As a result, the time gap between individuals in higher education having limited access to online resources within their educational institutions and unlimited access at home could potentially be several years. Google’ the most prominent search engine currently channelling approximately 65% of all US internet searches was fully released in 1998 with its creators having a vision ‘to organize the world’s information and make it universally accessible and useful’ [5]. PubMed hosting Medline perhaps the largest and most used international repository of medical literature was also released in 1998. With these advents has come the opportunity for post registration health professionals to undertake continuing professional development (CPD) activities online, with the vast majority of medical journals now being released electronically and many medically relevant special interest groups and organisations maintaining active websites.
0031-9406/$ – see front matter © 2012 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.physio.2012.12.006
202
N. Harland, B.T. Drew / Physiotherapy 99 (2013) 201–206
Due to the significant volume of medical information accessible online, however, finding the information required can be difficult [6]. This is a challenge for every medical professional opting to use online resources for CPD activities. To assist with this challenge a range of generic or focused online ‘search engines’ are available to use, with ‘Google’ fitting into the generic search engine category. An example of a specific medical information search engine, particularly pertinent to the UK population sampled, is ‘NHS Evidence’, provided by the National Institute for Health and Clinical Excellence (NICE). Although the internet has become rapidly embedded within society it remains a relatively new phenomena being less than 20 years, or one generation, old. On average those born into a time when the internet was commonly used have yet to have children. As a result the current adult population is, conceptually at least, still coming to terms with and learning how to use the internet, not having been brought up with it as children. The presence of this ‘generation gap’ can be seen within recent American survey results showing a 12% gap between 18 and 29 (93%) and 30 and 49 (81%) year olds using the internet [7]. From a professional education perspective it has been noted that current health care workers may be less skilled regarding internet use than health care students [8], although with this reference being 4 years old it may now be more correct to say that those in the early stages of their career may be more familiar than their more experienced counterparts. Despite the potential presence of a generational skills gap regarding internet use for CPD activities investigations into this possibility are almost entirely absent from the health literature with no studies of a UK Physiotherapy population identified. Aims and objectives The aim of the survey was to investigate UK Physiotherapists’ use of online resources for CPD activities. More specifically the aim was also to examine any skills gap regarding use of online CPD resources by respondents at different stages of their career. Aspects of usage investigated include both quantitative elements, such as frequency and type of use, in addition to more qualitative elements such as ‘frustrations’ when searching for information. Although multiple dedicated medical search engine sites exist, such as WebMD, PubMed and Bing Health, this survey also more specifically examined if respondents had heard of or used ‘NHS Evidence’ the service provided by NICE, a UK based resource. Method An online survey of UK Physiotherapists carried out using the online service, ‘Survey Monkey’ [9], was undertaken in 2011. Survey Monkey is an internationally available internet based resource for hosting internet surveys that allows users
to word their own questions and collect respondent data into a single database. The survey was advertised in: ‘Frontline’ the UK’s monthly national Physiotherapy news edition; through email alert by the Interactive Chartered Society of Physiotherapy (iCSP) online discussion and exchange site; and in issue no. 30 of the Journal of the Physiotherapy Pain Association. An additional e-mail request to complete the survey was circulated via regional research network distribution lists asking recipients to complete the survey and then cascade it through their own professional networks. The means of distributing the survey invitation were chosen to maximise the response rate through use of national paper and online distribution lists. Although not discussed in this paper a secondary aim of the channels of distribution chosen was to discover their effectiveness in generating survey responses. Specifically, though maintaining a relatively small distribution of approximately 650, an advert for the survey was placed in an edition of the Journal of the Physiotherapy Pain Association partly to evaluate the effectiveness of an article placed in a smaller special interest journal. The United Kingdom National Health Service (NHS) banding structure To interpret the following data some knowledge of the UK career structure is necessary. In the UK, a salary ‘banding’ system exists that relates to every non-medical job, e.g. excludes doctors and consultants, within the NHS. This banding ranges from band 1, the lowest paid worker, to band 9 the highest paid worker [10]. Band 8 pay is split into band 8a, b and c. Within physiotherapy a newly qualified therapist will start at band 5 and will rotate across different specialities to gain experience. Many band 6 physiotherapists are still often rotational but are seen as more specialist. Band 7 physiotherapists are often non-rotational specialising in a specific clinical area such as musculoskeletal out-patients or respiratory care [11]. In the UK due to a much lower availability of band 8a jobs, only 8% of therapists registering their work data with the Chartered Society holding band 8a roles [11], many physiotherapists will never progress past band 7 positions. Band 8a staff are more highly qualified and specialist staff who often also take on greater educational, research, managerial and/or leadership roles [12]. Only a very limited number of band 8b, 8c and band 9 positions exist in the UK. Although some data was collected from band 8b and 8c physiotherapists and from NHS managers as these respondents were very small in number, 6 managers for instance, their data is not discussed as results are unlikely to be representative. Although some data from students will be discussed data was only collected from (n = 20) students so again results may not be representative. Respondents A sample of 833 physiotherapists started the survey and 774 (93%) completed it. The largest group of respondents
N. Harland, B.T. Drew / Physiotherapy 99 (2013) 201–206
were band 6 (178/774, 23%) and band 7 (286/774, 37%) therapists. This demographic is moderately representative of the UK workforce, though the band 6 staff are slightly underrepresented, with band 6 and 7 physiotherapists making up a significantly greater proportion of the workforce [11]. Overall 10% of respondents were undertaking a health related MSc with 16% of band 8a (12/774), 8% (6/774) of band 7 and 12% (9/774) of band 6 being enrolled on an MSc program. The most common means by which respondents heard about the survey was through e-mail alert from the Interactive Chartered Society of Physiotherapy (iCSP) (418/774, 54%) and cascade e-mail from a colleague (330/774, 43%). The least common means were through the paper sources; ‘Frontline’ (5/774, 1%), and the Journal of the Physiotherapy Pain Association (17/774, 2%).
203
Information most commonly searched for The most common type of information searched for was ‘Evidence Based Recommendations or Guidelines’ with 89% (685/774) of respondents suggesting they most commonly search for this type of information. When split by NHS banding there is a steady increase across the bands of respondent’s commonly accessing this type of information from 80% (619/774) of students to 96% (743/774) at band 8a. Table 1 below shows the full range of responses by NHS band. Of the free text responses given in the ‘Other’ category searching for medical equipment was the most common response. Usefulness of sites used The survey asked respondents to report how useful they found the sites they usually use. Overall respondents were more than twice as likely to report they found sites ‘fairly useful’ (505/774, 65%) compared to ‘very useful’ (213/774, 28%). There was only a minimal difference across banding in this trend although band 8a therapists reported the highest ‘very useful’ figure at 31% (240/774). The highest reported figure of sites being ‘not very useful’ came from band 6 therapists at 5% (39/774).
Results Frequency of use The vast majority of physiotherapists reported to use the internet to search for information daily (312/774, 40%) or 2 to 4 times a week (286/774, 37%). Only 8% (60/774) of respondents use it less than once a week. Band 8a physiotherapists were most likely to use the internet daily (375/774, 48%) compared to band 6 physiotherapists who reported the lowest figure of 34% (266/774).
Ease of accessing information Respondents were asked; ‘How easy do you find accessing the information you are looking for’, a five point Likert scale ranging from ‘very easy’ to ‘very difficult’ was used. Overall the majority of respondents reported access to be ‘moderately easy’ (436/774, 56%) or ‘not easy or difficult’ (135/774, 18%). Table 2 shows the detailed results split by banding.
Sites most commonly used When asked which sources respondents ‘mostly frequently use’, with the survey allowing multiple answers, Google was the most used site (567/774, 73%). When split by NHS banding, Google remained the dominant site with lower bands, tending to use it more, band 5 (674/774, 87%) than higher bands, band 8a (498/774, 64%). Search engines accessed through a University login (194/774, 25%) and Hospital Library login (122/774, 16%) were the next most common sites used. ‘Other’ sites made up 11% (82/774) and the most common response in the free text response box available for this question was the Interactive Chartered Society of Physiotherapy (iCSP) site.
Most frequent frustrations When asked ‘Which of the following describe your frustrations when using the internet to search for health and medical information’ perhaps predictably the most frequent frustration expressed by all bands was being unable to access full content journals and articles (542/774, 70%). Getting irrelevant results (341/774, 44%) was reportedly more frustrating than not being able to find what was being looked for (204/774, 26%). Being unsure of the robustness of the
Table 1 Type of information searched for split by banding – all figures are integers.
Pathological diagnostic information Evidence based guidelines Individual articles Management information Patient information Information on medicines
Student
Band 5
Band 6
Band 7
Band 8a
60 80 70 5 5 30
72.9 84.3 72.9 1.4 28.6 17.1
68.2 87.2 75.9 5.6 33.3 20.5
66.6 88 72.4 13.3 40.9 17.9
66.7 96 80.2 29.4 44.4 22.2
204
N. Harland, B.T. Drew / Physiotherapy 99 (2013) 201–206
Table 2 How easy therapists found it to access the information they wanted, split by banding – all figures are integers.
Student Band 5 Band 6 Band 7 Band 8a
Very easy
Moderately easy
Not easy or difficult
Moderately difficult
Very difficult
35 5.7 9.2 10.1 7.7
45 68.6 55.9 53.9 69.2
15 20 16.9 20.1 15.4
0 4.3 13.8 11 0
0 1.4 0 1.3 0
Table 3 Most common frustrations when searching for information split by banding – all figures are integers.
I can’t find what I’m looking for I can’t narrow my search criteria I get lots of the same results I find it hard to save and return to a search I am not familiar enough with the site used I cannot access full content I get results that are not relevant I don’t know what key words to use I am unsure how robust the information is I have no particular frustrations
Student
Band 5
Band 6
Band 7
Band 8a
20 5 10 20 10 70 45 20 25 20
35.7 17.1 24.3 21.4 11.4 88.6 38.6 14.3 37.1 7.1
30.8 20 23.1 11.8 15.9 73.3 46.7 9.7 37.4 7.2
26.6 19.8 18.2 18.2 23.4 66.9 46.1 14.3 44.5 8.1
23.8 20.6 16.7 17.5 15.9 73 44.4 9.5 33.3 11.9
information found was also a significant frustration (298/774, 39%). Table 3 shows the more detailed results split by banding. Training to search the internet Respondents were asked if they had or wanted to receive training to help them search for information on the internet. Overall 30% (232/774) said they had no difficulties and did not feel they needed training. This percentage was highest in students (310/774, 40%) and band 8a staff (276/774, 36%). Overall, 24% (185/774) reported they would like training but did not know how to access it, band 6 and 7 therapists reported this more frequently than other grades. 24% (185/774) reported they had received formal training and it had helped them and 20% (156/774) said they had received informal training from a colleague that had helped. Band 8a staff were the most likely to have received formal training (234/774, 30%) while band 7 staff were most likely to have received informal training (201/774, 26%). NHS Evidence Results showed that 47% (361/774) of respondents had heard of NHS Evidence, and of these, 35% (126/361) had used it. When broken down, those most likely to have heard of NHS Evidence were students, band 5 staff and band 8a staff (216/361, 60%). Those most likely to have used it were also students, band 5 and band 8a staff. Discussion Rather than a detailed study of a specific aspect of physiotherapists’ use of online resources for CPD, the purpose
of the study was to explore the subject, using banding to contextualise results. The survey was therefore more inductive and hypothesis generating, rather than deductive or definitive. Hypotheses generated below are therefore inferred, requiring further deductive study to confirm or disprove. A comparatively short survey length was used to ensure a higher participation and subsequent completion rate [13]. At 93% the completion rate is deemed good in comparison to data from a survey company showing that for surveys of under 60 questions an average completion rate was 82% [14]. As no other examples of published online surveys directed at all physiotherapists were found, rather than surveys directed at a specific subset, it is difficult to comment on if results represent a ‘National Survey’ or if 774 complete respondents represents a large number. A recent online UK survey of physiotherapists treating frozen shoulder was found [15] that also advertised through iCSP and received 289 responses. Peer review literature search failed to uncover a survey of physiotherapists in any country with 774 respondents. The results of the survey potentially have implications for the ongoing training and development of working physiotherapists in the UK. The most striking trend the survey uncovers is a potential gap in the training and development of band 6 and 7 therapists regarding their use on online resources for CPD. This is important when these bands make up by far the greatest proportion of the working profession in the UK [11]. This trend can be seen to some degree regarding many of the survey questions. Band 6 and 7 respondents were the least likely to access the internet daily, were most likely to report sites being ‘not very useful’ and ‘moderately difficult’ to find information on, potentially implying a lack of skilled use rather than poor site design, and were most likely, though not by a large percentage, to report they would like training
N. Harland, B.T. Drew / Physiotherapy 99 (2013) 201–206
to use such sites but did not know how to access this. When asked about common frustrations using the internet they were also most likely to report being unable to find what they were looking for. The phenomenon described above can hypothetically be explained by historical examination of the learning culture of physiotherapists, affected directly by the availability of different types of learning resources to different generations of therapist [16–18]. Easy and convenient access to the internet during graduate or post graduate education is comparatively new being relatively unavailable 15 years ago. Though difficult to define exactly, saturated use of internet resources by students on and off campus has only been present for perhaps 10 years [19]. For further context it was only in 2006 that ‘relevancy ranking’ became an significant issue with the number of online search results increasing to unmanageable levels, requiring search engines to be re-designed to show the most relevant search results first [20]. It is therefore only over the last 5 to 6 years that the skills set needed to effectively search the internet for medical information has also had to expand [21]. When these time frames are applied to the employment hierarchy of physiotherapists a hypothesis can be generated. It is perhaps only the last 5 to 6 graduating years of physiotherapists that have been supported in developing more sophisticated internet search skills and knowledge of internet resources like NHS Evidence during their higher education [22,23]. Many of these therapists, particularly those qualifying in the last 2 to 3 years may have not been qualified long enough to have gained band 6 positions. This cohort’s familiarity with the internet is likely to be greater than that of the generations of therapists before them that dominantly occupy band 6 and 7 positions [24]. The results of this survey provide empirical data to support this argument, though generalisations have been made regarding the number of years it takes to progress between bands. When looking at the band 8a group that also appear to more frequently and more successfully use the internet for CPD other possible reasons can be identified for their apparent success. The likelihood of band 8a therapists having had to come to terms with formal educational internet use is very high when MSc courses or equivalent are present as an essential criteria in many band 8a job descriptions [12,25]. There is also significant competition for band 8a jobs with Chartered Society data showing band 8a’s only making up 8% of the workforce [11]. It is likely therefore that only the most qualified staff are likely to secure band 8a jobs. These factors potentially explain why this group also appears to more successfully use online resources, though again generalisations have necessarily been made regarding these points. It is perhaps justifiable to argue that the education and training gap tentatively identified in this survey is temporary and will reduce with each generation of newly qualified therapist. It is also likely that those current band 6 and 7 therapists may acquire improved online skills over time. It
205
may also be valid to argue, however, that there are generations of physiotherapist that would benefit from targeted training regarding the use of online resources [26] for continuing professional development. In addition many of this cohort will never become band 8a therapists and are therefore less likely to be more significantly exposed to further higher level or formal university based education. There could therefore perhaps be a large cohort of therapists with this relative skills gap within the profession for several decades to come. As an apparently unique example of a published online ‘National Survey’ aimed at all working UK Physiotherapists this study may also provide reference data for response rates, completion rates and distribution pathways for future online survey studies.
Limitations Many assumptions have been made in order to generate a hypothesis from the results of this survey. With a large number of respondents however the chances of significantly misleading results seems small. The survey only captures physiotherapists self-report answers to the questions framed and deeper investigation of the meaning of results in the context of the framing of the questions was outside the remit of this study. For instance, when asked how ‘useful’ respondents found sites this may as much be a measure of a therapists aptitude in critically analysing the information held as it is of their familiarity and skill with using the online format. Similarly when respondents were asked if they found what they were looking for this assumes the skill to recognise relevant sources when presented and could perhaps be independent of online skills. Many such questions remain unanswered and are beyond the remit of this paper to discuss. The purpose of the paper is to present the information gained in the hope it may stimulate debate and perhaps further study. Conflict of interest: None declared. Ethical approval: None required.
References [1] Office for National Statistics. Statistical bulletin: internet access 2010, Available at: http://www.ons.gov.uk/ons/rel/rdit2/internet-access —households-and-individuals/2010/index.html; 2010 [last accessed 02.02.12]. [2] Miniwatts Marketing Group. World internet users and population stats 2011, Available at: http://www.internetworldstats.com/stats.htm [last accessed 02.02.12]. [3] Hokanson B, Hooper S. Computers as cognitive media: examining the potential of computers in education. Comput Hum Behav 2000;16:537–52. [4] Office for National Statistics. Statistics bulletin: internet access households and individuals 2012, Available at http://www.ons.gov.uk/
206
[5]
[6]
[7]
[8]
[9] [10] [11]
[12]
[13]
[14] [15]
N. Harland, B.T. Drew / Physiotherapy 99 (2013) 201–206 ons/rel/rdit2/internet-access—households-and-individuals/2012/stbinternet-access–households-and-individuals–2012.html [last accessed 22.11.12]. Google. Corporate information: company overview, Available at http://www.google.com/about/corporate/company/ [last accessed 06.02.12]. Coumou HCH, Meijman FJ. How do primary care physicians seek answers to clinical questions? A literature review. J Med Libr Assoc 2006;94(1):55–60. Cullifer B. Web’s generation gap and internet stats. Web professionals.org 2010, Available at http://webprofessionals.org/websgeneration-gap-and-internet-stats/ Luke R, Solomon P, Baptiste S, Hall P, Orchard C, Rukholm E, et al. Online interprofessional health sciences education, from theory to practice. J Contin Educ Health Prof 2009;29:161–7. Survey Monkey, Available at: http://www. surveymonkey.com/ [last accessed 08.02.12]. Employers NHS. Agenda for change—NHS terms and conditions of service handbook. London: NHS Employers; 2005. Chartered Society of Physiotherapy. Physiotherapy workforce survey 2010, Available at http://www.csp.org.uk/sites/files/csp/secure/cfwi physiotherapy workforce review 2010.pdf [last accessed 05.02.12]. Green A, Perry J, Harrison K. The influence of a postgraduate clinical masters qualification in manual therapy on the careers of physiotherapists in the United Kingdom. Man Ther 2008;13: 139–47. Deutskens E, Ruyter KD, Wetzels M, Oosterveld P. Response rate and response quality of internet based surveys: an experimental study. Mark Lett 2004;15(1):21–36. Sleep D, Puleston J. The survey killer. Quirk’s Mark Res Rev 2008;22(11):54–8. Hanchard N, Goodchild L, Thompson J, O’Brian T, Davison D, Richardson C. A questionnaire survey of UK physiotherapists on the
[16] [17]
[18]
[19]
[20]
[21]
[22] [23]
[24]
[25]
[26]
diagnosis and management of contracted (frozen) shoulder. Physiotherapy 2011;97:115–25. Peacock S, Hooper J. E-learning in physiotherapy education. Physiotherapy 2007;93:218–28. Rappolt S, Tassone M. How rehabilitation therapists gather, evaluate and implement new knowledge. J Contin Educ Health Prof 2002;22(3):170–80. Ryan S, Bernard S, Freeman H, Patel D. The virtual university: the internet and resource-based learning. London: Kogan Page Limited; 2000. Jansen BJ, Molina PR. The effectiveness of Web search engine for retrieving relevant ecommerce links. Inf Process Manage 2006;42:1075–98. Casebeer L, Bennett N, Kristofco R, Carillo A, Centor R. Physician internet medical information seeking and on-line continuing education use patterns. J Contin Educ Health Prof 2002;22:33–42. Salbach NM, Jaglal SB, Korner-Bitensky N, Rappolt S, Davis D. Practitioner and organisational barriers to evidence-based practice of physical therapists for people with stroke. Phys Ther 2007;87:1284–303. Link T, Marz R. Computer literacy and attitudes towards e-learning among first year medical students. BMC Med Educ 2006;6:34. Brown T, Williams B, Jaberzadeh, Roller L, Palmero C, Mckenna L, et al. Predictors of attitudes to e-learning of Australian Health Science students. J Appl Res High Educ 2009;2(1):60–76. Boulos MNK, Maramba I, Wheeler S. Wikis, blogs and podcasts: a new generation of Web-based tools for virtual collaborative clinical practice and education. BMC Med Educ 2006;6:41. Sran MM, Murphys S. Postgraduate physiotherapy training: interest and perceived barriers to participation in a clinical masters degree programme. Physiother Can 2009;61(4):234–43. Rowe M, Frantz J, Bozalek V. Physiotherapy students’ use of online technology as part of their learning practices: a case study. S Afr J Physiother 2012;68(1):29–34.
Available online at www.sciencedirect.com