A qualitative study on barriers to evidence-based practice in patient counseling and advocacy in Germany

Overall, we performed nine face-to-face interviews and one group interview by using
a multi-faceted semi-structured interview guide. The interview sample involved six
PAs and three PCs, containing affected patients (four persons) and not affected persons
(five persons) as well as voluntary workers (six persons) and salaried staff (three
persons) as depicted in Table 1.

Table 1. Characteristics of patient counselors and advocates participating in the semi-structured
interviews

Determinants influencing the application of EBP among patient counselors and advocates

The interviews provide insights in the interplay of certain determinants working as
barriers and facilitators regarding the implementation of EBP among patient counselors
and advocates in the German health care context. Figure 1 displays all identified factors influencing the utilization of EBP in patient advocacy
and counseling. A thorough analysis of the qualitative data yields the finding that
PCs and PAs do not recognize EBP as a tool to support their vocational professionalization.
Even though EBP has the potential to help PCs and PAs to gain independence and improve
the way they are recognized or identified as health professionals. According to the
data, this negative attitude is due to certain factors working as barriers and facilitators
regarding the implementation of EBP in patient counseling and advocacy. In this regard,
our analysis demonstrates that individual and institutional barriers affect the attitude
of PAs and PCs regarding EBP utilization as presented in Table 2. Individual barriers found are a limited knowledge of EBP (cognitive-behavioral barriers)
and a negative attitude towards EBP (professional, attitudinal or rational emotional
barriers). Institutional barriers found encompass organizational barriers rooted in
the organizational processes (system and process barriers) and the limited availability
of resources. These barrier types influence the application of EBP in patient advocacy
and counseling through a wide array of mechanisms by interacting with each other or
affecting EBP directly. In contrast, we detected certain factors that facilitate the
application of EBP among PAs and PCs.

Table 2. Detailed contextualization of identified barriers of EBP among patient counselors
and advocates

Individual barriers to EBP in patient counseling and advocacy

Professional and attitudinal or rational-emotional barriers

The professional as well as attitudinal or rational-emotional barriers to EBP are
similarly recognized by PCs and PAs. It is apparent that there are certain concerns
associated with the application of EBP. Respondents emphasize that the use of EBP
might overwhelm patients by confronting them with too many complex information and
excessively demanding their decision-making abilities. In addition, they fear that
a less individualized approach to counseling will develop due to generalizations provided
by EBP when applied by laypersons. Respondents also argue that, generally, evidence
based counseling is a duty of physicians. They emphasize that, if PCs were to apply
evidence based counseling, they would need to integrate their own view on EBP and
specifically consider the social background of the patient. In this regard, respondents
report that one reason for PCs reluctance to use EBP is the concern to cause discrepancies
with physician’s advice given to the patient. This is also reported by PAs affirming
that EBP is seen as a specific competence of physicians rather than PAs. As a result
PAs indicate to follow the physicians opinion instead of stating the own professional
position on EBP. Further, PAs and PCs have a partly critical view on EBM questioning
its reliability. This view is based on the opinion that EBP is strongly affected by
emerging research findings and new guidelines leading to frequent practice changes,
which sometimes contradict prior guidelines and procedures and cause uncertainty.
In the majority of cases, PCs and PAs have predominantly critical attitudes towards
EBP. This is caused due to a lack of trust in its reliability and concerns regarding
unfavorable effects it may have on the relationship with patients and cooperation
with physicians. These attitudes contribute to the limited recognition of EBP as a
tool to strengthen PCs and PAs unique and independent position.

Cognitive-behavioral barriers

Respondents report several cognitive barriers rooted in a limited knowledge of EBM
that discourage them from engaging in EBP, ultimately leading to the limited recognition
of the benefits of EBP for patient counseling and advocacy as shown in Table 2. They report considerable difficulties when gathering evidence-based information
on health care issues or when trying to assess benefits of treatments and diagnostic
procedures. Moreover, they emphasize that the assessment of the quality of health
related information is difficult to achieve, due to limited understanding of statistics
as well as concepts and methods of EBM including effect sizes and level of evidence.
A further noteworthy finding is that PCs and PAs do not perceive the cost effectiveness
of medical interventions as relevant in their vocational context. In sum, cognitive
barriers can have an enormous effect on the acceptance of new concepts. Therefore,
novel concepts such as EBM may only be successfully implemented when its basic methodologies
are well understood and applied correctly. Otherwise, limited knowledge can cause
misjudgments and attitudes of rejection, such as described in the section “attitudinal
barriers”.

Institutional barriers to EBP in patient counseling and advocacy

System and process barriers

Participants agree that EBM trainings could help to enhance the role of EBP, but they
perceive a lack of infrastructure for adequate EBP training programs that are tailored
to the needs of PAs and PCs. Although they report to know of some workshops offered
to train PCs and PAs in EBM, they consider these inadequate to meet the vocational
needs of the target group. In this regard, PCs and PAs describe their expectations
in regard to the design and scope of EBP training programs. For the respondents, a
needs-based EBP training should be easily accessible, cover a period of 1 to 2 days,
include funding and require both personal class attendance and completion of online
courses (Table 2). Furthermore, programs should be tailored to a specific target group, but also include
individuals from diverse fields, such as physicians and members of self-help groups.
Respondents also recommend a region-wide provision of EBP trainings to increase accessibility.
The recommended temporal limitation of the training as well as the preference for
funding by a third party and a wide spread provision of trainings may be rooted in
a lack of resources in PCs and PAs, who often work on a voluntary basis without financial
compensation.

Overall, individual and institutional barriers hamper the application of EBP in patient
counseling and advocacy in the German health care context, leading to an underestimation
of the benefits of EBP. In contrast, there are some facilitators that are perceived
as beneficial for changing the attitudes of PAs and PCs towards the application of
EBP.

Facilitators of EBP application in patient counseling and advocacy

Despite the individual and institutional barriers towards the application of EBP among
PCs and PAs, respondents state that there are some factors, which could facilitate
the application of EBP in the future. Respondents admit that although they have concerns
regarding the effects of EBP on their relationship to patients and other professionals,
they concede that knowledge of basic EBM skills could possibly enhance patient counseling
by making it more structured and evidence based. Furthermore, they believe that an
improvement in methodological competencies could help to strengthen their vocational
self-esteem, support professionalization and improve their role functioning, ultimately
helping to raise the patient’s voice more effectively. In particular, PAs who are
often involved in important reimbursement decisions, report that effective patient
advocacy is impossible to achieve without better knowledge of EBM. Indeed, they emphasize
that increased professionalization of counselors and advocates, is required to better
serve the needs of patients.