Municipal Healthcare Workers Want Evidence-Based Care but Face Steep Obstacles

A new Swedish study has lifted the lid on a quiet but consequential problem inside municipal primary healthcare: the clinicians charged with caring for older and vulnerable adults overwhelmingly want to base their work on research, yet most say they cannot. In a mixed-methods investigation published in the Scandinavian Journal of Occupational Therapy, researchers from Lund University and collaborating institutions found that while 80 percent of surveyed registered healthcare professionals wanted to ground their practice in research evidence, fewer than half reported actually doing so. The gap between ambition and reality, the authors argue, is not a failure of motivation but a failure of systems, skills, and organizational support.

The study focused on occupational therapists, physiotherapists, and registered nurses working in a large Swedish municipality of roughly 150,000 inhabitants. These professionals deliver the bulk of municipal primary healthcare, including home healthcare, residential care facilities, and services for adults needing special support. Under Swedish law and their professional codes of ethics, all three groups are obliged to use science and proven experience in their daily work. Yet the researchers found that few had completed advanced-level education, the uptake of new knowledge was low, and care was more often grounded in personal experience than in research-based knowledge, leaving patients potentially exposed to out-of-date assessments and treatments.

Methodologically, the study combined five audio-recorded dialogue meetings with a web-based survey sent to all 290 employed registered healthcare professionals in the municipality. The survey drew 102 valid responses, a response rate of 35 percent overall, with notably higher participation among occupational therapists at 54 percent and physiotherapists at 50 percent compared with 27 percent among nurses. The qualitative strand used inductive, latent thematic analysis following Braun and Clarke’s six-step procedure, while the quantitative strand applied single-item logistic regression analyses to identify which attitudes and conditions were statistically associated with basing work on research. Convergent design principles guided the integration of the two data streams in joint display tables.

The qualitative analysis yielded one overarching theme: a struggle between personal and organizational conditions to use research and work according to evidence-based practice. This struggle unfolded along two dimensions. The first captured clinicians being torn between personal ambitions and a lack of skills to use research. The second described how organizational conditions and limited access to support challenged any attempt to translate evidence into practice. Participants were acutely aware of their professional obligations to use science and proven experience, but when they could not fulfil those obligations because of missing resources, structures, and support, many resigned themselves to relying on experience-based knowledge.

The skills gap emerged as a strikingly consistent finding. Slightly more than half of survey respondents said they did not feel confident searching for and interpreting research results. Advanced-level education made a measurable difference: 63 percent of those with education beyond the bachelor’s level felt confident interpreting research findings, compared with only 37 percent of those with a bachelor’s degree or less. Clinicians described research as hard to understand and generalize, noting that studies are typically conducted at the group level while their patients present complex, individualized problems. One physiotherapist wrote that it can be difficult to judge how reliable a result is and how to apply group-level findings to a single patient.

Despite these struggles, the regression analyses revealed that several individual attitudes and conditions were significantly associated with actually basing work on research. Clinicians who believed that evidence-based work saves time were more than three and a half times as likely to base their work on research. Finding research interesting nearly quintupled the odds, active searching for work-relevant research increased them eightfold, and feeling confident in searching for, reviewing, and interpreting studies each roughly tripled the likelihood. Critically, holding an advanced-level education was itself significantly associated with evidence-based working, with an odds ratio of 3.7, echoing earlier findings among physiotherapists and occupational therapists in Sweden and internationally.

The organizational picture was bleaker. Only a minority of participants said evidence-based practice was highly valued in their workplace, with the smallest proportion among occupational therapists, at just 24 percent, compared with 53 percent of nurses and 41 percent of physiotherapists. Fewer than 15 percent experienced that their manager encouraged the use of research results, and a similarly small share reported any ongoing systematic implementation of evidence-based methods. A lack of allocated time emerged as the single most-cited barrier: 91 percent said they had no time to read research during working hours, and 88 percent lacked access to research at work. When clinicians did carve out time, they described it as coming directly at the expense of hands-on patient care, creating a culture of busyness in which reading research could induce guilt.

Organizational conditions that did support evidence-based working were statistically meaningful. Having access to research results at work increased the odds of basing work on research more than fourfold, having support to try new methods nearly tripled them, and perceiving that evidence-based work was valued at work nearly tripled them. Participants also pointed to structural confusion: unclear boundaries between municipal primary healthcare and county council-run health centres, underutilized professional competencies, and missing structures for multi-professional teamwork. Occupational therapists and physiotherapists described being unable to initiate health-promoting or preventive interventions they had identified, because responsibility fell to another provider under Sweden’s so-called threshold principle, which directs patients who can travel to local health centres instead.

The researchers situate these findings within the knowledge-to-action gap, the well-documented chasm between what research produces and what clinical practice adopts. They draw on prior scholarship describing organizational cultures oriented toward doing, focused on tasks and outcomes, rather than being, which allows reflective time for assessing, reading, and critiquing research. In such cultures, direct patient care is valorized and evidence work is sidelined. The study also notes a troubling ethical dimension: although clinicians were aware they were falling short, there was a consistent absence of reflection on their individual responsibility to fulfil professional codes of ethics, and on the potential consequences for patients of receiving care not grounded in current evidence.

The authors conclude that strengthening clinicians’ competence, particularly through advanced-level education, is essential, but insufficient on its own. Managerial support, education, clinical goals, allocated time, access to research, and clear strategies for implementing evidence-based practice are all needed to shift the organizational culture. Participants themselves called for planning and management that clarifies professional roles and responsibilities, and for structures that make teamwork and evidence-based development possible. As Sweden’s national reform toward local, integrated care moves advanced care out of hospitals and into municipalities, the stakes of closing this gap rise. Without deliberate action, the study warns, the very professionals expected to anchor the new model of care will continue to run, in one participant’s words, like hamsters in a wheel, well-intentioned but unable to move the system forward.

Subject of Research: Evidence-based practice and research usage among registered healthcare professionals in Swedish municipal primary healthcare

Article Title: Ambitions and obstacles for evidence-based municipal primary healthcare – a mixed- methods study

Article References: Gustafsson, M., Zingmark, M., Iwarsson, S., & Ekstam, L. (2025). Ambitions and obstacles for evidence-based municipal primary healthcare – a mixed- methods study. Scandinavian Journal of Occupational Therapy, 32(1), Article 2451265. https://doi.org/10.1080/11038128.2025.2451265

Image Credits: AI Generated

DOI: 10.1080/11038128.2025.2451265

Keywords: evidence-based practice, municipal primary healthcare, research usage, occupational therapy, physiotherapy, nursing, knowledge translation, organizational culture, integrated care, mixed methods, health promotion, advanced-level education