RESEARCH ARTICLE
\nImplementation of evidence-based practice:
\nThe experience of nurses and midwives
\nAsrat Hailu DagneID*, Mekonnen Haile Beshah
\nDepartment of Midwifery, Debre Tabor University, Debre Tabor, Amhara Region, Ethiopia
\n* 1221Asrat@gmail.com, asrahail@dtu.edu.et
\nAbstract
\nBackground
\nImplementation of evidence-based practice in clinical practice is crucial. Nurses and midwives play a vital role in using updated evidence. However, limited support and barriers to
\nimplementing evidence-based practice hamper the use of up-to-date evidence in clinical
\ndecision-making practice. Therefore, this study aimed to explore the implementation of evidence-based practice of nurses and midwives working in public hospitals.
\nMethods
\nA qualitative descriptive study was conducted to explore the experience of implementing
\nevidence-based practice among nurses and midwives working in public hospitals. A total of
\n86 participants, of which, 25 in-depth interviews, 5 FGDs having 47 participants and 14 participants were involved during observations, were considered in Amhara Region public hospitals from November 17, 2019 to April 25, 2020. The observational data, interview and
\nFGD transcripts were imported into NVivo 12 plus to manage and analyze the data using
\nthe Computer-Helped Data Analysis Software Program (CAQDAS). The data were analyzed through thematic content analysis.
\nResults
\nNurses and midwives perceived that implementation of evidence-based practice is the use
\nof research findings, guidelines, hospital protocols, books, and expert experience in clinical
\ndecision-making practice. However, there was limited support for the implementation of evidence-based practice by nurses and midwives. The lack of knowledge and skill to use evidence like research findings, time mismanagement, the lack of motivation, the lack of
\nresources and training were the perceived barriers to the implementation of evidence-based
\npractice. Stick to the traditional practice due to lack of incentive and unclear job description
\nbetween diploma and BSc nurses and midwives were the perceived causes of the lack of
\nmotivation.
\nConclusions
\nThe experience of evidence-based practice of nurses and midwives indicated that there was
\nlimited support for the implementation of evidence-based practice. However, research
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\nOPEN ACCESS
\nCitation: Dagne AH, Beshah MH (2021)
\nImplementation of evidence-based practice: The
\nexperience of nurses and midwives. PLoS ONE
\n16(8): e0256600. https:\/\/doi.org\/10.1371\/journal.
\npone.0256600
\nEditor: Tareq Mukattash, Jordan University of
\nScience and Technology, JORDAN
\nReceived: February 25, 2021
\nAccepted: August 10, 2021
\nPublished: August 27, 2021
\nCopyright: \u00a9 2021 Dagne, Beshah. This is an open
\naccess article distributed under the terms of the
\nCreative Commons Attribution License, which
\npermits unrestricted use, distribution, and
\nreproduction in any medium, provided the original
\nauthor and source are credited.
\nData Availability Statement: All relevant data are
\nwithin the manuscript and its S1 and S2 Files.
\nFunding: This study was funded by the Center for
\nInternational Reproductive Health Training
\n(CIRHT). The funder is not listed in the FundRef
\nRegistry and there is no award number\/grant
\nnumber. The funding body had no role in the study
\ndesign and collection, analysis, and interpretation
\nof data and in writing the manuscript.
\nCompeting interests: The authors declare that they
\nhave no competing interests.
\nfindings were rarely used in clinical decision-making practice The Knowledge, attitude
\ntowards implementing evidence-based practice, lack of resources and training, time mismanagement and lack of motivation were the barriers to the implementation of evidencebased practice. Therefore, the promotion of adopting the implementation of evidence-based
\npractice and training on the identified barriers are mandatory.
\nBackground
\nImplementation of evidence-based practice (IEBP) refers to the use of best, valid, currently
\navailable and relevant research findings, expert opinion, standard guidelines and books in clinical decision-making practice [1]. IEBP improved quality healthcare and client outcomes in
\nthe care setting like reducing patient pain, hospital stay and ulcers due to pressure [2]. Therefore, future research needs to explore ways to foster the documentation of evidence-based
\npractice (EBP) interventions more effectively. Nurses and midwives who have higher educational status, and management and service provision experience can reduce barriers to the
\nIEBP. Thus, IEBP achieves quality health care through knowledge, skill, the experience of
\nhealth service providers, collaborative decision making and good time management [3].
\nThe best, valid, currently available, and relevant research findings were rarely used in
\nhealthcare and clinical decision-making practice [4]. Nurses and midwives use experiencedbased knowledge, and their observations, colleague and other collaborators\u2019 support in practice without considering best and current evidence [4]. International and national organizations have enhanced IEBP for the standard of quality health care service. IEBP is essential to
\nmeet patient safety and quality health services. It is also vital to increase formal and informal
\nhealth information, treatment expectation, and patient role related to clinical decision-making
\npractice [5]. Several standard guidelines, books, primary research and systematic review results
\nare produced continually [6].
\nThe uptake of EBP by updating knowledge, skill and attitude of nurses and midwives
\nimproved the advanced practice of nurses and midwives through role modeling, training,
\nproblem-solving and facilitating change [7]. However, nurses\u2019 and midwives\u2019 education for
\nmaster\u2019s and Ph.D. holders is not common even in European countries like France to implement evidence-based in clinical and healthcare practice, and research is conducted and is well
\nknown to use it for clinical decision-making practice in higher educational institutions [8].
\nWorldwide, the quality of research and standard guidelines engaging in evidence-based behavior is low. In addition to this, most factors influencing IEBP are not well identified and there is
\na call for further research to be done globally [9]. The study conducted in South Africa indicates that the use of evidence like research, standard guidelines and books require time and
\nperseverance from international researchers and stakeholders together with a readiness by
\nlocal researchers and stakeholders to take and actively promote IEBP in clinical and healthcare
\npractice [10].
\nIEBP involves solving complex problems that are basic in healthcare [11]. Nurses and midwives have to address IEBP gaps through the insertion of the evidence into clinical practice,
\ni.e., research findings, currently updated experts opinions, standard guidelines, and books. To
\nfulfill this proposed role, they have to prepare their clinical expertise [12]. Studies suggested
\nthat IEBP is intervened by an interplay between the individuals, the new knowledge, and the
\nactual context in which the sources of evidence are to be organized and utilized in daily practice [13, 14]. In addition to this, IEBP should be locally evaluated and the Assessment results
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\nmust be made actionable and usable, and adapted to the local situations to get the best-needed
\noutcomes [15\u201317].
\nThere is a paucity of literature that explores nurses\u2019 and midwives\u2019 experiences towards barriers and supporting factors of IEBP in Ethiopia. The study\u2019s findings will serve as a baseline
\nfor measuring and monitoring change in IEBP readiness following a tailored educational and
\norganizational intervention. Therefore, this study was designed to explore the IEBP of nurses
\nand midwives, barriers and supporting factors that affect the implementation of evidencebased practice among nurses and midwives.
\nMethods
\nStudy design and setting
\nA qualitative descriptive study was engaged from November 17, 2019 to April 25, 2020 to
\nexplore the experience of IEDBP among nurses and midwives working in Amhara Region
\nPublic Hospitals. Three specialized hospitals (Debre Birhan, FelegeHiwot, and Gondar), four
\ngeneral hospitals (MehalMeda, Motta, Debark, and FinoteSelam) and eighteen primary hospitals (Dembia, Durbetie, Deneba, Debre Sina, ShoaRobit, Feres Bet, Ataye, Adet, Addis Alem,
\nMekaneEyesus, Addis Zemen, Merawi, Burie, Wogera, Delgi, Nefas Mewcha, Wogeda,
\nandMetema) were involved in the study.
\nParticipants, sampling and recruitment
\nA total of 86 participants were considered for the in-depth interview (8 key informants and 17
\ninterviewees), five FGDs (47 participants) and fourteen observations were conducted. The key
\ninformants included three hospital managers, two medical directors and three case managers
\n(masters in emergency surgery and obstetrics). Each focus group discussion (FGD) consisted
\nof eight to twelve participants. A checklist was employed to observe nurses\u2019 and midwives\u2019
\nroles, and the availability of resources\/materials used for EBP in the fourteen hospitals. Nurses,
\nmidwives, doctors and masters in the emergency surgeon and obstetric participated in the indepth interview. Nurses and midwives participated in FGDs. Name of nurses, midwives, doctors and masters in the emergency surgeon and obstetric was coded for the participants of the
\ninterview (101\u2013125), FGD1 (FGD1-01 to 9), FGD2 (FGD2-01 to 10), FGD3 (FGD3-01 to 10),
\nFGD4 (FGD4-01 to 08), FGD5 (FGD5-01 to 10) and observation (H101- H114) (see S1 File).
\nA purposeful sampling strategy was used to select hospital managers, medical directors and
\ncase managers who have leadership roles as key informants. A similar strategy was used to
\nselect nurses and midwives for participation in the interview, FGD and observation. Participants who give optimal insight into the implementation of evidence-based practice were
\nrecruited through the hospital managers and the heads of department, and their contact details
\nwere obtained. Due to the busy schedule of participants, a pragmatic approach was favored to
\nget them for the interview and FGD. A calendar invitation was subsequently sent out inviting
\nthe professionals to participate, and all agreed.
\nData collection
\nThe theoretical framework of Klein and Knight was used as the basis of the FGD and interview
\nguide [18]. The in-depth interview and FGD guides and checklist for observation were developed by reviewing literature and feedback of experts in IEBP. The theoretical framework consisted of factors enhancing and challenging the IEBP. IEBPs established by an organization,
\nshared perceptions of the IEBP, a supportive organization to IEBP, the availability of resources
\nand a learning organizational knowledge and skill development were enhancing factors.
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\nHowever, unreliable evidence, lack of knowledge and skill, time mismanagement, lack of motivation, the decision to adopt and implement an innovation made by higher up in the hierarchy
\nthan the innovation\u2019s target users and lack of commitment are the challenges of implementation of evidence-based practice.
\nThe interview and FGD guide were divided into four sections i.e. Socio-demographic variables, perceptions towards IEBP, perceived barriers of IEBP and supporting factors for IEBP.
\nThe in-depth interview and FGD guide were also prepared first in English then translated to
\nAmharic and retranslated back to English for consistency. Eight data collectors (research Helpance) who had the educational status of master and Ph.D. with previous qualitative data collection experience were selected. They were trained to be familiar with the objective and the
\nmethodology of the research. Data were collected via FGD and face-to-face interview techniques using semi-structured questionnaires. Good communication started with the greeting
\nand the ground rule had been set before the focus group discussion started. The interviews and
\nFGDs took place in separate rooms at hospitals that guarantee good communication. The
\ninterview duration was between 45 minutes and 60 minutes and the FGD duration was 90
\nminutes to 120 minutes. Moreover, the data collectors were engaged in participatory observation using a checklist. The participants\u2019 emotions and non-verbal communication were
\nrecorded as field notes. The interviews and FGDs were audio-recorded and then later transcribed for analysis. Saturation was determined when there were multiple overlapping
\nresponses across participants.
\nData analysis
\nInterview and FGDs data were captured using voice recorders, and each day field notes
\nwere transcribed verbatim first in Amharic and then translated into English and retranslated back to Amharic by interviewers and FGD data collectors each day to check for consistency. The transcripts were read repeatedly and checked independently by investigators for
\nconfirmation. Initially, the observational data, and interview and FGD transcripts were
\nimported into NVivo 12 plus to manage and analyze the data using the Computer-Helped
\nData Analysis Software Program (CAQDAS). The data were analyzed through content analysis. First, a list of codes was created and described. Then after adding and defining the concept, categories were developed. The number of categories was reduced by\u201d collapsing those
\nthat are similar or dissimilar into broader higher-order categories\u201d [19]. Finally, the codes
\nwere ordered into essential categories, and the main contents and categories were identified.
\nMoreover, essential quotations were clustered. The quotations were used to elaborate on the
\ncontext that affects the participants\u2019 experience and how the participants experienced the
\nevents.
\nTrustworthiness
\nThe investigators, research facilitators, nurses and midwives expert were invited to review
\nthe study\u2019s findings and the right idea that represents their point of view was taken for the
\nstudy to maintain credibility. Dependability was addressed by analyzing all the observational
\ndata, and interview and FGD transcripts by at least two researchers with a third \u201cchecker\u201d to
\nensure consistency across the data analysis process. Moreover, the investigators and research
\nfacilitators discussed the emerging categories from the dataset and resolve any different perspectives by foraging consensus on interpretation. The decision of transferability of the findings to a new set of situations depend on the contextual information provided by the
\ninvestigators.
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\nEthics approval and consent to participate
\nEthical approval was obtained from the Ethical Committee of Debre Tabor University, health
\nScience College and we communicated it to Amhara Region Ethical Review Board. A formal
\nletter of cooperation was written for Amhara Region Public Hospitals and permission to conduct the study was obtained from the hospital and the unit managers. Participants were
\ninformed that they had the right to withdraw from the study at any time. Moreover, we
\ninformed the purpose, procedures, advantages and disadvantages. Finally, informed written
\nconsent was obtained from each study participant.
\nResults
\nThe participant\u2019s ages ranged from 21 to 50 years, and their mean age was 31 years. Thirtyeight participants were married and thirty of them were single. Sixty male and twenty-six
\nfemale participants have participated in the study. The work experience of the participants ranged from 1 year to 34 years and its mean was seven years. Of the total 86 participants, 46
\n(53.5%), 32(37.2%), 8 (9.3%) were nurses, midwives and key informants respectively. Five MSc
\nnurses, forty-one BSc nurses, three MSc midwives and twenty-nine BSc midwives participated
\nin the study. In terms of participants\u2019 positions, six head nurses and three head midwives participated in the study. Two medical directors, three hospital managers, three quality health
\ncare cordinators, and three case managers also participated in the study.
\nThe data analysis of observation, FGD, and interview produced four themes. These four
\nthemes were the perceptions towards implementing EBPe, the nurses\u2019 and midwives\u2019 attributes
\nthe supporting of nurses and midwives for the IEBP and the perceived barriers to implementing EBP. The four themes were further subdivided into eleven subthemes. Of which, four subthemes were included under the nurses\u2019 and midwives\u2019 attributes, three subthemes were
\nincluded under the supporting of nurses and midwives for IEBP and four subthemes were
\nincluded under the perceived barriers to implementing EBP.
\nThe perceptions towards the IEBP
\nThis is the theme defined as the awareness of participants towards the IEBP. The interviewees
\nand FGD participants perceived that IEBP is using research findings, guidelines, hospital protocols, books, and experts\u2019 experience during health services, particularly in clinical decisionmaking. One of the interviewees describes the perception towards the IEBPe like this:
\n\u201cFirst of all, evidence-based practice is the use of hospital protocols, guidelines and training
\nmanual for health care service especially when we give patient care and do procedures. It is a
\nmatter of reading books and search for research findings. It is also to get updated information
\nduring morning sessions and seminar presentations from experts\u2019 experience (119).\u201d
\nAnother focused group discussion participant expressed his perception as follows:
\n\u201cI understand that EBP is the use of scientifically proved evidence in the health service. It is a
\nmeans of clinical practice based on rules and follows the scientific procedure (FGD5-02).\u201d
\nThe nurses\u2019 and midwives\u2019 attributes
\nThe nurses\u2019 and midwives\u2019 attributes are personal attributes that affect the ability to implement
\nEBP. The nurses\u2019 and midwives\u2019 attributes include knowledge, skill, attitude and experience in
\nIEBP. Knowledge, skill and attitude indicate the credibility of nurses\u2019 and midwives\u2019 expertise
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\nin implementing EBP. However, nurses and midwives felt that they did not have the knowledge, the skill and the attitude to implement EBP. Further, they could not differentiate quality
\nresearch. This was described by one of the interviewees:
\n\u201cI am working in all wards and my colleagues too. . .. I do not expect knowledge and skill at
\nthe competency level to use evidence like standard guidelines, books and research findings. I
\ndo not think that we have the knowledge and the skill to perform every procedure using evidence particularly quality research. Some of the nurses and midwives may not be positive to
\nread the evidence. They are negligent in using evidence (121).\u201d
\nThe observation of BSc midwife using a checklist revealed that there were challenges to perform tasks without difficulty. Skilled delivery was attended without the steps of procedures.
\nThe skill and getting ready to perform the procedure were the practical challenges (H111).
\nExperience in IEBP
\nExperience in IEBP is the subcategory of nurses\u2019 and midwives\u2019 attributes. It is participants\u2019
\nexperience in using evidence such as standard guidelines, hospital protocols, experts\u2019 opinions,
\nbooks and research findings. Nurses and midwives use guidelines and hospital protocol for
\ntheir day-to-day activities. Sometimes, they read books to increase their confidence in clinical
\ndecision-making practice. However, they use research findings to provide health services
\nrarely. The experience of nurses and midwives in IEBP was stated by one of the FGD
\nparticipants:
\n\u201cYou see, implementation of evidence-based practice is beneficial. Medicine is updated every
\ntime. Evidence that we use today may not work for tomorrow. Most of the time, I use guidelines and hospital protocols. However, I didn\u2019t use a research article. Even if, there is an off
\nlibrary in our hospital, we refer to some books. We know our job is teamwork and there is supporting and sharing ideas between team members (FGD4-03).\u201d
\nThe supporting of nurses and midwives for IEBP
\nThe theme \u2018the supporting of nurses and midwives for IEBP\u2019 included the subthemes \u2018the supportive organization to implement EBP\u2019, \u2018the support from Non-governmental Organizations
\n(NGOs) and other stakeholders to implement EBP\u2019 and \u2018the supportive supervision, monitoring and Assessment of IEBP\u2019. The support for nurses and midwives to implement evidencebased practice and managers\u2019 role in supporting organizations affect the ability to implement
\nEBP.
\nSupportive organization to implement EBP
\nNurses and midwives\u2019 managers and ward heads experienced that they did not support organizations to implement EBP. However, they understand that supportive organizational resources
\nlike electronic journals, work-based libraries, books and research findings had an impact upon
\nIEBP. This was described by one of the interviewees:
\n\u201cI ask chief manager, \u201chow to implement evidence- based practice through training and fulfill
\nresources in the hospital?\u201d I did nothing beyond this. I cannot communicate with higher officials and other stakeholders outside this hospital. The chief manager can do this. I understand
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\nusing guidelines, books, hospital protocols, training manuals and experts\u2019 opinions to improve
\nquality health care. (124).\u201d
\nThere should be a strong supportive organization for the existence of the IEBP. However,
\nnurses and midwives felt no support and commitment in using updated guidelines, journals
\nand protocols. This was described by one of the FGD participants:
\n\u201cUpdated evidence like guidelines, hospital protocols, books and journals should be available
\nto apply the evidence-based practice. I do not think that we are using updated guidelines and
\nhospital protocols. As a nurse and midwife, commitment is essential. We have to support each
\nother and get support. I do not remember this was done practically (FGD3-06).\u201d
\nNGOs\u2019 and other stakeholders\u2019 support for IEBP
\nOne cannot expect the IEBP without the support of both local and international stakeholders.
\nNon-governmental organizations like the world health organization, the health bureau and the
\nEthiopian ministry of health support hospitals by providing training for nurses and midwives,
\ndistribution of guidelines and training manuals. However, the NGOs\u2019 and other stakeholders\u2019
\nsupport for implementing EBP is still inadequate. There is no training considering research
\nfindings to use in clinical decision-making practice and healthcare. One of the labor and delivery ward head midwife describe the stakeholders\u2019 support as follow:
\n\u201cThere are NGOs like CDC, World Vision and Gender Health Ethiopia that provide shortterm training and different guidelines. These organizations did well but it is not adequate support. We use these updated guidelines. Nevertheless, there is a big gap in using research articles
\nand there are no supporters to use it (105).\u201d
\nThe supportive supervision, monitoring and Assessment of IEBP
\nMentoring and supportive supervision, control and Assessment were identified in all FGD and
\ninterview participants to change IEBP. One of the interviewees stated his experience:
\n\u201dWhat do you mean? How could we change without the mentoring and supervision of the
\nIEBP? I understand that it is important. However, there is no direct mentoring and supportive
\nsupervision, control and Assessment of nurses\u2019 and midwives\u2019 use of guidelines, books and
\nmanuals. We do it indirectly. I do not expect something good towards the use of research in
\nour clinical settings (112).\u201d
\nThe perceived barriers to IEBP
\nThe theme \u2018the perceived barriers to IEBP\u2019 involved the subthemes \u2018knowledge and skill\u2019,
\n\u2018insufficient time\u2019, \u2018lack of resource and training\u2019, and \u2018lack of motivation\u2019. The data analysis of
\ninterview, FGD, field note and observation identified the barriers of IEBP.
\nInsufficient time
\nAll the study participants described that shortage of time was a barrier to implement EBP. One
\nof the emergency ward head nurses described this barrier as follow:
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\n\u201cWe do not have any plan of implementation of evidence-based practice because of emergency
\nactivities. We work for 24 hours. We are too busy. We can get different pieces of evidence from
\nthe library. However, we cannot go to the library due to a lack of time in this emergency ward.
\nNurses are few compared to emergency activities. Nurses are working continuously. They are
\nstrong. Nurses do not use evidence because of the workload. As I told you, we have a shortage
\nof time. I have no time to read books. There is tiredness. We sleep, when we get time. We cannot consider anything rather than this because of a shortage of time (111).\u201d
\nLack of resources and training
\nThe data from FGD, interview, field note and observation indicated that participants did not
\nimplement EBP because of a lack of guidelines, hospital protocols, books, research articles and
\ntraining. One of the key informants described the condition:
\n\u201cNurses and midwives use guidelines, books and hospital protocols. However, it is not easy to
\nget books, guidelines and recent research. Nurses and midwives do not understand the best
\nresearch findings. They do not have the skill to use it and we need training. We cannot get
\nupdated guidelines and manuals for most of the procedures (122).\u201d
\nDuring the hospital visit, the observation revealed that most of the procedures did not have
\nguidelines and hospital protocols and there were no books and literature in the ward. Moreover, most of the hospitals had no library, computers and internet access in the wards. The
\nnurse claimed the nonuse of these resources (H105).
\nLack of motivation
\nThe majority of interviewees and FGD participants believed that motivation is one of the driving forces of implementing EBP. They describe personal derive and motivation to change the
\nIEBP. It is impossible to change the existing EBP of health care and clinical decision-making
\nwithout personal drive and motivation. This was described by one of the key informants:
\n\u201dLet me tell you the real history of an educated patient and doctor. The doctor has been a long
\ntime in the hospital. He was frustrated and he was as he had been graduated from college.
\nThere was no incentive for him to do his job and negligence is his habit which does not lead to
\na good attitude. The patient knows the doctor very well. The patient got this doctor during the
\nexamination, and the patient said that no. . .he did not read anything about his profession
\nafter he had been graduated. The patient went to another doctor who was working in the university thinking that he read many books and articles. Similarly, nurses and midwives were
\nnot motivated to update themselves through reading books, guidelines and research articles.
\nThey stick to traditional practice (108).\u201d
\nNurses and midwives blamed that having unclear job descriptions decrease their interest
\nand motivation in doing their job. One of the participants stated that an unclear job description decreases motivation to implement EBP.
\n\u201cThere are no job descriptions of MSc, BSc and diploma nurses and midwives. There is no
\nclear demarcation of job descriptions among nurses and midwives based on the level of education. You see here, this is a matter of morals. I feel less interested when I am always doing the
\nsame job of diploma (101).\u201d
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\nDiscussion
\nThis study presented that the participants\u2019 perception towards IEBP, the nurses\u2019 and midwives\u2019
\nattributes, the supporting of nurses and midwives for IEBP, and the perceived barriers of IEBP
\nwere the main themes of analysis. The participants had an understanding of how to implement
\nEBP. The supporting of nurses and midwives to implement EBP indicates quality healthcare
\nand working for safe patient care [2, 20]. Barriers to IEBP of nurses and midwives were the primary concern in the experience of IEBP [21, 22].
\nIn this study, participants were seen to perceive the concept of IEBP. They understood that
\nIEBP was using different types of evidence as a source of knowledge and skill in clinical decision-making practice and healthcare service. They know which types of evidence they used frequently. Commonly, participants use guidelines, hospital protocols and training manuals for
\nclinical decision-making practice in our study conducted among nurses and midwives working in Amhara Region public hospitals. The studies conducted in Ghana and England were in
\nline with this finding which indicated participants\u2019 understanding of IEBP [7, 20]. However,
\nour study findings showed that research was rarely used. This is because of a lack of understanding to use research and participants\u2019 trust to use it for IEBP.
\nThis study conducted in Amhara region public hospitals revealed that there was little support for nurses and midwives to implement EBP, and managers\u2019 and ward heads\u2019 commitment
\nto support nurses\u2019 and midwives\u2019 IEBP was not successful. Moreover, nurses and midwives use
\nguidelines and protocols without concern for the update. This finding let us understand the
\nsupport for IEBP consisted of all the management team that provided mentorship, delivering
\nresources and commitment to collaborative activities. This finding agrees with the studies that
\nreported that barriers and facilitators to EBP occurred at the organization and individual level
\n[21\u201324]. The reason could be less support of staff to decrease barriers of IEBP due to lack of
\nmanagers\u2019 commitment, poor access of resources and lack of expertise to share updated information in all studies with the same finding. Therefore, there should be support where there
\nwere barriers to the IEBP.
\nThis study identified that the barriers to implementing EBP were time mismanagement,
\nlack of knowledge, negative attitude, lack of motivation, lack of resources and training. These
\nbarriers could be categorized under individual and institution level barriers. Studies conducted
\nin Canada, Ghana, Germany, Iran, China and Jordan presented these barriers to implementing
\nEBP [20, 22, 23, 25\u201327]. However, the perceived causes of these barriers to use guidelines, hospital protocols, books, experts\u2019 opinions and research in our study were different from causes
\nof barriers to IEBP in other studies. In our study, participants perceived that barriers to implementing EBP stem from the lack of incentive and unclear job descriptions between diploma
\nand MSc nurses and midwives. Diploma and MSc nurses and midwives were seen to have the
\nsame clinical practice activities because of unclear job descriptions between diploma and MSc
\nnurses and midwives. Participants had no interest in implementing EBP. Our study findings
\nalso indicated that nurses and midwives did not read books, guidelines and research in clinical
\ndecision-making practice due to negligence in doing the same thing. Otherwise, the USA\u2019s
\nstudy revealed that the lack of motivation was common among nurses working for long years
\nin one health facility which resulted in the loss of interest due to the length of time between
\nformal academic training and current employment [28].
\nDenmark\u2019s study also revealed that lack of motivation of nurses presented and the perceived
\ncause of lack of motivation was failed IEBP due to nobody taking action on the agreed plan
\n[29]. Otherwise, our study also presented that the participants were inclined to traditional clinical practice. Our study participants think that the use of updated evidence added the burden
\nor workload to their day-to-date activities. They were negligent and they were not interested.
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\nThey were not motivated. They also wanted incentives and support to implement evidencebased practice.
\nOur study revealed a lack of supportive organizational resources to get electronic journals,
\na work-based library, and access to books and research. Otherwise, the lack of support presented in the study of Denmark was non-formalized at the organizational level. Denmark\u2019s
\nstudy had no problem of sharing new sources of evidence and consensus decision to use the
\nnew evidence [29]. The possible reason for this difference in this lack of support for both studies could be better promotion of implementing EBP in Denmark.
\nOne of the outcomes identified as subthemes was \u201cthe lack of resources and training.\u201d The
\nparticipants had difficulty of getting updated guidelines, books and research findings. They
\nhad a knowledge gap even if they got journals and they wanted training to use research. As far
\nas our search for other similar studies, no other studies reported this finding.
\nThe strengths and limitations
\nThe study\u2019s major strength is the use of interviews, FGDs and observation data collection techniques that contributed to providing insight into the complexity of IEBP in the health care system. The risk of bias was restricted by ensuring privacy for the interviewee and a quiet room to
\nconduct FGD. This study addresses that IEBP in this study is typically underpinned through
\naddressing supporting factors for IEBP, perceived barriers of IEBP and the experience IEBP.
\nThe first limitation of this study was the possibility for social desirability bias as the study
\nwas conducted using interview and FGD methods, while nurses and midwives were working
\nin the hospitals. Moreover, the response of the participants might be inflated or underestimated due to individuals with some interests. Second, this study was conducted in hospitals
\nwhere a more advanced human resource dynamic, quality medical service and well-organized
\nstructure were available. Hence, transferability is difficult for health centers and health posts.
\nConclusions
\nThe experience of IEBP indicated that there was limited support for IEBP. Nurses and midwives used guidelines, hospital protocol and training manuals in the clinical decision-making
\npractice. However, the research was rarely used in clinical practice. The knowledge, attitude
\ntowards IEBP, lack of training, time mismanagement and lack of motivation were the barriers
\nto implementing EBP. The study\u2019s findings will serve as a baseline for measuring and monitoring change in IEBP readiness following a tailored educational and organizational intervention.
\nTo implement EBP and to provide high-quality healthcare, organizational and individual level
\nsupport for the IEBP is crucial. Moreover, the promotion of adopting EBP and training on the
\nidentified barriers are mandatory. Future research should be conducted to see the impact of
\nIEBP on the quality health care.
\nSupporting information
\nS1 File. Availability of data and materials. The data set necessary to replicate our study findings as supporting information files.
\n(DOCX)
\nS2 File. Tools. The interview, FGD and observation guides used in the study were both
\nAmharic and English language.
\n(DOCX)
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\nAcknowledgments
\nWe are thankful to data collectors and all nurses and midwives working in Amhara region
\npublic hospitals for their willingness to participate in the study. We would also like to thank
\nDebre Tabor University College of health science department of midwifery for the facilitation
\nof activities of the Center for International Reproductive Health Training and Amhara Region
\nHealth Bureau for giving information on the study population.
\nAuthor Contributions
\nConceptualization: Asrat Hailu Dagne, Mekonnen Haile Beshah.
\nData curation: Asrat Hailu Dagne, Mekonnen Haile Beshah.
\nFormal analysis: Asrat Hailu Dagne.
\nInvestigation: Asrat Hailu Dagne.
\nMethodology: Asrat Hailu Dagne, Mekonnen Haile Beshah.
\nProject administration: Asrat Hailu Dagne.
\nSoftware: Asrat Hailu Dagne.
\nSupervision: Asrat Hailu Dagne, Mekonnen Haile Beshah.
\nValidation: Asrat Hailu Dagne, Mekonnen Haile Beshah.
\nVisualization: Asrat Hailu Dagne, Mekonnen Haile Beshah.
\nWriting \u2013 original draft: Asrat Hailu Dagne.
\nWriting \u2013 review & editing: Asrat Hailu Dagne, Mekonnen Haile Beshah.
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\nPLOS ONE
\nEvidence-based practice
\nPLOS ONE | https:\/\/doi.org\/10.1371\/journal.pone.0256600 August 27, 2021 12 \/ 12<\/p>\n","protected":false},"excerpt":{"rendered":"
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