Knowledge , Practice and Self-Efficacy in Evidence-Based Practice among Midwives in East Iran

OBJECTIVES
The successful implementation of evidence-based practice (EBP) can lead to appropriate and effective midwifery care during pregnancy, childbirth and in the postnatal period. However, levels of knowledge and confidence in one's ability to apply EBP are related to its effective implementation. This study aimed to investigate levels of knowledge, practice of and self-efficacy towards the use of EBP among midwives in East Iran.


METHODS
This cross-sectional study took place between January and February 2016 and involved 98 midwives employed at two hospitals and all four urban health care centres in Torbat-e Heydariyeh, Iran. Two subscales of the Evidence-Based Practice Questionnaire were used to assess participants' knowledge and practice of EBP, respectively, while a modified version of a previously described scale was used to determine self-efficacy.


RESULTS
A total of 76 midwives participated in the study (response rate: 77.6%). Mean knowledge, practice and self-efficacy scores were 4.48 ± 0.94, 3.53 ± 0.68 and 2.80 ± 0.81, respectively. Significant relationships were found between mean self-efficacy, practice and knowledge scores and proficiency in English language (P = 0.001 each) and statistical methods (P <0.050 each). Additionally, significant relationships were found between knowledge and practice of EBP and proficiency in the use of databases (P <0.050 each). Knowledge and self-efficacy scores were significantly correlated with practice (P = 0.001 each).


CONCLUSION
These findings demonstrate a need for improvement in the self-efficacy, practice and knowledge of EBP among midwives in East Iran. Interventions that promote these factors may help increase the use of EBP in this population.


Application to Patient Care -The implementation of EBP is a vital competency for midwives. The moderate levels of EBP knowledge and self-efficacy and poor levels
of practice reported among the Iranian midwives in the current study have alarming implications for future patient care.As such, interventions to promote EBP implementation are recommended in this population.

P
][5][6][7] The National Academy of Medicine in the USA recognises EBP as an essential skill for healthcare providers in the 21 st century. 8Several studies have also indicated that EBP improves the quality and safety of patient care. 6,7,9evertheless, many healthcare decisions are still based on traditional practices, assumptions, personal experiences and individual opinions and skills. 10,11The possession of adequate knowledge and skills is essential for gathering and appraising evidence and implementing best practices in a clinical setting. 42][13][14] In a study analysing perceptions of EBP among nurses, Melnyk et al. found that fewer than half of the participants believed that their colleagues consistently used EBP in patient care. 5Similarly, Zhou et al. indicated that most Chinese nurses lacked practice in many EBP-related skills. 157][18] Several studies have indicated that the majority of healthcare professionals do not have the desired level of selfefficacy in the implementation of EBP. 11,19o the best of the authors' knowledge, few studies have focused on the knowledge, practice and selfefficacy of EBP among Iranian midwives.As health policies in Iran are based on population growth, the role of midwives is becoming more prominent, due to their importance in the pregnancy and childbirth process.This study therefore aimed to determine levels of knowledge, practice and self-efficacy towards EBP in clinical decision-making among midwives working in hospitals and healthcare centres in Torbat-e Heydariyeh, Iran.

Methods
This descriptive cross-sectional study took place from January to February 2016 and included 98 midwives employed at two public hospitals and all four urban health centres in Torbat-e Heydariyeh.Only those midwives with at least six months of work experience at the time of the study were included.Midwives who were sick or on maternity leave during this period were excluded from the study.A convenience sampling method was used to recruit the midwives.All midwives in the hospitals and health centres were informed of the study goals and were invited to participate at the beginning of each work shift.
A questionnaire was designed to collect information regarding the participants' sociodemographic and professional characteristics, including age, education level, number of years of work experience, previous participation in EBP courses, proficiency in English, statistical methods and use of databases, participation in conferences or congresses and number of previously published articles in national and international journals.The frequency of use of various print (five items), electronic (eight items) or human (six items) health information sources was scored on a 5-point Likert scale, with a score of 1 indicating never and 5 indicating always. 11In order to assess EBP knowledge and practice, the 14-item and 6-item subscales of the Evidence-Based Practice Questionnaire were used; items were scored on 7-point Likert scales ranging from 1 to 7, indicating poor and best knowledge for knowledge items and never and frequently for practice items, respectively. 20A modified version of a previously described EBP self-efficacy scale was used to determine the participants' self-efficacy towards implementing EBP. 11These eight items were scored on a 5-point Likert scale, with scores of 1 and 5 indicating poor and best efficacy, respectively. 11ll of the questionnaire items were translated from the original English into Persian, after which two linguists made revisions to ensure the validity of the translations.Subsequently, the content and face validity of all questionnaire items was confirmed by a group of experts.Additionally, Cronbach's alpha values indicated good internal consistency reliability of the knowledge (0.81), self-efficacy (0.88), practice (0.70), print information sources (0.72) electronic information sources (0.88) and human information sources (0.72) questionnaire items.The various questionnaire subscales were compiled into one survey which was distributed individually to each midwife.The researchers then collected the completed surveys from midwives at each hospital and healthcare centre.The entire survey took approximately 15 minutes to complete.
Data were analysed using the Statistical Package for the Social Sciences (SPSS), Version 19.0 (IBM Corp., Chicago, Illinois, USA).Means, standard deviations and frequencies were calculated for the descriptive data.To determine relationships between variables, Pearson and Spearman's correlation tests were performed.A P value of <0.050 was considered statistically significant.
This study was approved by the Ethical Board Committee of Torbat Heydariyeh University of Medical Sciences (#IR.THUMS.REC.1394.2).All of the midwives provided written informed consent before participating in the study.Midwives were assured of the confidentiality of the data before recruitment.Once analysed, the results of this study were provided to the midwives and officials of the participating health centres and hospitals.

Results
A total of 76 midwives participated in the study (response rate: 77.6%); of these, 42 (55.3%)were employed by hospitals and 34 (44.7%) by health centres.The mean age of the participants was 29.30 ± 4.86 years (range: 22-43 years old).The percentage of midwives with a bachelor's or master's qualification was 93.4% and 6.6%, respectively.The mean number of years of work experience was 5.22 ± 4.21 years (range: 6 months-18 years).Overall, 44.7% of the midwives had previously taken part in EBP training courses.Most of the participants were moderately proficient in English (63.2%) but had low proficiency in statistics (48.7%) [Table 1].
Mean knowledge, practice and self-efficacy scores were 4.48 ± 0.94, 3.53 ± 0.68 and 2.80 ± 0.81, respectively.Mean scores for individual items in the knowledge subscale ranged from 3.78-5.29.Determining the validity and usefulness of material were the knowledge items with the lowest mean  4].
In terms of health information sources, print sources were most frequently employed, closely followed by electronic sources (3.43 ± 0.86 and 3.13 ± 0.97, respectively).Among print information resources, textbooks and instructions/handouts produced by the Iranian Ministry of Health (MOH) were the most frequently used (3.96 ± 1.15 and 3.92 ± 1.06, respectively).Websites identified via an Internet browser search engine were the most frequently used electronic source (3.50 ± 1.43), followed by online tutorials provided by professional associations, medical libraries or overseas hospitals (3.36 ± 1.28).Finally, the most common human sources of health information were colleagues (3.41 ± 1.27) and physicians (3.32 ± 1.24) [Table 5].
A bivariate correlational analysis was performed to determine relationships between EBP knowledge, self-efficacy and practice scores and the demographic and professional characteristics of the midwives.Significant relationships were observed between education level and knowledge, self-efficacy and practice (P = 0.001, 0.010 and 0.013, respectively).Moreover, significant correlations between knowledge, self-efficacy and practice were observed with   proficiency in English (P = 0.001 each) and statistical methods (P = 0.002, 0.016 and 0.015, respectively).Similarly, knowledge and practice had statistically significant relationships with proficiency in the use of databases (P = 0.015 and 0.005, respectively).Midwives with a higher number of published articles in national journals also had significantly higher self-efficacy scores (P = 0.023).No correlation was noted between previous EBP training and knowledge, self-efficacy or practice.Finally, significant relationships were found between mean knowledge scores and self-efficacy and practice (P = 0.001 each) and between mean self-efficacy scores and practice (P = 0.001) [Table 6].

Discussion
Overall, different levels of EBP knowledge, practice and self-efficacy have been reported among health professionals. 6,11,21,22These findings may be useful in developing a comprehensive and appropriate strategy for promoting EBP, leading to more effective patient care. 23In the current study, levels of knowledge and self-efficacy among the midwives were slightly higher than average, while their practice scores were below average.Previous research has also demonstrated moderate mean knowledge scores among nurses and nursing faculty. 5,13,24,25 Participants of the current study demonstrated the least self-efficacy when it came to their ability to convert a clinical problem into a well-formulated question and to apply an intervention based on the most applicable evidence.Similarly, Mohsen et al. found that most clinical nurse specialists had no confidence in their ability to translate clinical problems into well-formulated questions. 26The ability to apply interventions based on the most applicable evidence was also one of the highest priorities identified in another Iranian study. 19In general, EBP should begin with a precise and structured clinical question; it is therefore important that midwives develop the necessary skills to convert informational needs into questions.Subsequently, evidence can be applied to a clinical decision. 27In the current study, mean scores for the remaining self-efficacy items were comparable, indicating moderate levels of confidence among the midwives for other aspects of EBP self-efficacy.Other studies have reported mean self-efficacy scores of 2.5-3.5 among nurses. 11,19n terms of mean practice scores, results from the current study indicated that the ability to critically appraise literature, evaluate outcomes of practice and track down relevant evidence were the most important priorities for an EBP intervention among midwives in East Iran.These findings are consistent with those of Shafiei et al. and Brown et al. 24,25 Therefore, educational interventions would be useful to familiarise midwives with the entire EBP process, from formulating answerable questions to finding recent and relevant material, critically evaluating evidence and applying that evidence in practice.
In the current study, midwives with a higher level of education had significantly greater knowledge, self-efficacy and practice of EBP.This may be because midwives with more advanced academic degrees had more knowledge and experience in practicing EBP and were therefore more likely to be confident in their EBP skills.Farokhzadian et al. observed no significant relationship between self-efficacy and academic degree in another study of Iranian nurses; in contrast, Weng et al. also reported that healthcare professionals with more advanced academic degrees more frequently implemented EBP. 12,199][30] In the present study, midwives who were older and had more work experience were not significantly more likely to have greater EBP knowledge, self-efficacy or practice.This finding was supported by a previous study which found no relationships between age or clinical experience with EBP knowledge among nurses. 13However, both Majid et al. and Ferguson et al. have suggested that new nurses have limited practical knowledge and experience and are less confident in the implementation of EBP. 11,31Nearly half of the participants in the current study reported previously taking part in EBP training courses; however, relationships between this variable and EBP knowledge, practice or self-efficacy were not significant, which is inconsistent with previous findings from Iran and Singapore. 11,19ignificant relationships were noted in the present study between proficiency in English language and the use of databases with EBP knowledge, self-efficacy and practice.Previous studies have considered lack of familiarity with English to be a barrier to EBP implementation among non-English speakers. 12,32,33his may be because the majority of up-to-date medical resources are in English.Unfortunately, Frequency of use of health information sources was self-assessed by participants using a Persian version of a previously described questionnaire. 11ignificant at P <0.050.
most midwives in the current study had a low understanding of statistical methods; this is important as significant relationships were identified between proficiency in statistics and EBP knowledge, selfefficacy and practice.Numerous EBP studies have reported that an inadequate understanding of statistical terms and difficulties in understanding statistical analysis are two of the most notable barriers to adopting EBP. 11,24,34,35Therefore, welldesigned education and training courses focusing on familiarity with the English language, database searching skills and statistical methods are potential approaches to increasing knowledge and facilitating the implementation of EBP among Iranian midwives.According to Farokhzadian et al., Iranian nurses use more human and print resources than electronic resources to gain information. 36Similarly, more than half of the nurses in a study by Yoder et al. utilised physicians or nursing peers as their primary information sources. 37Print materials were the most frequently used source of health information in the current study, in particular textbooks and instructions/handouts from the Iranian MOH.Due to the structure, peer review process and legal aspects associated with the publication of these resources, their use in clinical decision-making is justifiable.A significant relationship was observed between use of print resources and EBP knowledge, self-efficacy and practice; this may be due to the continuous updating of printed medical resources.Electronic sources were the second most commonly used source of health information, particularly online tutorials and websites identified via an Internet browser search engine; however, no significant relationships were found between this factor and EBP knowledge, self-efficacy or practice.This may be because browser search engines do not solely provide results from evidencedbased websites.Use of medical e-books and medicinespecific databases was infrequent among midwives in the current study; this may be due to limited Internet access and access to valid databases at home.Midwives in the current study least frequently utilised people as a source of health information; among those who did, colleagues and physicians were the most common information sources.As with electronic sources, no significant relationships were identified between frequency of use of human information sources and EBP knowledge, self-efficacy and practice.
In the present study, significant associations were observed between knowledge of and self-efficacy towards EBP, both of which were associated with practice.Recent quantitative studies have demonstrated that interventions to promote knowledge can improve EBP implementation. 24,25Adequate training may therefore be helpful in increasing confidence and engagement in EBP among Iranian midwives; additionally, the findings of the present study may aid hospital managers and policy-makers in the development of strategies to promote EBP in this population.Employing midwives with more advanced academic degrees, providing advanced education programmes-including statistics training-and holding journal clubs to improve midwives' confidence in appraising medical literature are potential strategies to encourage EBP implementation in East Iran.
The results of the present study are subject to certain limitations.First, the findings were based on responses to self-administered questionnaire items and may therefore be inaccurate or biased; data collection using interviews and focus groups might have generated more objective results.Second, since the study was cross-sectional, a causal relationship could not be established.As a result, interventional studies are recommended to confirm these findings.In addition, there is a need for further research to investigate other variables affecting the use of EBP among Iranian midwives.

Conclusion
The findings of the current study indicate that there is a need to improve EBP knowledge, self-efficacy and practice among Iranian midwives.In addition, there was significantly greater knowledge, practice and self-efficacy in EBP among participants with more advanced academic degrees, those with increased proficiency in English, statistics and the use of databases and among midwives who more frequently used print sources of health information.Consequently, interventions and training that support these factors may help to increase the use of EBP among midwives in East Iran.

c o n f l i c t o f i n t e r e s t
The authors declare no conflicts of interest.

f u n d i n g
This study was funded by the Torbat-e Heydariyeh University of Medical Sciences (grant number #132).

Number of previously published articles in national journals*
*Due to missing data in the completed questionnaire of one participant, the total cohort for this variable was 75.†Due to missing data in the completed questionnaires of four participants, the total cohort for this variable was 72.scores (3.78 ± 1.36 and 3.97 ± 1.36, respectively) [Table2].In the self-efficacy subscale, mean scores ranged from 3.26-3.88,indicatingthatthe midwives had above-average self-efficacy.However, conversion of a clinical problem into a well-formulated clinical question resulted in a lower mean self-efficacy score in comparison to the other items (3.26 ± 0.98) [Table3].For the practice subscale, mean scores ranged from 3.94-4.97.The most practiced items included sharing information with colleagues (4.97 ± 1.53),

Table 3 :
Self-efficacy towards evidence-based practice* among midwives in Torbat-e Heydariyeh, Iran (N = 76) 11elf-efficacy was self-assessed by participants using a Persian version of a previously described evidence-based practice self-efficacy scale.11Responseswere scored on a 5-point Likert scale, with scores of 1 and 5 indicating poor and best efficacy, respectively.

Table 2 :
Knowledge of evidence-based practice* among midwives in Torbat-e Heydariyeh, Iran (N = 76) 20 = standard deviation; IT = information technology.*Knowledgewasself-assessedby participants using a Persian version of the knowledge subscale of the Evidence-Based PracticeQuestionnaire.20Responses were scored on a 7-point Likert scale, with scores of 1 and 7 indicating poor and best knowledge, respectively.

Table 5 :
Frequency of use of health information sources* among midwives in Torbat-e Heydariyeh, Iran (N = 76)

Table 6 :
Correlations between demographic and professional characteristics and evidence-based practice knowledge, self-efficacy and practice scores* among midwives in Torbat-e Heydariyeh, Iran (N = 76) Knowledge and practice were self-assessed by participants using Persian versions of the knowledge and practice subscales of the Evidence-Based Practice Questionnaire while self-efficacy was self-assessed by participants using a Persian version of a previously described EBP self-efficacy scale.11,20† *