In this study, we have shown that surgeons at a university hospital in The Netherlands appear to have a positive attitude toward the paradigm of EBS and are familiar with EBS terminology but that conflicting results and methodologic shortcomings of research reports appear to be major barriers to practicing EBS. These barriers have also been reported in nonsurgical settings [24
]. To implement EBM successfully in daily practice, further teaching of the EBM principles to nurses and stimulating and reminding surgical colleagues to apply these principles is required.
Although not specified by the surgeons stating this barrier, the “major methodologic shortcomings” generally are well known flaws in the design or conduct of the studies that jeopardize study validity and thus the strength of the evidence. Among the shortcomings are nonrandomized trials (most surgical studies are case series), no allocation concealment or blinding used (patients and surgeons are usually aware of the treatment given), insufficient follow-up, no intention-to-treat principle applied, and small sample size [27
Surprisingly, surgeons and trainees indicated that they use only about half of the convincing evidence as presented during the quiz, even though it was decided earlier in the group of surgeons to include this evidence in local guidelines or to change local surgical policy. Apparently, the decision whether to apply evidence is often difficult (e.g., because of other available evidence showing a favorable outcome on one endpoint but a harmful effect on another relevant clinical endpoint).
Nurses had a moderately positive attitude toward the principles of EBS but were rather unfamiliar with EBS sources and terminology. They indicated that unawareness of research reports was the major barrier to using research findings in surgical nursing practice.
To facilitate the practice of EBS, both surgeons and nurses suggested constant involvement of EBS in daily practice, interactive education, and the availability of a digital expert system to support practice, which is also described in the literature [11
A limitation of this study design is that self-perception of attitude, awareness, and barriers toward EBS were assessed. One would rather determine these parameters during “real-time” surgical practice and ultimately measure if patient outcomes improve owing to the application of surgical evidence by surgeons and nurses. Although the number of instruments to evaluate EBS is growing [29
], valid assessment instruments to evaluate EBS behavior are still lacking.
Second, the absolute number of participants in this study was limited and derived from one university hospital only. However, the response rate of surgeons and nurses within our department was satisfactory. Our findings may be indicative of the situation in other (academic) centers because similar implementation barriers and positive attitudes regarding EBM have been reported [7
]. Despite these similarities, further research is needed in other specialties and other medical centers to see if general recommendations can be made on interventions to promote EBM.
Implementation of EBS needs further improvement. Several tailor-made interventions have become clear from our findings and experience in creating a professional environment that incorporates EBS. First, continual confrontation with available evidence through frequent critical appraisal meetings or grand rounds is necessary [30
]. Second, as our nurses were unfamiliar with EBS and received less postgraduate EBS training than surgeons, it is expected that they will benefit from EBS training focusing on basic skills, integrated in everyday surgical nursing practice [31
]. Third, surgeons may enhance their efficiency by using more aggregate sources of evidence [33
], such as the National Guideline Clearinghouse or BMJ Clinical Evidence. Finally, collaboration is advocated among doctors and nurses with the same zest for EBS.