508ReseaRchBritish Journal of Midwifery • July 2016 • .docx

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British Journal of Midwifery • July 2016 • Vol 24, No 7
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Practitioners’ views and barriers
to implementation of the Keeping
Birth Normal tool: A pilot study
The use of unnecessary interventions in labour and birth

continues to rise. A rate of > 19% is seen as medically
unnecessary by
the World Health Organization (WHO) (Gibbons
et al, 2010); in Europe, caesarean section rates
vary between 30–58%, except in the Netherlands
and Scandinavian countries where the rate is
16–17% (Zeitlin et al, 2013). The caesarean
section rate in the UK is currently 26.2%, but
wide variations of 18–34% are reported (NHS
England, 2013). Morbidities associated with such
interventions may have an impact on the long-
term physical, mental and sexual health of women
and disrupt maternal–infant relationships (Beck
and Watson, 2008; Koblinsky et al, 2012; Firoz et
al, 2013). Evidence that such interventions increase
childhood asthma, obesity, diabetes, cancers and
atopic diseases is increasing (Hyde et al, 2012;
Dahlen et al, 2013).
A significant policy initiative in the UK to
reduce unnecessary interventions is promoting
the choice of midwife-led settings for birth. This
model of care recognises women’s ability to give
birth with minimal intervention. A review of
this policy demonstrated that interventions in
obstetric-led environments are 15–25% higher
among low-risk women when compared to
midwife-led settings (Birthplace in England
Collaborative Group, 2011). Currently, only 8% of
women in the UK use midwife-led settings for
birth. Efforts to increase the use of these settings
are hampered by dominant discourses about birth
as a risky process and medical interventions as
necessary to reduce or prevent harm (Coxon et al,
2014). In this context, it is important to consider
how findings of poorer neonatal outcomes among

primigravid women choosing homebirths, and
a transfer rate of 35–45% from midwife-led to
obstetric settings, will have an impact on women’s
decisions (Birthplace in England Collaborative
Group, 2011).
Updated National Institute for Health and Care
Excellence (NICE, 2014) guidelines recommend
midwife-led environments as the choice of place
of birth for women with low-risk pregnancies.
Abstract
Background: Poor implementation of evidence in practice has
been
reported as a reason behind the continued rise in unnecessary
interventions in labour and birth. A validated tool can enable
the
systematic measurement of care to target interventions to
support
implementation of evidence. The Keeping Birth Normal tool has
been
developed to measure and support implementation of evidence
to reduce
unnecessary interventions in labour and birth.
Aims: This pilot sought the views of midwives about the
usefulness and
relevance of the Keeping Birth Normal tool in measuring and
supporting
practice; it also identified barriers to implementation.
Methods: Five midwives supported by five preceptors tested the
tool on a
delivery suite and birth centre in a local NHS Trust. Mixed
methods were
employed. Participants completed a questionnaire about the
relevance
and usefulness of the tool. Semi-structured interviews explored

participants’ experience of using the tool in practice.
Findings: The domains and items in the tool were viewed as
highly
relevant to reducing unnecessary interventions. Not all
midwives
were open to their practice being observed, but those who were
reported benefits from critical reflection and role-modelling to
support implementation. An important barrier is a lack of
expertise
among preceptors to support the implementation of skills to
reduce
unnecessary interventions. This includes skills in the use of
rating
scales and critical reflection. Where expertise is available, there
is a
lack of protected time for such structured supportive activity.
Norms
in birth environments that do not promote normal birth are
another
important barrier.
Conclusions: Midwives found the items in the tool relevant to
evidence-
informed skills to reduce unnecessary interventions and useful
for
measuring and supporting implementation. To validate and
generalise
these findings, further evidence about the quality of items needs
to be
gathered. Successful implementation of the tool requires
preceptors
skilled in care that reduces unnecessary interventions, using
rating
scales, role-modelling and critical reflection. Such structured
preceptorship requires protected time and can only thrive in a
culture
that promotes normal birth.

Keywords: Normal birth, Validity, Midwifery, Evidence-
informed skills,
Preceptorship
Florence Darling, midwife/researcher, City University London
[email protected]
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Improving the availability and utilisation of such
environments is necessary to improve outcomes.
However, the use of unnecessary interventions
in obstetric environments must be addressed if
women who choose these environments are to
experience positive outcomes. High-risk women
in such units will also benefit from normalisation
(O’Connell and Downe, 2009; Kennedy et al, 2010).
Although midwife-led environments are
associated with reduced intervention, it is
important to consider whether improving
implementation of evidence-informed skills
further can reduce the rate of transfer to obstetric
units. The transfer rate from freestanding
midwifery units of 16.5% with better outcomes,
compared to 21.2% in alongside midwifery
units, suggests that there may be differences
in the quality and quantity of implementation
(Birthplace in England Collaborative Group, 2011).
It also important to investigate whether a lack of
implementation of evidence and involvement of
women in decision-making has resulted in poorer
outcomes among primigravid women who chose
homebirth.
The strength of evidence from research
investigating the reasons for differences in
interventions and outcomes between birthing
environments is of variable quality. However,
a finding common to these studies is poor
implementation of evidence and the lack
of involvement of women in decision-making
(O’Connell and Downe, 2009; Kennedy et al, 2010;

McCourt et al, 2012; Walsh and Devane, 2012).
The importance of systematically measuring care
to understand these variations and improve the
consistency of care and outcomes is emphasised
in policies, research and investigations into
midwifery practice (Kennedy et al, 2010; Stones
and Arulkumaran, 2014; Alderwick et al, 2015;
Kirkup, 2015).
The Keeping Birth Normal tool
This study piloted a tool to measure the
implementation of evidence to reduce unnecessary
interventions in labour and the first hour of
birth. The validation of the Keeping Birth Normal
(KBN) tool is in the developmental stage. The
tool is based on a model that sees birth as a
normal and healthy event, and the involvement of
women as necessary to achieve positive outcomes
(Department of Health (DH), 2007; Green, 2012).
The care includes the first hour of birth, where
risk of intervention is increased if there is a lack
of skills to support the physiological birth of
the placenta and promote transition of the baby
to external life (Dodwell and Newburn, 2010;
American College of Nurse-Midwives et al, 2012).
Several tools have been developed to measure
Table 1. Domains in the Keeping Birth Normal tool
Twelve domains Evidence-informed skills
1. Philosophy Orientation to reduce interventions
2. Facilitating choice Inclusion of women to improve outcomes

3. Guidelines Use of evidence to improve outcomes
4. Partnership working and communication Use of evidence to
promote safe practice
5. Environment Supports physiological birth
6. Supporting women in labour Care that supports physiological
processes to reduce interventions
7. Progress in early labour Care that supports physiological
processes to reduce interventions
8. Active labour Care that supports physiological processes to
reduce interventions
9. Imminent birth Care that supports physiological processes to
reduce interventions
10. Birth of placenta Care that supports physiological processes
to reduce interventions
11. Birth of baby and breastfeeding Care that supports
physiological processes to reduce interventions
12. Respecting women Building relationships that improve
outcomes
Table 2. An example of two domains, items and rating scale
2. Facilitating choice 0 1 2 3 4
2.1. The woman’s choice is the focal point of my
discussions with her regarding plans for her birth
2.2. I am up to date on evidence to support choices
in normal birth

2.3. I act as the woman’s advocate when the woman’s
choice falls outside of guidelines
3. Guidelines 0 1 2 3 4
3.1. I use local and national guidelines during
information-giving
Rating scale: 0 = unable to assess; 1 = rarely uses this skill; 2 =
sometimes uses this skill;
3 = frequently uses this skill; 4 = consistently uses this skill
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to surveys and interviews, often used to study
implementation (Ubbink et al, 2013). It could
be used widely in the field of normal birth to
measure and support the implementation of
evidence, gather evidence of why interventions
are reduced in some environments compared
to others, measure the inclusion of women
in decision-making, and potentially enable
researchers to draw causal links between the
use of approaches associated with reduced
interventions and outcomes.
Validation
The validation of the KBN tool is informed by
Kane’s Interpretation and Use framework
(Figure 1). This framework is based on the theory
that validity is not about the properties of a tool,
rather the inferences that are drawn from its use
(Messick, 1989; American Educational Research
Assocation et al, 1999; Kane 2013). This is relevant
to health care, where interventions are concerned
with achieving a particular outcome. For example,
where evidence-informed care is used, does it
result in reduced interventions and improved
outcomes, and how is the use of evidence to
be supported so that positive outcomes can be
achieved?
This framework is chosen because it offers
a practical and easy-to-use guide on a complex
process. It promotes an iterative process to

maximise validity and reduce error from
instrument design (Kane, 2013). There are two
stages to the validation, a developmental stage
and an appraisal stage. The validation of the KBN
tool is in the developmental stage. This study aims
to pilot the tool in the practice environment.
Aims
This study’s objectives are:
l To rate the relevance of the domains to reducing
unnecessary interventions
The Keeping Birth
Normal tool has the
potential to support
implementation through
structured preceptorship
and peer-review
processes to reduce
variations, promote
physiological birth and
improve outcomes ’
‘
support in labour (Ross-Davie et al, 2013; Dunne
et al, 2014). Though shown to be vital to improving
outcomes, this is only one measure of care
described to reduce unnecessary interventions
(Dodwell and Newburn, 2010; NICE, 2014). The
KBN tool measures care under 12 domains and
50 items (approaches) on evidence-informed skills
to support a normal birth (Table 1; Table 2).
Post-validation, the KBN tool has the potential

to support implementation through structured
preceptorship and peer-review processes to reduce
variations, promote physiological birth and
improve outcomes. It can be used by midwives
to provide evidence of skill development when
preparing for revalidation with the Nursing and
Midwifery Council (NMC). It may be considered
for use by Trusts, which may be given responsibility
for supervision under current changes proposed by
the Government to the statutory supervision of
midwives (DH, 2016).
In relation to research, the KBN tool can be
used to produce more robust evidence compared
Figure 1: Interpretation and Use framework (Kane, 2013)
State the
interpretation and
use of the tool
Decide what types
of validity evidence
are needed
Developmental stage:
Use appropriate
methods to gather
the different types of
validity evidence
Appraisal stage:

Test plausibility of
validity argument
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l To explore the views of practitioners about the
domains, items and scales of the KBN tool
l To explore the usefulness of the tool in

supporting the implementation of evidence-
informed skills
l To identify barriers to implementation of the
tool.
The evidence gathered will be used to refine
domains, items and rating scales prior to gathering
validity evidence about content. The study will
also explore the practitioners’ experiences of
using the tool in practice. This is particularly
relevant to developing tools in health care,
where usefulness and relevance—including how
successful implementation can be achieved—must
be considered prior to engaging in the lengthy and
expensive process of validating a tool (Moore et al,
2015; Streiner et al, 2015a).
Ethical approval
The chair of the local Research and Development
Office advised that National Research Ethics
Service ethical approval was not required as
the study did not involve NHS patients as
participants. The risk of harm to women being
cared for by a registered midwife with support
from an experienced preceptor are minimal.
The women were informed about the study by
preceptors and no concerns were expressed. The
midwife participants were fully informed about
the study and were aware that they could with-
draw participation at any time. Confidentiality
and security of data were ensured in line with
the Data Protection Act 1998 and Declaration of
Helsinki 2008.
Methods and methodology

This study drew on pragmatism to inform
its design. Pragmatism is often linked with
practicalities associated with the ‘how to’ aspects
of research and the use of mixed methods
(Creswell and Clark, 2011). Morgan (2014) argues
for a philosophical foundation to pragmatism.
He draws on the work of John Dewey and notes
that research is a process of inquiry based on
thoughtful ref lection informed by experience.
In gathering validity evidence, this study
applied the philosophical underpinning of
pragmatism by using practitioners and their
experiences of using the KBN tool to inform the
development of domains, items and scales, and
strategies to promote successful implementation.
It resonates with validity theory where processes
are not purely focused on developing the prop-
erties of a tool but includes gathering evidence
to support the interpretation and consequences
from the use of the tool (Wolming and Wikström,
2010; Kane, 2013). Preceptorship offered the
opportunity to pilot-test the tool. Preceptorship
is not mandatory and the manner in which it
is organised varies among Trusts (DH, 2010).
However, it is an important process for targeting
interventions to support implementation.
Mixed methods were used in this study
(Creswell and Clark, 2011). A quantitative method
was used to rate the relevance of domains to
reducing unnecessary interventions and the
usefulness of the tool. A qualitative approach
was used to explore the experiences of preceptors
and midwives who used the tool in practice;

refine domains, items and rating scale; explore
usefulness in greater depth; and identify barriers
to implementation.
Sample
Midwives
All midwives (n = 35) involved in the care of
labouring women at a local Trust were invited to
participate in the study. Participants were sought
via an email list. Flyers inviting participation
were displayed prominently in all birthing
environments. The consultant midwife identified
several midwives who could benefit from
participation, but recruitment from this group
was unsuccessful. The final sample comprised
three midwives from the birth centre and three
midwives from the delivery suite (Table 3).
Table 3. Description of sample: Midwives
Midwife Current location Experience
Midwife 1 Birth centre (freestanding) 1 year (delivery suite)
Midwife 2 Birth centre (freestanding) 1 year (delivery suite)
Midwife 3 Birth centre (freestanding) 6 months (delivery suite)
Midwife 4 Delivery suite; moved to the
birth centre after second
evaluation
6 months (delivery suite)
Midwife 5 Delivery suite 2 years
Midwife 6 Delivery suite; dropped out after

third evaluation
2 years
Table 4. Description of sample: Preceptors
Preceptor Experience
Preceptor 1 Senior midwife/researcher/PhD student/lecturer
Preceptor 2 Senior midwife/researcher
Preceptor 3 Senior midwife
Preceptor 4 Senior midwife
Preceptor 5 Senior midwife/midwifery lecturer/researcher
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Preceptors
Midwives with expertise in working in the field
of normal birth were invited (Table 4). Four
had several years of experience working in a
freestanding maternity unit and had regularly
acted as preceptors. Apart from relevant practice
experience, three were also involved in research
into normal birth. Two were lecturers in midwifery
and acted as preceptors on the delivery suite,
where it was felt that piloting the tool without
external preceptors would not be possible because
of staffing shortages.
Using the tool
Midwives began the process by assessing their
practice with the tool. This was followed by
five sessions in practice with preceptors, where
the midwife’s practice was assessed, supported,
and progress measured by their preceptor. The
portfolio at the end of the preceptorship included
five rated practice sessions by the midwife and
preceptor, five ref lections on using approaches to
reduce unnecessary interventions, and a record of
practical application of these approaches.
Data collection and analysis

Midwives and preceptors who used the tool
completed a questionnaire which had been
previously piloted with two other researchers
before use. It comprised statements about the
relevance of the domains to reducing unnecessary
interventions, the need for such a tool in practice
and its usefulness in different categories of staff,
and the provision of preceptorship to support
implementation. It employed a four-point Likert-
type scale ranging from ‘very useful’ to ‘not at all
useful’. Quantitative data from the questionnaire
were recorded on a Microsoft Excel spreadsheet
and frequencies calculated.
Semi-structured interviews of 1-hour duration
with five midwives and five preceptors were
used to explore in greater depth all the elements
contained in the questionnaire. The interviews
were conducted at the participants’ place of
work, in privacy. All the participants were
practitioners and known to the researcher, except
for three midwives from the delivery suite. The
interviews were audio-recorded and transcribed
in full by the researcher. Raw data were stored
in a master file and kept in a locked cabinet
in the researcher’s office. Data were entered
onto a password-protected computer at the same
location. Personal identifiers known only to
the researcher were used to ensure anonymity
while enabling communication for clarification,
in line with the Data Protection Act 1998. The
raw anonymised data were retained for future
development of the tool and archived in a secure
university database for a minimum of 5 years,
complying with sponsorship guidance.

Data were analysed using thematic analysis. The
researcher read the data several times, compared
the data sets and colour-coded commonly recurring
themes (Green and Thorogood, 2009). Specificity
and frequency were noted. Under each theme,
descriptive text was used to explore the theme,
supported by quotes drawn from transcribed data
(Mays et al, 2005). The data analysis and report
were subsequently sent to all participants in the
study for comments, and no disagreement was
expressed (Mays et al, 2005).
Findings
Five midwives and four preceptors completed
the questionnaire in full. One of the preceptors
felt unable to use the Likert-type scale to rate the
relevance of the domains.
Generally, the midwives and preceptors felt that
the tool:
l Acted as a checklist to keep care on a normal
pathway and provided a platform to discuss
and support the implementation of evidence-
informed skills
l Fostered a physiological understanding of birth
l Provided an opportunity for reassurance,
Table 5. Midwives’ rating of usefulness of measuring practice
in different categories of staff and preceptorship
Midwives Very
useful
Quite

useful
Not very
useful
Not at all
useful
Use in measuring practice 1 4
Use in student midwives 5 0
Use in newly qualified midwives 4 1
Use in experienced midwives 1 3 1
Usefulness of preceptorship 3 1 1*
* Did not receive preceptorship from the same midwife
throughout the pilot
Table 6. Preceptors’ rating of usefulness of measuring
practice in different categories of staff
Preceptors Very
useful
Quite
useful
Not very
useful
Not at all
useful
Use in measuring practice 3 2

Use in student midwives 3 1
Use in newly qualified midwives 3 1
Use in experienced midwives 2 2
Note: one preceptor rated the tool’s use only in measuring
practice; she did not feel
comfortable using the rating scales and preferred to speak about
her experiences
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feedback and developing confidence.
Three preceptors and one midwife saw the
tool as ‘very useful’ for measuring practice, and
two preceptors and four midwives felt it was
‘quite useful’. The midwives had been in practice
for 6 months to 1 year before participation and
explained that they would have benefited far more
if they had used the tool soon after qualification
(Table 5; Table 6).
Midwives felt that interventions via
preceptorship with the tool offered opportunities
for ref lection, critical discussions, writing about
their experiences in reducing unnecessary
interventions, and building confidence to
implement evidence-informed skills. One midwife
felt she would have benefited far more from the
experience if she was supported by same preceptor
throughout the pilot.
Of the three midwives who participated
from the delivery suite, only one completed her
participation there. Despite having been qualified
for 2 years, she found the tool very useful. One
moved to the birth centre after her second meeting
with her preceptor, while another dropped out of
the study.
One of the preceptors (P5) described the tool
as ‘difficult to get to grips with’, particularly
the use of the Likert scale to monitor progress.

This preceptor felt that the scale of 0–4 did not
adequately capture the development that had
taken place; it was seen more as a tool to support
and ref lect on practice. The use of the tool to
rate practice was questioned because of the many
constraints on the ability of the midwife to use
skills to reduce unnecessary interventions.
Refining domains, items and rating scale
All domains were scored highly for relevance to
reducing unnecessary interventions, with a score
of 7/10 or more (Table 7). One of the midwives
wrote that domains where standards are often
allowed to slip were 1, 2, 6, 7 and 12: philosophy,
facilitating choice, supporting women in labour,
progress in early labour, and respecting women.
She hoped that ‘when the tool was used, these
would be the areas that showed the greatest
improvement or receive the highest rating’ (M1).
The relevance of these domains was also scored
highly by all midwives.
Midwives and preceptors endorsed items in
each domain as relevant to reducing unnecessary
interventions, but felt that the number of items
could be reduced because they were similar. Based
on their feedback, items were reduced from 56 to 50.
Qualitative analysis of data from interviews
Four main themes were identified: usefulness
and relevance, measuring practice, supportive
relationships, and preceptorship.
Usefulness and relevance of the tool
All participants felt the tool was useful and

relevant to measuring and providing support to
keep birth normal.
Table 7. Rating of relevance of domains
Relevance of domains in measuring and
supporting evidence-informed skills in
Keeping Birth Normal, using scale of 1–10
Number of
midwives
Number of
preceptors
Domains (Scale 1–10) (Scale 1–10)
7 8 9 10 7 8 9 10
1 Philosophy 1 4 1 3
2 Facilitating choice 1 1 3 1 3
3 Guidelines 5 3
4 Environment 2 3 2 2
5 Partnership working and communication 1 1 1 2 1 3
6 Supporting women in labour 3 4
7 Progress in early labour 1 1 2 1 3
8 Active labour 2 1 2 1 3
9 Imminent birth 2 1 2 1 3

10 Birth of placenta 2 1 2 4
11 Birth of baby and breastfeeding 2 1 2 1 1 2
12 Respecting women 1 4 1 1 2
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‘The tool is comprehensive. Its biggest

strength is it enables us to speak
concretely and objectively about
reducing unnecessary interventions.
Everything we do has a physiological
impact. Breaking it down, assessing,
identifying needs with plans to
improve is fundamental to improving
practice.’ (P1)
‘We went to work on the delivery suite.
We changed everything around to
create a good environment, dimmed
light. It was good to know why I was
doing what I was doing. This was not
guesswork. The tool probes these
discussions which I would not otherwise
have with my preceptor.’ (M3)
For the midwives, the structured approach
acted as a reminder to use evidence-informed
skills. It presented an opportunity for ref lection
and created dialogue about the approaches being
employed. It fostered confidence in the use of
effective approaches; one midwife simply stated:
‘It works’ (M5).
The tool was described as particularly
necessary in the delivery suite environment,
where normalising birth is more challenging
than in a midwife-led environment. Normalising
birth in high-risk women was also identified
as an important area for development using
the tool. One midwife who was supported
described the experience of using the tool among
high-risk women:

‘It is a tool that can be used in all
groups of women to reduce unnecessary
interventions. It was a good experience
for the student midwife as well and
an opportunity to observe and be
part of a team which allowed women
to move from high-risk to as normal
as possible.’ (M5)
This midwife felt confident after her participation
in the study, ‘to not just to keep birth normal but
also to challenge unnecessary interventions’.
Measuring practice
The five midwives in the study rated themselves
highly in their ref lection on practice. However,
preceptors found that several items (approaches)
needed further support and development. The
midwives agreed:
‘After using the tool, I felt able to offer
more options and better able to support
women’s choices. I was using some
of the skills in the tool more than my
colleagues on the delivery suite but on
the birth centre it was deeper, a whole
change in attitude to birth. There was a
lot to ref lect on…’ (M1)
This demonstrates the need for some form
of peer or external assessment to develop
expertise. Rating also allows the preceptor to
provide specific support described by midwives
as more useful, both in this study and in other
work exploring experiences of preceptorship in

practice (Hughes and Fraser, 2011). Two preceptors
questioned whether rating could be discouraging
to midwives who were newly qualified. There
were concerns about the impact on practice by
other pressures in their work environment. A
softer rating, demonstrating a need for support,
was suggested by one preceptor. Others felt
differently, describing it as smart way to learn
and needed in midwifery practice, where learning
was very much ad hoc. One preceptor argued that
formal assessments were an important part of
improving standards; ‘such a tool would fill this
gap’ (P3). Another said:
‘It is unacceptable for midwives not
to be skilled in the items that the tool
describes, or say they do not want to use
such approaches. Can you say you do not
want to do an epidural top-up? If you
cannot say this, how can you say you do
not want to do a water birth?’ (P1)
None of the midwives expressed concern about
being rated. They understood that they were being
supported to improve their skills and were glad to
receive the support:
It was a good
experience for the
student midwife…
an opportunity to be
part of a team which
allowed women to move
from high-risk to as
normal as possible ’

‘
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‘I knew what I did well and what I could
do better next time.’ (M3)
However, it is worth noting that these midwives
were a self-selected group who were keen to

participate in the study.
One midwife described herself as having an
‘enhanced understanding of physiological labour
and birth’ and another as ‘being supported to apply
theory to practice’. This was evidenced in written
ref lections by the midwives and provided greater
detail regarding specific learning that had taken
place in relation to several items in the tool.
Supportive relationships
The midwives felt they needed the support of
their preceptor, not only to implement approaches
in the tool but also to receive reassurance that
they were on the right path, and be praised and
encouraged. Not all of them used the approaches
the tool describes prior to qualifying or during
their induction on the delivery suite.
Initial ref lection on their practice prior to
meeting their preceptors was particularly useful
in helping them assess their own needs in a
non-threatening way. Subsequent discussions and
ref lections with their preceptors and preceptor
role-modelling of approaches were important
facilitators of midwife learning:
‘I have witnessed how simple words said
in the right manner helped my client
calm down. I understood how good
communication [and] close relationship
with the client was important.’ (M5)
Preceptors felt working with the tool helped
foster a relationship where the midwives felt more
able to ask for support without feeling that they

would be judged:
‘It can create a culture of open critique
where the midwife can readily ask
for help to improve their practice,
communicate freely to learn…’ (P3)
Preceptors reported that the tool provided a
platform for raising issues with midwives which
they otherwise might not have done, particularly
if they did not know the midwife or his/her
practice. They were always conscious that they
were working with a qualified practitioner.
The midwives felt better supported to develop
their skills in the birth centre than on the
delivery suite. They felt that even experienced
midwives on the delivery suite lacked the ability
to support their development in skills to reduce
unnecessary interventions. All the preceptors and
some midwives felt that senior midwives on the
delivery suite could benefit from being observed
and supported in their practice using the tool.
The midwives described their experience on the
delivery suite as follows:
‘We were always coming up against
people and situations that did not want
us to keep birth normal.’ (M2)
‘They did not want to explore options.
They said, this is how we have always
done it. I was glad my preceptor was
external or I would not have been able

to do this. Sometimes it was easier to
get support from obstetricians than
midwives.’ (M5)
One of the midwives on the delivery suite felt
bullied and unsupported within the unit, and
withdrew from the study. The preceptor of the
midwife who left the study said:
‘She moved from keeping birth normal
to not engaging in these practices
depending on the pressures put upon
her. Often she was overloaded with work
so she could not cope or be assigned to
complex cases.’ (P1)
This midwife did not consent to an interview.
Her preceptor felt the midwife still benefited
from the three sessions in which she was involved.
Another moved to the birth centre to continue her
practice, and felt that this affected her ability to
use the tool’s approaches:
‘If I had not come to the birth centre,
I would not be using the approaches
the tool described. I was always
confronted with “this is not how we do
it here” and I did not feel able to stand
up to this.’ (M4)
Both preceptors on the delivery suite found
that such attitudes also interfered with their
ability to support midwives. Midwives
participating in the study were assigned to
tasks that did not allow the use of the tool,
despite coordinators being informed about their

participation. They were assigned to high-risk
women when the study required them to be
assigned to low-risk women. Preceptors had
to rearrange the planned engagement with
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midwives. One preceptor eventually decided to
support her midwife by using the tool among

high-risk women, with good results.
Preceptorship
Preceptors felt their ability to build relationships
was affected by time allocated to other
responsibilities. In the birth centre, this included
antenatal, labour and postnatal work. Each
shift was covered by just two midwives. On
the delivery suite, problems included a lack of
staffing, rostering that did not assign preceptors
to their midwives, and a culture that did not
view preceptorship as important to midwife
development.
‘We were given a portfolio to complete
but no one looked at it after this. We
were expected to get on with it.’ (M2)
Both midwives and preceptors questioned the
ability of midwives to act as preceptors and use
tools that are not currently in use nor supported
in midwifery.
‘The quality of preceptorship needs
to improve. There is very little actual
preceptorship that takes place.
Midwives have become de-skilled in this
area. You need competence in the use
of the tool, be a competent practitioner
as well as skilled in helping others
knowing when to intervene and when to
step back…” (P1)
However, there was optimism about the
possibility of the tool creating a ‘snowball effect’

to develop a team of expert preceptors in normal
birth in the future.
Discussion
This pilot study explored the usefulness and
relevance of the KBN tool to measure and support
the implementation of evidence to reduce
unnecessary interventions. All participants felt
that the tool was useful and relevant for this
purpose. This was supported by the high ratings
given to all the tool’s 12 domains. The midwives felt
it should be introduced soon after qualification for
greatest benefit, but findings suggest introduction
at any point can still offer benefits.
The tool promotes a closer scrutiny of
midwifery practices to target specific support
and improve outcomes. Ratings by preceptors
challenged midwives’ perceptions of the use of
evidence-informed skills and created dialogue
and ref lection to improve implementation. There
was a reluctance among some preceptors to rate
practice because of perceptions that it is unfair
in difficult work environments; it was suggested
that the scale include a rating to denote need for
support. However, a 5-point scale can result in
bias from a reluctance to be critical (Streiner et
al, 2015b). This reluctance was not universal, with
some preceptors noting that such assessments
were crucial to improving implementation.
Such an approach is identified as needed in
midwifery supervision and peer review processes
(Alderwick et al, 2015; Kirkup, 2015; Royal College
of Midwives, 2015).
A willingness to be assessed and supported is

necessary to improve implementation. The lack
of response to participation in the study by some
midwives suggests that such willingness may not
always be present. This may be related to cultural
barriers to the implementation of such evidence in
some birth environments. In their metasynthesis,
O’Connell and Downe (2009) describe cultural
obstacles to keeping birth normal, describing
power and control exerted by senior midwives
to ensure that other midwives subscribed to and
complied with norms in the environment; this is
evident in this study.
Midwives were questioned about using
approaches to reduce interventions that were not
commonly employed in the unit. Team leaders
were not open to exploring options, preferring
to intervene in the labour. Preceptors also
encountered midwives who were obstructive in
failing to assist those midwives who wanted to
implement evidence or develop their skills, by
not making opportunities to work with low-risk
women available to them.
Key points
l The Keeping Birth Normal tool is useful and relevant to
measure and
support the implementation of evidence-informed skills to
reduce
unnecessary interventions in labour
l Successful implementation will require midwives’ openness to
scrutiny
of practice and supportive development
l Preceptors are needed who are skilled in keeping birth

normal, with
abilities to engage in supportive development using rating to
assess
needs and progress while employing reflection and role-
modelling
l A culture of open critique and learning, which sees effective
preceptorship as a crucial intervention to support
implementation and
reduce unnecessary interventions in labour, is necessary
l Using such a tool to measure and improve the implementation
of
evidence-informed skills requires a culture that supports—and
does
not penalise—midwives who strive to develop expertise in
keeping
birth normal
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Midwives who felt unsupported on the
delivery suite moved to the birth centre, where
they believed they would be better supported to
develop skills to reduce unnecessary interventions;
this could be a reason why approaches to reduce
interventions tend to be confined to midwife-led
environments. However, as only 8% of women
use such environments, this might be detrimental
to improving outcomes (Birthplace in England
Collaborative Group, 2011).
Kennedy et al (2010) identified a need for further
research on midwifery practices that contribute to
lower caesarean section rates and exploring why
practice varies between environments. The KBN
tool may permit such evidence to be gathered in
the context of a mixed-methods study to include
factors that act as barriers to implementation
of these skills. This is important in promoting
consistency of utilisation of such approaches
across different birth environments.
One of the questions that this study raises
is whether the use of the tool can develop

midwives who are better able to resist dominant
medicalised cultures on delivery suites. This is
worth investigating, as most midwives work in
large tertiary settings and reducing unnecessary
interventions in delivery suites is important to
ensuring positive outcomes for both low-risk and
higher-risk women.
The successful implementation of such a tool
requires expertise in approaches that reduce
unnecessary interventions among midwives who
act as preceptors. Investment in training is needed
in the use of structured approaches that employ
ref lective models to support learning, and the
use of rating scales and measures of progress to
ascertain effectiveness.
In the birth centre, despite the availability of
skills to reduce unnecessary interventions, lack
of staffing and the organisation of work in the
unit interfered with the ability to provide effective
support. On the delivery suite, similar factors—
along with a culture that did not promote normal
birth—acted as barriers (O’Connell and Downe,
2009; Hughes and Fraser, 2011; NMC, 2011).
This suggests the need for mandatory skilled
preceptorship as a crucial intervention to ensure
support for midwives in all birth environments,
including protected time for such activity
(DH, 2010).
The KBN tool requires and warrants further
tests for validity and reliability prior to large-scale
use: it has the potential to measure and support
the development of expertise in keeping birth
normal. However, its successful implementation

in the context of preceptorship, and possibly
other supportive peer relationships, will require
commitment and investment in the education of
midwives and leadership that challenges cultural
barriers to promoting normal birth.
Study strengths and limitations
One of the main strengths of this study is the use
of a framework to ensure a thorough application
of validity theory to practice. The inclusion of
practitioners who were known to the researcher
and a keenness to promote a physiological
approach may have resulted in response bias. The
use of an iterative process that the Interpretation
and Use framework promotes will addresses such
biases (Kane, 2013). The next stage in this iterative
process is content validation, where further
validity evidence about domains and items using
subject experts and women will be gathered.
This was a small study. On completion of
the developmental stage, the tool will undergo
plausibility testing using a larger sample. This
promotes generalisabilty of the tool for large-scale
implementation and validity of inferences drawn
for its use.
Conclusions
All of the midwives in this study, whether newly
qualified or experienced, felt they had benefited
from structured preceptorship using the KBN
tool. The tool provided a platform for measuring
the use of evidence-informed skills, promoting
dialogue and building a relationship that fostered
role-modelling and ref lection to promote

implementation.
Staffing shortages, which reduce the
opportunity to implement such formal and
structured processes that facilitate support, need
to be addressed. Organisations need to develop
and support a culture of preceptorship in the
clinical environment. This includes rostering
and staff allocation during the course of a shift,
assigning of midwives to supportive relationships
and ring-fencing time for such activity. There
is an urgent need for management to address
a culture that is obstructive to approaches that
normalise birth and penalises midwives who want
to implement and develop such approaches.
In conclusion, this study shows that the
KBN tool has the potential to be used in the
context of the preceptor–midwife relationship
to measure and support the implementation of
evidence-informed skills to reduce unnecessary
interventions. Other types of validity evidence
about content, response processes and internal
structure will need to be gathered prior to
testing in a larger study before implementation.
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Successful implementation will require expertise
in the use of approaches to reduce unnecessary
interventions among preceptors in obstetric-led
environments. Additional training in the use of
rating scales, specific skills in role-modelling and
critical ref lection is also needed. The readiness
of midwives to learn is fundamental. Investment
in the use of structured approaches to improve
implementation, supported by organisational
cultures that promote normal birth, is crucial. BJM
Acknowledgement: The author would like to thank her
supervisor, Dr Christine McCourt, City University, for her
support during the study and in writing the article.
Funding: £20 000 was provided for this study by a local
NHS charity.

Conf lict of interest: The author has declared no conflict
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539The Journal of Continuing Education in Nursing · Vol 46,

No 12, 2015
clinical updates
Associate Editors: Elaine L. Smith, EdD, MSN, MBA, RN,
NEA-BC, ANEF
Karen L. Rice, DNS, APRN, ACNS-BC, ANP
Author: Marie Agrell-Kann, RN, MSN, CDE, CWCN
Improving Quality Outcomes Using a Champion Model
for Ancillary Nursing Staff
According to the Institute for Healthcare Improvement (n.d.),
2.5 million patients in the United
States develop pressure ulcers annu-
ally, with 60,000 patients dying as a
result of the complications associ-
ated with this condition. A financial
burden is associated with pressure
ulcers as well. In the U.S., pressure
ulcer care “is estimated to approach
$11 billion (USD) annually, with a
cost of between $10,000 (USD) and
$86,000 (USD) per individual pres-
sure ulcer” (Sendelbach, Zink, &
Peterson, 2011, p. 84).
As early as 2007, the Institute
for Healthcare Improvement (n.d.)
began endorsing the use of a skin care
cham pion model to facilitate improve-
ment in skin and wound care out-
comes. Many hospitals and health
care systems have implemented such
a model to drive an improvement in
skin and wound care initiatives and

ultimately to decrease their hospital-
acquired pressure ulcer (HAPU)
rates. Through the implementation
of a champions model, the hospitals
and clinics of Allina Health, Min-
neapolis, Minnesota, were able to
decrease their HAPU rate by 33%,
with an estimated cost savings of
$430,000 (Sendelbach et al., 2011).
Similarly, the University of Penn-
sylvania Health System was able to
reduce the prevalence of HAPUs
by 37% across four of its hospi-
tals through the use of a champions
model (Carson, Emmons, Falone, &
Preston, 2012).
A literature review demonstrated
that the majority of skin champion
programs were designed with the
registered nurse in mind. Although
several programs involved or included
nonlicensed nursing staff, few were
designed specifically with the ancil-
lary nursing staff in mind.
One such program, Skin–Saver
CNA (Certified Nursing Assistant),
was implemented at Kindred Health-
care, Louisville, Kentucky. Accord-
ing to Kindred Healthcare, CNAs
account for nearly 33% of the direct
care productive work force, and they
spend approximately 60% of their
time at the bedside (Holmes, 2011).

The quality champion model de-
veloped at one hospital in New York
sought to maximize the impact of
its patient care associates (PCAs) by
empowering them with the knowl-
edge necessary to take an active role
in the recognition and prevention of
HAPUs.
The hospital is an academic medi-
cal center located in New York and
has 806 beds and a staff of more than
6,000 individuals. The catchment
area includes more than 1 million
individuals between the ages of 18
and 44, more than 900,000 individu-
als between the ages of 45 and 64,
and approximately 500,000 individ-
uals aged 65 and older.
WHAT IS A CHAMPION?
Champions are opinion leaders,
facilitators, or change agents who
promote the use of evidence-based
practice through effective commu-
nication and interaction with other
staff. Their goal is the diffusion of
new knowledge. They are advo-
cates of new ideas or initiatives and
work diligently to promote them
(Berquist-Beringer, Derganc, &
Dunton, 2009). Champions are lead-
ers who enable change through the
development of self and organiza-

tional awareness. A question from
abstract
The goal of this article is to
describe the implementation of a
champion model for ancillary nurs-
ing staff. As Quality Champions,
nursing assistants attended special-
ized education classes to promote
improvement in quality outcomes
related to skin care, diabetes care,
and prevention of catheter-associated
urinary tract infections.
J Contin Educ Nurs. 2015;46(12):539-
541.
Ms. Agrell-Kann is Wound Care Specialist, North Shore
University Hospital, Manhasset,
New York.
The author has disclosed no potential conflicts of interest,
financial or otherwise.
Address correspondence to Marie Agrell-Kann, RN, MSN,
CDE, CWCN, Wound Care Spe-
cialist, North Shore University Hospital, 300 Community Drive,
Manhasset, NY 11030; e-mail:
[email protected]
doi:10.3928/00220124-20151112-03
540 Copyright © SLACK Incorporated
a highly motivated ancillary staff
member initiated the unique cham-
pions endeavor described in this

article. Knowing about the hospital’s
nurse champion models for various
quality initiatives such as decreas-
ing catheter-associated urinary tract
infections (CAUTIs), central line-
associated bloodstream infections,
patient falls, and pressure ulcers, one
PCA asked, “Can we have a skin
champion program for the PCAs?”
The Wound and Skin Program
at the hospital is led by a team of
advanced practice nurses who are
certified in wound, ostomy, and
continence care. A collaborating
physician, who is a wound care
specialist and a vascular surgeon,
oversees the team, which also in-
cludes a surgical physician’s assistant
and a physical therapist certified in
wound care. This interdisciplinary
team conducts daily team meetings
and wound care rounds to expedite
the care of patients with complex
wounds. The certified wound care
nurses have been offering biannual
skin champion classes for RNs since
2007. Lunch and Learn sessions
were held on a monthly basis at the
outset but are now held on a quar-
terly basis. The RN skin care cham-
pions conduct the monthly pressure
ulcer prevalence rounds and serve as
resources for skin and wound care
issues in their units.

The hospital also has a diabetes
champion program led by a certified
diabetes educator and an interdisci-
plinary diabetes team, whose qual-
ity measures include the reduction
of hypo- and hyperglycemia in the
hospitalized patient and the increase
in patient education and obtaining
A1C blood tests.
All of the aforementioned cham-
pions programs feature an RN as
the champion. When designing a
professional development program
for PCAs, it was decided that select
ancillary nursing staff would receive
special education about skin care,
patient fall prevention, CAUTI pre-
vention, and hypoglycemia manage-
ment; thus, the PCA Quality Cham-
pion Program was born.
WHAT IS A PCA QUALITY
CHAMPION?
A PCA Quality Champion is a
PCA who is an advocate for qual-
ity patient care and a champion of
quality initiatives in their unit. A
PCA Quality Champion serves
as a resource to others, ensuring
that fellow staff are knowledge-
able and safe providers of care with
advanced knowledge of skin care,
diabetes care, and prevention of

CAUTIs. PCA Quality Champions
are charged with promoting a unit
culture of quality and demonstrate
proactive approaches in the identi-
fication and prevention of adverse
outcomes. They also promote effec-
tive and open communication among
the members of the health care team.
The roles and responsibilities of
the PCA Quality Champions were
delineated in a document similar to
a job description, which was shared
with the nurse management staff.
Potential champion candidates were
selected based on their clinical per-
formance, their ability to meet the
criteria established in the roles and
responsibilities mentioned above,
and their internal motivation to par-
ticipate.
In July 2014, the first group of
PCA Quality Champions started
on their journey. They attended an
8-hour on-site class. Speakers from
various areas of the hospital led the
sessions via lectures, presentations,
discussions, and hands-on participa-
tion. Fifty-nine champions attended
the first class. The class proved to
be valuable in many ways. PCA
attendees were excited about their
role in skin care and HAPU preven-
tion. They embraced the idea of being
role models charged with ensuring

that the protocols for skin care were
being followed in their units, includ-
ing patient turning and positioning,
early identification of skin care is-
sues, incontinence management, and
use of appropriate devices for pres-
sure ulcer prevention that included
off-loading products and support
surfaces and linen management. The
PCA is directly involved in point-
of-care testing, and thus would
play a pivotal role in assisting with
the management of hypoglycemia;
therefore, the protocol for hypo-
glycemia was reviewed at length.
The PCAs were curious about
communication—how would they
approach a fellow staff member
who was not following protocol or
policy? Effective communication
techniques and when to escalate
concerns were discussed during the
class.
The PCA Quality Champions
then attended monthly follow-up
meetings. The goal of these meet-
ings was to share information and
discuss the progress of initiatives in
their units and across the hospital.
Topics included deep vein throm-
bosis prevention and prophylaxis;
linen and hazardous waste disposal;
infection control (e.g., procedures

for isolation); use of skin care
products; review of blood glucose
monitoring, including use of the
new SAFETiCET™ lancet. Demen-
tia education, with a focus on the
roll-out of a special activity box
to assist patients who are confused,
was also provided. The PCA Qual-
ity Champion group also designed a
flyer, which was posted in hospital
units, for the hospital’s Safety Week
Program.
RESULTS
To determine their response to
becoming a champion, the PCAs
completed a survey on the 1-year
anniversary of the program. Re-
sponses to questions such as “What
541The Journal of Continuing Education in Nursing · Vol 46,
No 12, 2015
do you like best about being a Qual-
ity champion?” included:
• We feel pride in what we do as
champions.
• It’s important to know why
you need to do something a cer-
tain way, the reason behind it, not
just doing it.
• I like bringing new info back to

my coworkers.
• I like when staff come to me
and ask me questions.
• I like being involved in making
decisions in my unit.
• I feel honored to have this role.
• It’s about doing the right thing
all the time.
• Now I get the chance to say
something when I see some-
thing—staff will hear me.
• Empowerment from more
learning and being educated.
One exemplar of the benefits
of this program was when a PCA,
empowered through her role as a
champion, voiced her concerns to
the nurse manager when she wor-
ried that a nurse in the unit was not
correctly following the protocol
for hypoglycemia. Together, the
concern was communicated and the
nurse emerged with a proper under-
standing of hypoglycemia treatment.
Although other initiatives
throughout the hospital have had
an impact on decreasing hypogly-
cemia, the PCA Quality Champion
Program was one element that had
an impact on both the occurrence
of hypoglycemia and staff’s adher-
ence to the hypoglycemia protocol.
From May 2014 to September 2015,

a 26% increase in fingersticks being
repeated as per protocol was noted.
Also, documentation of treatment
for hypoglycemia increased by 23%
between May 2014 and September
2015. Overall hypoglycemia for the
hospital also decreased from 18%
in May 2014 to 12% in September
2015.
The PCA Champions have con-
tributed to the achievement of the
hospital’s goal for HAPU reduction.
The goal for 2015 was 41 occurrences
annually; as of September 2015,
there have been only 22 occurrences
of HAPUs.
Positive results were noted by
the Environmental Services Depart-
ment when, after a presentation to
the PCA champions on appropriate
linen disposable, compliance with
these techniques rose from 40% to
95%, with a cost savings associated
with linen that no longer was able to
be used now being returned to the
laundry company for credit.
FUTURE IMPACT
The PCA Quality Champion
Program has demonstrated a vari-
ety of benefits for the patients, the
PCAs, the health care team, and
the hospital. Additional education,

training, and practice improvement
programs are underway to continue
to develop the role and engagement
of highly valued PCAs.
REFERENCES
Berquist-Beringer, S., Derganc, K., & Dun-
ton, N. (2009). Embracing the use of
skin champions. Nursing Manage-
ment, 40(12), 19-24. doi:10.1097/01.
NUMA.0000365465.01722.4b
Carson, D., Emmons, K., Falone, W., & Pres-
ton, A.M. (2012). Development of pres-
sure ulcer program across a university
health system. Journal of Nursing Care
Quality, 27, 20-27.
Holmes, C.G. (2011). My scope of practice:
Skin-saving CNAs—Power in leadership
and education. Ostomy Wound Manage-
ment, 57(2), 20-21.
Institute for Healthcare Improvement.
(n.d.). Prevent pressure ulcers: Getting
started kit. Retrieved from http://www.
ihi.org/topics/pressureulcers/pages/
default.aspx
Sendelbach, S., Zink, M., & Peterson, J.
(2011). Decreasing pressure ulcers across
a healthcare system: Moving beneath the
tip of the iceberg. The Journal of Nursing
Administration, 41, 84-89.

Reproduced with permission of the copyright owner. Further
reproduction prohibited without
permission.
SYSTEMATIC REVIEW
Barriers to evidence-based medicine: a systematic review
Homayoun Sadeghi-Bazargani PhD,1 Jafar Sadegh Tabrizi PhD2
and Saber Azami-Aghdash PhD3,4
1Professor, PhD of Epimiology, Road Traffic Injury Prevention
Research Center, Tabriz University of Medical Sciences, Tabriz,
Iran
2Professor, PhD of Health Service Management, 3PhD Student,
Tabriz Health Services Management Research Center,
Department of Health
Service Management, Tabriz University of Medical Sciences,
Tabriz, Iran
4PhD Student of Health Policy, Hospital Management Research
Center, Iran University of Medical Sciences, Tehran, Iran
Keywords
barrier, content analysis, evidence-based
medicine, guideline, research utilization,
systematic review
Correspondence
Dr Saber Azami-Aghdash
Hospital Management Research Center
Iran University of Medical Sciences
Tehran, 59771-45556

Iran
E-mail: [email protected]
Accepted for publication: 30 May 2014
doi:10.1111/jep.12222
Abstract
Introduction Evidence-based medicine (EBM) has emerged as an
effective strategy to
improve health care quality. The aim of this study was to
systematically review and carry
out an analysis on the barriers to EBM.
Methods Different database searching methods and also manual
search were employed in
this study using the search words (‘evidence-based’ or
‘evidence-based medicine’ or
‘evidence-based practice’ or ‘evidence-based guidelines’ or
‘research utilization’) and
(barrier* or challenge or hinder) in the following databases:
PubMed, Scopus, Web of
Knowledge, Cochrane library, Pro Quest, Magiran, SID.
Results Out of 2592 articles, 106 articles were finally identified
for study. Research
barriers, lack of resources, lack of time, inadequate skills, and
inadequate access, lack of
knowledge and financial barriers were found to be the most
common barriers to EBM.
Examples of these barriers were found in primary care,
hospital/specialist care, rehabili-
tation care, medical education, management and decision
making. The most common
barriers to research utilization were research barriers,
cooperation barriers and changing
barriers. Lack of resources was the most common barrier to
implementation of guidelines.
Conclusion The result of this study shows that there are many

barriers to the implemen-
tation and use of EBM. Identifying barriers is just the first step
to removing barriers to the
use of EBM. Extra resources will be needed if these barriers are
to be tackled.
Introduction
The main reason for different performance in health care is the
gap
between knowledge production and its implications. To
eliminate
this gap, in recent years, the evidence-based practice (EBP)
approach has been considered [1–3]. EBP has emerged as a
inter-
national priority in efforts to improve health care quality [4]
and
defined as the integration of clinical experience with high
quality
evidence and patients’ values [5,6]. EBP is achieved by
translating
the need for information into an answerable clinical question,
then
tracing the most valid information, critically appraising and
finally
making use of it in a clinical setting [7].
Unfortunately, despite the positive role of EBP in health care
quality and the improvement in patient care [8,9], the evidence
clearly shows that there are many barriers in both the use of
evidence and the implementation of EBP. The major barriers
included lack of time, lack of knowledge, lack of medical
resources, negative attitudes about EBP, financial constraints,
etc.
[2,10–13].
EBP has been introduced at many levels and in many fields of

health care systems, such as primary health care [14,15],
second-
ary and specialist care (hospitals) [16,17], rehabilitation care
[18,19], medical education [20], management and decision
making [21] and other fields. Many studies have been conducted
to
identify the barriers to EBP in recent years. There is however
not
one comprehensive study that combines the results of these
studies
and provides a clear view of the barriers. Therefore, the primary
aim of this study was to systematically review and carry out
content analysis to determine barriers to EBP in Primary Health
Care (PHC), secondary and specialist care (hospitals),
rehabilita-
tion care, medical education, management and decision making,
implementation of guidelines, use of research results.
Methods and materials
In the systematic review to find relevant studies, a search
strategy
was developed with the cooperation of an experienced librarian.
The search strategy was conducted first on PubMed, than
adjusted
bs_bs_banner
Journal of Evaluation in Clinical Practice ISSN 1365-2753
Journal of Evaluation in Clinical Practice 20 (2014) 793–802 ©
2014 John Wiley & Sons, Ltd. 793
mailto:[email protected]
to search other databases (Supporting Information Appendix

S1).
The keywords was selected from MeSH and included evidence-
based*, ‘evidence-based medicine’, ‘evidence-based practice’,
‘evidence-based guidelines’, ‘research utilization’, barrier*,
chal-
lenge, hinder. These were used in PubMed, Scopus, Cochrane
library, Web of knowledge, Pro Quest, Magiran (Persian
database)
and SID (scientific information database – Persian database)
data-
bases. Manual journal searching (such as evidence-based medi-
cine, evidence-based mental health, evidence-based nursing,
medical decision making, evidence-based complementary and
alternative medicine, evidence-based ophthalmology, Interna-
tional Journal of Evidence-Based Healthcare and etc.) was also
conducted. Articles from the reference list of the studies and
which
were found to be relevant were also considered. The literature
search was conducted from January 2000 to September 2013.
Articles in English and Farsi (Persian) were included that
reported barriers to EBP in PHC, secondary and specialist care
(hospitals), rehabilitation care, medical education, management
and decision making, implementation of guidelines, use of
research results. The exclusion criteria were letters to the
editor,
case reports, papers presented in seminars and conferences and
articles, which resulted from interventions.
Two reviewers evaluated the articles according to the checklist
from STROBE (Strengthening the Reporting of Observational
studies in Epidemiology for observational studies [22], Critical
Appraisal Skills Program (CASP) for qualitative study [23] and
Preferred Reporting Items for Systematic reviews and Meta-
Analyses (PRISMA) for systematic review studies [24]. First,
arti-

cles with non-relevant titles to the subject of this review were
excluded. Then, the abstract and the full text of articles were
reviewed respectively to exclude those articles that matched the
exclusion criteria of the study, or had a weak relevance to the
subject of the study. A computer software for reference manage-
ment (Endnote X5, Thomson Reuters, Philadelphia, PA 19130,
USA) was used for organizing and assessing the titles and
abstracts, as well as recognizing the repetitive items.
Deductive content analysis was carried out to categorize and
understand the barriers and facilitators related to EBP. Coding
and
categorizing was done by two people from the research team
using
the following process:
1 Familiarization with data (identifying and extracting barriers
from selected studies);
2 Searching for themes (gathering extracted barriers and
facilita-
tors into potential themes);
3 Formulating themes (generating a thematic ‘map’);
4 Naming themes (generating clear definitions/examples for
themes), and
5 Assessing reliability of analysis by use of two researchers
trying
to achieve full agreement.
The searches returned 2592 articles, and excluding those that
were non-relevant, repetitive between databases, with weak rel-
evance to the study, or matching the exclusion criteria, 106
articles
were entered in the study (Fig. 1). These articles were fully
read,
and the required data were extracted into the extraction table
designed for the purpose of the study in spreadsheet computer

software (Excel, Microsoft Office, Microsoft, USA).
Results
In this study, out of 2592 articles, 106 articles completely
related
to the study aims were finally selected, carefully studied and the
relevant data extracted into the extraction table (Supporting
Information Appendix S2).
The frequency of each area of study is following: primary care
15(%14.1), hospital/specialist care 29(27.6%), rehabilitation
care
14(%13.3), Medical education 6(5.7%), management and
decision
making 4(3.8%), Guideline implementation 16(15.2%),
Research
utilization 8(7.2%) and General (all above mentioned)
14(13.3%).
In this study, 1144 barriers were identified and using content
analysis categorized into 18 categories (Fig. 2).
As can be seen in Fig. 2, the most common barriers were related
to ‘research barrier’ by 126 frequencies.
In Table 1, for greater clarification of the categorizing of barri-
ers, some examples are given for each category.
In Table 2, the first five most common barriers in primary care,
hospital/specialist care, rehabilitation care, medical education
and
management and decision making were compared.
As can be seen in Table 2, lack of resources, lack of time,
research barriers and lack of knowledge are the most common

Excluded at full text = 276
Inadequate results: 204
Poor quality of article in assessing: 72
Full text selected = 371
Total included article = 106
Relevant article identified = 2592
Excluded at duplicate between
database = 856
Excluded at Title and abstract = 1365
Non relevant = 989
Presented at conferences and seminars = 189
Letter to the editors = 78
Case reports = 50
Interventional study = 59
Included at hand searching and
references of references =11
Titles and abstract for screening = 1736
Figure 1 Flow diagram of the searches and
inclusion process.
Barriers to EBM H. Sadeghi-Bazargani et al.
© 2014 John Wiley & Sons, Ltd.794

barriers respectively in primary care, hospital/specialist care,
reha-
bilitation care, medical education and management and decision
making.
The most common barriers to RU are shown in Fig. 3.
As can be seen in Fig. 3, barriers related to research with 52
repeated was the most common barriers to research utilization
(RU) in the health care system.
Most common barriers to guideline implementation in the
health care system are shown in Fig. 4.
As can be seen in Fig. 4, lack of resources was the most
common barrier to implementation of guidelines.
Discussion
The summary and analysis of the study results show that
research
barriers, lack of resources, lack of time, inadequate skills, and
inadequate access, lack of knowledge and financial barriers are
the most common barriers to the implementation and use of
EBP.
Examples of these barriers are to be found in primary care,
hospital/specialist care, rehabilitation care, medical education,
management and decision making. So that lack of resources,
lack
of time, research barriers and lack of knowledge are
respectively
the most common barriers in this area. The most common
barriers
to RU in the health care system were research barriers,
cooperation
barriers and changing barriers. Lacks of resources were the

most
common barriers to implementation of guidelines. In this study,
for
18 categories of barriers, 37 facilitators were suggested.
In consistence with some of previous studies [10,19,25–28],
the results of this study show that barriers related to ‘research’
are one of the most common barriers to the implementation and
use of EBP. We can categorize these barriers into three main
categories namely (1) heterogeneity in distribution of studies
(high volume in some areas and inadequate studies in other
areas); (2) methodological problems in study design and execu-
tion and (3) conducting of studies that were not applicable and
usable (such as duplicate or unnecessary studies). Many inter-
ventions could be done to improve these problems, such as
conducting educational workshops or courses for health care
pro-
viders to improve their ability and knowledge in the designing
and conducting of studies, comprehensive and clear reporting of
research results, using rigorous criteria and standards for publi-
cation of studies, conducting research according to the user’s
needs, collecting the study’s results in one place and providing
access for health care providers.
In this study, another important barrier to EBP was ‘lack of
resources’ such as inadequate facilities, institutional support
and
lack of equipment. Results of previous studies also show that
lack
of resources is one of the most serious barriers to the implemen-
tation and use of EBP [29–34]. To solve this problem, in the
first
phase, we would try to provide adequate resources. If this is not
52

22
16
13
12
6
6
5
5
4
3
3
2
1
1
1
0 10 20 30 40 50 60
Researech barrier
Changing barrier

Cooperate barrier
Lack of knowledge
Lack of time
External factors
Negative attitude
Inadequate access
Languge barriers
Lack of source
Inadequate skill
No incentive
Lack of training
Financial barrier
Not priority
Logistical barrier
Frequency
Barriers
Figure 2 The most common barriers to EBP
at health care system level (n = 1140).

H. Sadeghi-Bazargani et al. Barriers to EBM
© 2014 John Wiley & Sons, Ltd. 795
possible, in the next phase, we would use low-cost strategies for
the implementation and use of EBP. Unfortunately, sometimes
there are adequate resources but we cannot use them
appropriately.
Because there is not appropriate planning we are unable to do
proper resource allocation.
The results of this study are in agreement with previous study
results [16,18,35–44] and show that barriers related to ‘lack of
time’
are one of the most common kinds in EBP. We can categorize
these
barriers into two main categories: (1) lack of time to search for,
study and learn from studies, and (2) lack of time in the
implemen-
tation of study results in the job setting. One of the probable
reasons
for lack of time is health care providers’ high workload. To
solve
this problem, it is proposed that the staff workload is reduced or
that
more staff is employed. Another likely reason for the lack of
time
may be the staff’s lack of ability in time management. To solve
this
problem, running ‘time management’ workshops can be useful.
According to the results of this study, the pattern of barriers in
primary care, hospital/specialist care, rehabilitation care,

medical
education, management and decision making, implementation
and
use of guidelines and research utilization are deficient.
Therefore,
it is considered necessary that policymakers and managers con-
sider this issue when decision making and planning.
Among the deficient areas in this study, management and deci-
sion making have the lowest frequency of studies. Due to the
importance of evidence-based management and decision
making,
more study needs to be carried out in this area.
Out of 106 studies that are surveyed in this study, a few of them
were conducted in Low and Middle Income countries (LMIC).
In
Table 1 Examples for most common barriers
Barriers Examples
Research barrier Conflicting results, methodological problems,
lack of replication, poor generalizability, understanding
statistics, literature not
being compiled in one place, implications for practice not being
made clear, limited relevance of research to practice
Lack of resources Inadequate facilities, lack of medical
resources, inadequate institutional support, lack of equipment
Lack of time Lack of time to search for guidelines or practice
EBD, lack of time to study, no time to search for information,
insufficient
time on the job to implement new ideas, no overtime or comp
time for after-hours appointments

Inadequate skills Lack of research skills, lack of skills to
effectively communicate, inability to evaluate
Inadequate access Guidelines are not accessible, guidelines are
too complicated and it is difficult to find the information,
distance from the
library,
Lack of knowledge Do not know how to search, lack of self-
learning skills, lack of exposure to evidence-based
interventions, lack of awareness
of interventions, ignorance of the research relevant to clinical
practice areas, lack of capability to evaluate the quality of
the research
Financial barriers Lack of infrastructure, EBP is too costly,
funding shortage/limited, the costs of patient choice, the costs
of consumerism,
the costs of accessing evidence
Lack of training Insufficient/inappropriate EBD training in
dental school, inadequate continuing education in EBD
Cooperate barriers Lack of teamwork, being isolated from
colleagues, doctors not cooperating with change, doctors
unwilling to cooperate
with nurses’ implementation of EBP
Negative attitude Negative attitudes about EBP, guidelines
reduce doctors’ autonomy, guidelines limit treatment options,
guidelines limit
flexibility and individual approach, there is no need for
treatment guidelines as treatment routines exist
No incentive Lack of motivation to update knowledge, no
motivation from trainer
unsupported Inadequate supervision and leadership,

Changing barriers Difficulty in changing current practice
model, willingness to change, lack of autonomy, lack of
authority, insufficient
resources to change practice
Not priority Low management priority, lack of agreed priorities
Patient barriers Consumer demand, client resistance/non-
participation/disengagement, clients difficult to reach/follow-
up/track
Logistical barrier No clear structures or process, loss of
therapeutic freedom
Language barriers Language barrier, written in English
External factors Negative sociocultural beliefs, difficulty in
application with national health insurance
Table 2 Five most common barriers in primary care,
hospital/specialist care, rehabilitation care, medical education,
management and decision
making
Field
priority Primary care Hospital/specialist care Rehabilitation
care Medical education
Management and
decision making
1 Lack of source Lack of time Research barrier Research barrier
Lack of knowledge
2 Inadequate skills Research barrier Lack of source Lack of
time Lack of time
3 Lack of training Lack of source Lack of time Lack of
knowledge Research barrier
4 Lack of time Inadequate skills Inadequate access Lack of
training –*
5 Not priority Cooperate barriers Lack of training Unsupported

–
*There is not enough study in this field
agreement with this result, Agarwal and colleagues (2008) [45]
emphasized that South Asian countries have weak performance
in
the field of EBM and there are many barriers in these countries.
Lack of resources, inadequate skills, lack of knowledge and
finan-
cial barriers are some of the most common barriers. To deal
with
these barriers, educational programmes to improve staff’s
ability
and knowledge, strategic planning for implementation and use
of
EBP, use of high-income countries’ experience, following local
health guidelines, modifying and removing legislation barriers
and
other effective interventions can be used.
Figure 3 The most common barriers to RU
in health care system (n = 152).
Figure 4 The most common barriers to
guideline implementation in health care
system (n = 155).
H. Sadeghi-Bazargani et al. Barriers to EBM

© 2014 John Wiley & Sons, Ltd. 797
The main weakness of this study is the combination of the
results of quantitative studies with qualitative studies.
Therefore,
it is recommended that in future studies, results of these
different
kinds of studies are reported separately. The other limitation of
this study was being limited in the searches to only English and
Persian because of the researchers only knowing these two
languages.
Conclusion
Nowadays, due to rapid growth in the volume of medical
informa-
tion and complex treatment procedures, we need to use the best
and most valid evidence. But a review of studies shows that
there
are many barriers to achieving this goal. Barriers related to
‘research’, ‘lack of source’ and ‘lack of time’ are most
common.
Therefore, a priority for future effective interventions could be
activities such as holding research methodology educational
work-
shops or courses, using rigorous criteria and standards for
publi-
cation of articles, providing extra resources for the collection
and
use of evidence, resource allocation and holding ‘time manage-
ment’ workshops.
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