A collective of eight midwifery leaders who all had expert experience of either overseeing or implementing a practice change in their workplace took part in this study. Participants shared experiences from both metropolitan and rural clinical sites, which represented all public health sectors of the region. Examples of practice change initiatives ranged from implementing sterile water injections as a method for pain relief during labour, implementing midwifery-led models of care, introducing water birth facilities, overseeing the integration of ‘peanut balls’ (labour equipment) into birth suites and introducing bedside clinical handover. One overarching core finding, expressed as an interpretive statement, emerged to characterise participants’ change leadership experiences and views. Four major categories underpin this finding, which were collapsed from 72 interpretive statements. Three of these major categories represent the factors that hinder midwives’ efforts to implement practice change, the other comprises factors that facilitated midwives efforts to introduce and sustain EBP. These are presented in Table 1.
(Please insert table one)
The core finding is presented below, followed by the four major categories and their supporting findings.
5.1 Core finding: “Fear can stop change, and midwives lack the confidence and time to implement new evidence-based practices, however having high level midwives in leadership roles is a huge advantage.”
What emerged from the data collected for this study was that fear at an executive level and by the service providers themselves hindered midwives’ efforts to initiate and implement sustained practice change. This was influenced by midwives not having the confidence or skills to successfully implement evidence-based practices during worktime and was made more difficult by medical personnel who, to some extent, challenged the implementation efforts of all midwifery leaders. These hindering factors are discussed in detail in major categories one, two and three. Although hindering factors were explored extensively by the expert midwifery participants, a number of change facilitators were also identified and contribute to the core finding of this study. Executive buy-in and midwifery leader ‘champions of change’ were considered to be leverages for midwives wanting to initiate evidence-based practice change. This aspect of the findings is reported below in major category four.
5.2 Major category 1: The stumbling block is medical opposition and workplace culture; they are two of the biggest challenges for midwives.
The most significant challenges reported by all midwifery leaders relate to the resistance midwives experienced when trying to introduce new practice or policy changes to clinical areas. This came largely from medical practitioners, but also included management, administration and practicing midwives who obstructed midwifery leaders’ efforts to implement new evidence-based practices. MW3 shared the difficulties she experienced when trying to implement waterbirth facilities in her workplace; ‘primarily because of…medical opposition, the obstetrician’s threw tantrums…literally stormed out of rooms and threatened to withdraw their services…or not attend waterbirths.’ This was, she said, made more challenging by several midwives labelled “resisters” saying ‘all the things the executives wanted to here.…but behind closed doors saying we can’t do it now, let’s start try it [waterbirth] next year.’ MW4 experienced similar challenges when trying to introduce Midwifery Group Practice (MGP) into her organisation. She recalled ‘we didn’t think it was going to be an issue, well…the medical directors refused to participate…they resisted and they weren’t going to let it go.’ Reflecting on the struggles she encountered, she questioned ‘why do we [midwives] need medical approval for something that is essentially midwifery-led and entirely within our scope of practice?’, and stated that in the end ‘medical directors were bypassed’ to get MGP ‘across the line’.
The source of the resistance to practice change the participants encountered was explored by MW7, who offered that ‘midwives think it’s too much hassle [implementing practice change] and too much work when they’re in the middle of a busy shift.’ She later continued ‘it’s difficult to motivate them [midwives] when there’s so much change that occurs.’ MW1 agreed and added ‘our midwives don’t necessarily want it [practice change].’ These discussions led to participants identifying various contextual factors that influenced change efforts, with work place culture identified as “one of our biggest problems “(MW3). This was exemplified by MW6, who shared her experience of trying to introduce sterile water injections as an option for pain relief in her organisation’s birth suites. She experienced ‘rumour mongering’ from ‘people working in the service who did not trust the evidence…it was a cultural thing.’ This was made more challenging by staff saying, ‘I want to do it, but can’t do it now….’ and later disclosed “I’ve received hate mail from people thinking what I wanted to bring in was unsafe…there was so much distrust for a practice that is essentially evidence-based.” MW1 had a similar experience and recalled a midwife colleague expressing her anger at a practice change, which included accusing MW1 thus “You’re making us jump through hoops” and saying “I won’t do it.”
MW7 shared her experience of trying to introduce bedside clinical handover in her workplace, stating midwives “seemed keen, but there was an unspoken resistance… and if I wasn’t physically present at handover time…it just didn’t happen.” MW2 agreed and recollected the personal effort required to introduce ‘peanut balls’ into her birth suites: “we had all the evidence to support this equipment, paid for our midwives to attend…workshops…and demonstrated the peanut balls increased our vaginal birth rates significantly,” but expressed frustration at the resistance she experienced from staff: “I still see the peanut balls put in the cupboard three months on and question is change actually happening here?...I have to be onto it, physically checking the rooms to make sure the balls are being used, and this equipment is evidence-based.”
There were also practical reasons reported by staff who challenged participants’ efforts to implement new evidence-based practices. For example, MW5 stated “[the resistance] wasn’t related to what midwifery was about…midwives were concerned by how it would affect them working in practice…” she recalled her midwifery colleagues saying “I would love to do it [MGP], but I only work 0.5” and “it’s a good idea, but I just don’t have the time.” This resonated with MW6, who shared her thoughts on why she experienced difficulty getting compliance with new practice and policy within her workplace “it’s just that [the midwives are] too busy delivering direct care…they work hard and there are too many barriers.”
The overarching essence of this major category is reflected in a comment by MW5, who suggested that the degree of success change leaders have when trying to implement new evidence-based practices relates to having “good evidence…removing the emotions and just playing it out.” This can be challenging for midwives as fear and personal attributes were also reportedly put forward by participants to be hindrances of practice change. These factors are explored in more depth in the next major category.
5.3 Major category 2: Fear can stop change: it’s personal for midwives.
In addition to the inter-professional and collegial opposition experienced by all midwifery leaders, fear was identified as a significant barrier to implementing new practice innovations. For many midwives, this was derived from distrust and not understanding how introducing a practice change worked operationally. MW3 described this when she shared her story of trying to implement water birth facilities; ‘‘part was not understanding how it [water birth] would affect what midwives had to do and how it [waterbirth] would affect midwives working rosters.’ She went on further to say that “people didn’t really have an understanding of it [water birth] and that brought about a fear, and when there is fear that stops change.” MW1 had similar experiences trying to implement water birth in her labour unit; she recalled staff saying “I don’t trust the evidence” and asking “does this mean more paperwork?”, which caused trepidation “as staff struggled to accept a practice that is happening in similar environments around the world.”
MW4 told a similar story of the challenges she experienced when trying to introduce MGP within her organisation. She reported midwives questioning “how is this going to affect my income and time away from work? [And] when it came to actually signing up for MGP, fear came in…and some of that is personality, which was what I really believe held up the process.” MW7 concurred and offered, “midwives want to know why, even when they’ve been shown the evidence…and they want to know how it affects them on the floor.”
What resonated between the stories of all participants was that fear hinders change, and as a consequence change takes time. MW2 suggested “what I’ve learned is that operationally, change takes about 12 months and is a continual cycle of thinking, reviewing and revisiting the initiative to ensure its sustainability.” MW3 agreed, stating her implementation efforts took “…8 months and even 10 years on, it’s still hard work and the criticisms keep coming.” All midwifery leaders agreed with MW8, who suggested “change is sometimes not a good fit for the organisation…it’s personal for staff.” This resonated with MW7 who said “some of it’s personality…and the behaviours of individuals can affect the success of change initiatives.” She went on to state “it also depends where the change is coming from…is it being driven by us [midwives]…or is it being driven by the organization?”
Two midwifery leaders reported they had better success with introducing evidence-based practices when the change initiative was midwife-led and midwives were directly involved in the process. MW7 shared her experience of introducing a midwifery-led antenatal clinic, stating “we sat down with the staff and identified the problems they were having… and asked them [midwives] what they wanted to do to improve the situation.” On reflection, she said ”I think because it was a midwife-led initiative we had instant buy-in…and that made a huge difference to the outcome of the project.” MW5 concurred, sharing her experience of introducing bedside clinical handover: “involving the staff seemed to embed the change more easily” because “when there’s a perceived threat to midwives family time or income…there’s distrust, and fears comes in.” MW4 disclosed it was her midwifery colleagues that caused the most resistance and tried to sabotage her efforts to introduce MGP services. She stated “[midwives] got in under me… cut the reeds down while I was doing it [implementing change]…you know the culture of women.” MW7 suggested to improve the adoption of evidence-based practices “midwives need praise and reassurance to let them know their efforts are being noticed.”
The personal effort required to introduce new practice initiatives was reported by all midwifery leaders to be another factor that contributes to the success of change implementation efforts. These data are presented below in major category 3.
5.4 Major category 3: Midwives are tired of fighting the battle for EBP; they need knowledge and the confidence to bring about practice change
All participants described varying degrees of hardship when trying to implement practice change, which stemmed not only from the resistance exhibited by staff and management, but also from midwives lacking the confidence and knowledge to efficiently implement evidence-based practices. MW3 told a story of talking with midwives about EBP, and confirmed that “there are still a lot of midwives who are unsure of how to read the evidence…they’re not confident with the interpretation despite doing research units at uni.” She went on further to question “how do we translate something we can’t interpret?” and suggested “we need our midwives to feel confident that they have the ability…and the evidence to defend their practices…and believe in their knowledge.” MW7 shared similar experiences with trying to implement practice change and observed “our midwives are fatigued, they work hard and are tired of fighting the battles that change brings.” MW6 agreed that “the average midwife doesn’t have the time or energy to implement practice change” and went on to articulate “midwives and managers are extremely busy, we need time allocated during work hours to implement new practices…” This resonated with MW4 who also noted that “midwives are time poor and there are less resources and more activity…” She went on to suggest that “changing practice is just not a priority for midwives working day-to-day.”
The continual publication of new evidence based practices was considered by MW6 to be challenging for midwives, who acknowledged ”in this massive change environment we want to fix everything and do it quickly, but there’s so much to fix and midwives are too busy…we don’t do change well and there’s not enough resources to support us to do it properly.” MW3 concurred, and proposed that
…change is something we do badly in everyday practice…we’re very reactionary and don’t go back to evaluate…we might change a policy quickly, tell them [midwives] to get on with it and move onto the next job…sometimes that’s not easy.
MW3 suggested the only way to optimise the uptake of change initiatives was to “link change with good evidence and make initiatives not labour intensive.” MW7 added “the success of change efforts depends on the resources you’ve got and the people available to embed initiatives into workplace environments.” In addition to all midwifery leaders speaking at length about the hindering factors that impinge on midwives’ efforts to successfully implement new evidence-based practices, five out of eight participants also reported leveraging factors that facilitated the implementation process. These are discussed in major category four.
5.5 Major category 4: It all comes down to being the ‘squeaky wheel’ and having stakeholder buy-in and high level midwives in leadership roles is a huge advantage.
Although participants reported largely on the challenges they experienced with implementing practice change there was also talk of leveraging factors, and how these factors could be used to support midwives efforts to embed latest evidence into everyday practice. MW4 reflected on her efforts to implement MGP, acknowledging that, “to get to the point where we actually introduced change…it was about being the squeaky wheel and getting buy-in from the people who could actually implement the change.” Having stakeholder buy-in was also identified as a helping factor by MW1, who stated “having high level midwives in leadership roles…and buy-in at all levels” contributed to the successful implementation water birth in her place of work. MW6 asserted that “getting the right stakeholders on board from the start” is a huge advantage as she recalled the effort required to introduce an evidence-based policy for delayed cord clamping, suggesting “change initiatives have to be endorsed from the top.”
Change-leaders’ and ‘champions of change’ were terms used interchangeably by MW8 to describe the value of “having somebody at the top level, a driver of change.” MW5 advocated for “an expert in what you are trying to implement” involved in change initiatives, and suggested “you need someone who’s had a positive experience so you don’t get all that negative stuff that people don’t want to hear when they’re trying to bring about change.” MW7, who talked about the challenges of trying to introduce clinical bedside handover, proposed that “what assisted the change …was having somebody to keep on driving the project…to lead the initiative and not let it go backwards…because things do with time.
Finally, what resonated between all participants stories was that to successfully embed evidence-based practices, persistence and strong midwifery leadership is required. MW5 surmised “you just chip away at change…even when you’re told there’s no money or buy-in, change comes with time and focused direction.”
Comparison of the findings to the combined COM-B and TDF domains
As stated earlier, the findings of this study were mapped to the combined COM-B and TDF for further contextual exploration (as exemplified in Table 2). This exercise provided an indication of how effective combining a behavioural theory with a context assessment tool is to assess the helping and hindering factors that might impact evidence-based practice initiatives. It also yielded insight into appropriate intervention strategies that may support midwives’ efforts to introduce evidence-based practice in clinical areas. What emerged from this mapping exercise is that the change helping or hindering factors that influenced participants’ efforts to implement evidence-based practice were related to twelve of the fourteen domains within the TDF.
(please insert table 2)
Three of the TDF domains were described by participants in their experience of implementing evidence-based practices within the Capability system of the COMB-B. Namely, these factors were mapped to Knowledge, Skills and Behaviour Regulation within the TDF (domains 1, 2 and 14). Participants described a lack of knowledge amongst midwives with regard to implementation processes. Specifically, participants described most midwives to have limited skills in sourcing, interpreting and translating best available evidence into everyday care. Concerning Behaviour Regulation (domain 14), all midwifery leaders acknowledged the challenges midwives experience introducing change initiatives in addition to their daily workload, and the general consensus was that “change takes time and you need a visible presence…you’ve got to drive it [change initiatives] and that’s sometimes not easy” (MW7). Further, two midwifery leaders acknowledged the importance of ongoing audit and evaluation to ensure change initiatives were sustained.
Two of the TDF domains (Environmental Context and Resources and Social Influences) were evident in the transcribed data that were subsequently mapped to the COM-B Opportunity component. Participants talked of local and organisational hindrances (TDF domain 11) within their work environments that hampered midwives’ efforts to introduce new evidence-based practices. For example, MW4 identified multiple contextual and social factors that hampered her efforts to introduce Midwifery Group Practice (MGP) during all stages of the project. She commented that the level of success she had with introducing MGP was dependent on “the resources we had at the time… and the people available to actually embed the change.” Social Influences were explored by MW5 who recalled conversations with a midwife who said: “that sounds like a great idea, and in a perfect world if I didn’t need sleep, have my family and need to pay the bills I would [trial MGP]…let’s wait till next year” (MW5). The resistance experienced by all midwifery leaders not only delayed the opportunity to introduce new practices but also lengthened the time it took to embed practice change in clinical areas. This resulted in varied levels of success and also exacerbated the personal stress and fatigue of all midwifery leaders’ implementation endeavours.
When mapped to the COM-B, the TDF domains identified in this system included: Beliefs about capabilities (4), Beliefs about consequences (6), Social/professional role and identity (3), Emotion (13), Optimism (5), and Reinforcement (7). What resonated in the transcribed data with these was that midwives lacked the time and confidence to implement new practices, which led to aversion by some midwives who were faced with adopting new evidence-based practices. This reflected the beliefs of other midwives, who questioned their capability to initiate practice change and the consequences of adopting new behaviours. MW7 recalled a conversation with one of her midwives, who questioned “why are we changing things again?...we’re busy enough already…I just don’t have the time now” (MW7). Practicing midwives were also reported by participants to be driven by automatic (emotional) responses to change, which often related to their perceived views of how of practice changes would affect their workload and personal time. This was evident in the experiences shared by MW3, who reported conversations with midwives during the implementation of water birth at her place of work. One midwife was quoted to say “I didn’t say I don’t believe it (the evidence), I just want to know how it’s going to affect my family time and income?” Within the constructs of domain 13; stress, fatigue and anxiety were described by the participants in relation to their own evidenced-base change efforts and in their accounts of how practicing midwives who demonstrated mixed feelings of optimism/pessimism towards new evidence-based practices in clinical areas. A core finding of this study is that fear stops change, and the TDF proved valuable in deconstructing this further to underpin the reasoning behind many midwives resistance around introducing practice change and implementing EBP.
Midwives incentives to change were explored under Reinforcement (TDF domain 7). MW6 suggested “there’s not enough pre-education to motivate midwives to change…and there are so many changes and innovations…it’s difficult to motivate them [midwives] when there is so much change that occurs.” Comparatively, MW8 highlighted that when midwives’ efforts to adopted new practices were acknowledged, change initiatives seemed to embed more easily into everyday practice. No participants reported the use of other reinforcement techniques as articulated within the constructs of domain 7. For example, references to the use of rewards, punishment, consequents or sanctions and contingencies were not voiced by any of the midwifery leaders.
Feelings of Optimism (TDF domain 5) resonated in the stories shared by the majority of midwifery leaders, as exemplified by MW8, who said “I think they’ve (midwives) done amazing [sic] with embracing change…we can’t lose sight of that.” The constructs within this domain also reflect the Social Professional Role and Identity (TDF domain 12) and professional responsibility of midwives to lead change initiatives in maternity care settings. MW3 reflected on these issues in her experience of implementing waterbirth: “when we lead initiatives we get things done…and we don’t do things individually, you need buy-in at all levels…and we have to be united…all in or all out.” Additionally, MW6 identified that embedding practice change can also be influenced by other healthcare organisation’s policies and practice. For example, when she tried to introduce a policy for sterile water injection for pain relief during labour MW6 argued with management: “this is what other hospitals are doing nationally and internationally, why are we so behind?... and that’s how we got it across the line.”