In this mixed method study, we tried to analyze and evaluate the frequency of EBP implementation in dietitians’ practice, their knowledge on EBP method and their capability to implement EBP in daily practice. The study population was well balanced in terms of age, employment, working time, and seniority. Almost all the participants had a high level of education with at least a 3-year Bachelor (Table 2), but were not specifically trained on EBP and EBM.
Overall, EBP knowledge of Italian dietitians was just moderate to good (mean score: 8.5/13; Table 3), suggesting room for improvement, especially in specific topics, regardless of the baseline characteristics. However, there was a statistically significant difference in EBP knowledge scores according to age: the higher total scores in dietitians < 50 years old, compared to the older ones (+ 2.5 points; Table 4), are probably due to more efficient integration of EBP method in university programs. Nowadays most of the courses are based on systematic reviews of the literature available on a topic and guidelines to guarantee the best evidence possible to the students. Also, during their internship, dietetic interns need to use and consult medical databases to answer clinical nutritional questions. That is why a good knowledge of EBP and EBM methods provided by the university is a good tool to adopt in future clinical practice.
Moreover, concerning EBP knowledge and perception of EBP implementation there is an interesting gap between what the dietitians presume to know and what they really do to implement EBP in their daily clinical practice: in fact, the worst score was obtained by who declared to have already accomplished a complete integration of EBP method. This might reflect a Dunning – Kruger effect, a cognitive bias of people with low competence and expertise who overestimate their knowledge and skills on a particular topic, due to lack of self-awareness of their own limitations8. This highlights the importance of an open-minded approach to new evidence updating the current practice.
Overall, frequency of EBP use was just moderate (mean score: 22.8/45; Table 3). Apparently in opposite direction to EBP knowledge, frequency of EBP use seemed to be higher in dietitians > 50 years old and with more than 20 years of experience (+ 6.9 and + 7.0 points, respectively; Table 4). Without a good quality knowledge, it is difficult to hypothesize a higher frequency of application, but this result may suggest open-mindedness towards this method, even if more education on EBP and EBM advantages is needed. Furthermore, this discrepancy between low EBP knowledge and high frequency of EBP use, in senior dietitians, may also reflect more difficulties/barriers encountered by this category.
On the other hand, young dietitians may be overwhelmed by the continuous education required by the current academic and social setting, with a consequent burn-out effect that makes them less willing to apply the theoretical knowledge to the real practice. In addition to this paradox, too long school, academic, and post-graduate programs tend to procrastinate the access to work, with detrimental effects on motivation, that is discouraged also by the temporary nature of many employments.
In terms of EBP proficiency, results were quite poor (mean score: 1.9/5, Table 3), as most questions related to this area were not correctly answered (Table 3). Since no particular factors seemed to be associated with EBP proficiency (Table 4), these results might be caused by the mismatch between theoretical knowledge and proficiency in applying EBP in daily practice.
The focus group confirmed a good awareness of EBP in dietitians. They tended to attribute characteristics such as rigor and strict methodology to EBP. However, as a consequence, EBP is perceived as a demanding task which requires efforts ant time. As seen before in literature dietitians expressed in the survey and also in the focus group two main barriers to the implementation of EBP: lack of time and resistance to change5,9–13. Both are reasons that are difficult to break down, as time is very important, especially in everyday work: people try to save time, relying on habits and automatisms, as they often work frantically and feel overloaded with commitments. It could also trigger a mechanism of overestimating the positive aspects of not implementing EBP, such as time savings, habit, speed of work and an underestimation of risks, such as not taking into account some fundamental information such as those of obtain an unfavorable and uncertain outcome for the patient, which would consequently affect their work.
The resistance to change raised from the study is referred not only to the implementation of EBP method itself, but also to the relationship between young/junior and old/senior dietitians that, in hierarchal settings, could prevent junior dietitians to make any changes to the daily practice. Resistance to change can be defined as the reluctance to change our attitudes, ideas and habits, as they are the fundamentals of our knowledge and certainties 14,15.
Change represents something unknown that frightens and even if it can generate innovation and resources, it can also bring critical issues, as well as loss of control. In this perspective, change is considered as an act of faith towards an unknown direction, in the hope of obtaining an advantage. Especially in healthcare field, where fast progresses cause fast changes in knowledge too, getting used to that very fast rhythm may not be easy. This could be the reason behind our results showing that those who graduated long time ago have a poorer knowledge of EBM and EBP, compared to younger dietitians.
Interactions with other colleagues was a matter of debate. The “active” comparison with colleagues could give the perception of playing an active role, in a propositional perspective, also managing to propose interesting solutions, and not passively undergoing the change or decision. However, also the “passive” habit of seeking for advice from colleagues and supervisors, when there is a unknow situation, is not always wrong: it could be of help to have a deeper understanding of the studies found and could lead to a combined approach across healthcare providers, but only if it comes after an independent search and analysis of clinical studies. Unfortunately, the relationship with older and more experienced colleagues is not always beneficial, in hierarchical settings, for the above-mentioned resistance to change of senior colleagues.
Our results highlighted a promising willingness to implement EBP in the future. This is helpful, as an active attitude to search and evaluate clinical studies even in nutritional field is the key to have a more comprehensive approach to be always up to date and provide the best care. An active attitude could also help students not to fall in the “gap” between what they have learned at the university and what it is really necessary during daily clinical practice. Remembering that team-working is always the best way to assess patients in healthcare daily work.
Essentially, despite some differences in the methods compared to the other studies, our results tend to align to others seen in literature before4–6,12. Hinrich et al.6 also reported a good awareness about the importance of EBP for the profession, and highlighted the discrepancy between EBP method and daily practice, observing similar barriers that hamper the application of EBP method in real-world clinical settings.
Some limitations must be highlighted in our study. First, only few dietitians from Southern Italy were recruited, and the results are therefore based mostly on results from Center and Northern Italy. Second, the questionnaire was taken from Hinrichs et al.6, but not formally validated in Italian language and administered to a slightly different target population (already graduated dietitians, instead of interns).
In conclusion, this is the first study conducted in Italy to investigate EBP and EBM knowledge, frequency of use, and implementation in a well-balanced study population representing the real-world practice of Italian dietitians. Overall, our results show that EBP knowledge (mean score: 8.5/13) and implementation (mean score: 22.8/45) are still too low, as well as EBP proficiency (mean score: 1.9/5). The value of EBP and EBM is well-acknowledged by most of the dietitians in our study, who would be willing to use them in their practice, but barriers are reported to hamper their implementation, namely lack of dedicated time, poor EBP training, and resistance to change, especially in hierarchical environments.
Specific courses to explain and make clear the importance of EBP, together with training applied to daily practice to show the real benefits of this method, should be encouraged. Signals from our study suggest that these strategies are starting to yield good results, particularly among younger dietitians, in terms of EBP knowledge. Future research could consider the possibility to add comparison arms of dietitians to investigate the efficacy of possible solutions/strategies to further improve the EBP implementation process in daily practice.