Implementing Evidence Into Everyday Practice: Midwifery Leaders’ Views About What Helps and Hinders Clinical Innovation.

Background Despite the ongoing production of new scientic evidence in the eld of maternity care, midwives continue to face challenges when translating latest evidence into evidence-informed care, and report uncertainty in both knowledge and condence to implement sustained evidence-based change in clinical areas. This study aimed to explore midwifery leaders’ views on what factors help or hinder midwives’ efforts to implement evidence-based practices, and test the usability of the Capability, Opportunity, Motivation and Behaviour model and Transtheoretical Domains Framework to analyse the barriers and facilitators of evidence-based change. Methods This qualitative study formed part of a larger Participatory Action Research (PAR) project designed to improve the processes by which midwives implement evidence-based practice change in clinical areas. Data were obtained by a nominal group workshop and individual face-to-face interviews between July – September 2019. Thematic analysis was used to interpret the transcribed data, which were then coded and categorised into meaningful themes.


Introduction
The bene ts of using evidence-based practices in healthcare have been well reported in the literature

Background
Midwifery is a research-informed profession and midwives are expected to apply best available evidence to clinical practice and decision-making. In many countries this is included in mandatory standards for the midwife (NMBA, 2018). Evidence implementation knowledge is, however, not commonly taught in midwifery education and although literature on the topic is continually growing, it does not tend to provide guidance on how to use IS processes to support practice change initiatives (Nilsen, Neher, Ellstrom, & Gardner, 2017). A key reason for the continued evidence-practice gap in midwifery, like other areas of healthcare, is the limited focus on identifying factors critical to the successful implementation of evidence-based practices (Handley, Gorukanti, & Cattamanchi, 2016).
One of the fundamental tenants of IS is that closure of evidence-practice gaps requires consideration for mechanisms that are applicable to real-world situations and target both individual and organisational factors in uential to the translation of latest evidence into clinical areas (Birken et al., 2017). To achieve this, the factors that both help or hinder the implementation process must be uncovered and addressed, as knowing these will guide clinicians' efforts to optimise clinical innovation outcomes (Vogel et al., 2016).
Although there is an established body of evidence on the barriers and facilitators of EBP in healthcare, there remains limited knowledge of the factors that help or hinder midwives' efforts to implement new evidence-based practices in clinical areas (Azmoude, Aradmehr, & Dehghani, 2018). Further, little is known about midwives' use of implementation tools to facilitate the process (Bayes, Fenwick, & Jennings, 2016).
The purpose of this study was to address this uncertainty by exploring midwifery leaders' experience of implementing evidence-based practice change.

Aims
The aims of the study reported in this paper were to explore midwifery leaders' views on what factors helped or hindered midwives' efforts to implement evidence-based practices, and to test the usability of the Capability, Opportunity, Motivation and Behaviour model (COM-B) and Transtheoretical Domains Framework (TDF) to analysis the barriers of evidence-based practice change.

Methods
This study formed part of a broader Participatory Action Research (PAR) project designed to improve the processes by which midwives implement evidence-based practice change in clinical areas. The study employed a qualitative study design whereby a nominal group workshop (focus group) and individual face-to-face interviews were conducted to gain insight into the views of eight midwifery change-leaders, who all had extensive experience of implementing practice change at both individual and organisational levels. Unlike quantitative research, qualitative inquiry encourages participants to talk freely and often around emotionally laden issues in order to obtain a deeper understanding of how people think and feel about real-world problems. In this respect, qualitative research can be described as conversation with a purpose (Krefting, 1991). Arguably, qualitative studies are able to probe in more depth around a particular issue and thus are more attuned to the verbal and non-verbal cues of the persons involved (Schneider & Whitehead, 2013). This method of inquiry was bene cial for achieving the aim outlined in this study.

Study design
An exploratory qualitative study was conducted based on one nominal group workshop and ve in-depth interviews, all of which were underpinned by the methodological reasoning of Action Research (Kemmis & McTaggart, 1988). This design enabled the authors to gain an insiders perspective about the midwifery issues uncovered during the data collection process.

Ethical considerations
The Human Research and Ethics Committee at XXXXXX in XXXXXX approved the study. No risks to the participants or the researchers were anticipated and none eventuated.

Participants
The participants were recruited as part of a wider Participatory Action Research (PAR) project designed to improve the processes by which midwives implement evidence-based practices. Eight midwifery experts with experience in leading practice change initiatives were nominated by their managing Directors to participate in the study. These midwifery leaders were sent an electronic invitation to participate, a plain language information sheet and a consent form. All nominated midwives accepted the invitation to participate and consented either to take part in a nominal group workshop or an individual face-to-face interview depending on their work commitments.

Data collection
The Nominal Group Technique (NGT) was used in the workshop to achieve general agreement and convergence of opinion relating to several discussion points derived from the aim outlined in this study. Commonly referred to as a consensus technique for establishing priority information, the NGT was used to direct problem solving, generate ideas and prioritise action planning (Harvey & Holmes, 2012). A key strength of conducting a nominal group workshop was the balanced contribution of all participants and the semi-structured format of the group discussion. The NGT also aligns with the constructs of qualitative research in that it has proven more effective in obtaining participant responses in greater depth and breadth compared with traditional focus group discussions (Langford, Schoenfeld, & Izzo, 2002). The nominal group workshop was co-facilitated by (BLINDED FOR PEER REVIEW) over three hours, wherein discussions were audio-recorded with consent and additional eldnotes were documented throughout the session. All participants were ascribed pseudonyms.
Due to work commitments, three participants opted to participate in audio-recorded individual face-toface interviews that focused on the same discussion points explored at the nominal group workshop. In person interviews were preferred over telephone interviews because observation and recording of both verbal and non-verbal communication was possible, and the interviewer could improvise to elicit clearer and more elaborate responses from participants when needed (McIntosh & Morse, 2015).

Data analysis
The audio-recordings and eld notes from the nominal group workshop and face-to-face interviews were transcribed and analysed ('coded') as soon as possible afterwards. This was through a process of re exive thematic analysis as described in Braun and Clarke's approach (Braun & Clarke, 2006). This qualitative method involved initial familiarisation with the data, coding of key statements and then grouping emergent themes and patterns within the data into meaningful categories. These categories were presented on a storyboard to the research team where additional re nement of them occurred.  Table 2). The TDF is particularly applicable to those wanting to adopt a more systematic approach to problem-solving and re ne the design of intervention strategies speci c to real-world problems (Fuller et al., 2014).
While using a single theory or framework may be appropriate to solve implementation issues in some healthcare contexts, midwifery is a highly specialised profession where midwives work in varied clinical areas and may be subjected to numerous individual, organisational and contextual factors that in uence their efforts to implement evidence-based practice change. The COM-B and TDF are two strategies that, when used in combination, may be useful tools for midwives wanting to optimise the e ciency and outcomes of implementing EBP in clinical areas.

Trustworthiness
The research team sought to assure the study's methodological trustworthiness in three ways. Firstly, a detailed audit trail was recorded whereby all steps of the data analysis process were tabulated and clearly reported to capture each stage of thematic analysis. Second, major analytical decisions were discussed between the research team on three occasions to progressively re ne the emergent categories.
Finally, a member checking exercise was conducted wherein the nal categories derived from the data used to explore the phenomenon of interest were presented to academic midwifery colleagues to ensure that the analysis and emergent ndings were a clear and accurate representation of the ndings reported in this study.

Results
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 nding, expressed as an interpretive statement, emerged to characterise participants' change leadership experiences and views. Four major categories underpin this nding, 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 nding is presented below, followed by the four major categories and their supporting ndings.
5.1 Core nding: "Fear can stop change, and midwives lack the con dence 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 in uenced by midwives not having the con dence or skills to successfully implement evidencebased practices during worktime and was made more di cult 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 identi ed and contribute to the core nding 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 ndings is reported below in major category four.

Major category 1:
The stumbling block is medical opposition and workplace culture; they are two of the biggest challenges for midwives.
The most signi cant 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 di culties 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.' Re ecting 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 di cult 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 in uenced change efforts, with work place culture identi ed as "one of our biggest problems "(MW3). This was exempli ed 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 signi cantly," 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 di culty 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 re ected 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. 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 oor." 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 t 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 identi ed the problems they were having… and asked them [midwives] what they wanted to do to improve the situation." On re ection, 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.

Major category 3:
Midwives are tired of ghting the battle for EBP; they need knowledge and the con dence 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 con dence and knowledge to e ciently implement evidence-based practices. MW3 told a story of talking with midwives about EBP, and con rmed that "there are still a lot of midwives who are unsure of how to read the evidence…they're not con dent 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 con dent 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 ghting 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 x everything and do it quickly, but there's so much to x 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, ve 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 re ected 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 identi ed 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 evidencebased 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 ndings to the combined COM-B and TDF domains As stated earlier, the ndings of this study were mapped to the combined COM-B and TDF for further contextual exploration (as exempli ed 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 in uenced participants' efforts to implement evidence-based practice were related to twelve of the fourteen domains within the TDF.
(please insert   (7). What resonated in the transcribed data with these was that midwives lacked the time and con dence to implement new practices, which led to aversion by some midwives who were faced with adopting new evidence-based practices. This re ected 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 evidencebased practices in clinical areas. A core nding 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 di cult 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 exempli ed 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 re ect the Social Professional Role and Identity (TDF domain 12) and professional responsibility of midwives to lead change initiatives in maternity care settings. MW3 re ected 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 identi ed that embedding practice change can also be in uenced 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."

Discussion
The eight participant midwifery leaders' practice change experiences heard in this study clearly illustrate the hindering and helping factors that typically contributed to the success or otherwise of implementing evidence-based practice change in various maternity practice settings. The data were represented in four major categories that broadly characterise the individual, workplace and system level factors that either stalled or were used as leverages to embed EBP. Issues of fear, fatigue, medical opposition, lack of time and limited knowledge of implementation processes were reported as hindering factors.
Comparatively, having strong leadership and a solid evidence-base were highlighted to facilitate the implementation efforts of midwifery change-leaders in clinical areas. Only three publications relating to implementation challenges in midwifery could be sourced against which to compare what we discovered, and the ndings of those studies broadly resonate with the helping and hindering factors identi ed in this study ( (Bayes et al., 2016) proposed that the CFIR is bene cial for conducting broad contextual assessments, but that the language used in it renders the tool inappropriate for midwifery contexts in its original form. Bayes and colleagues recommended the need for increased knowledge and use of IS processes in midwifery, and further research into implementation mechanisms developed speci cally for the needs of practicing midwives wanting to implement evidence-based practices.
There has seemingly been no other work describing the use of either the COM-B or TDF in midwifery settings, however there is a small number of published studies (three) that broadly report on the use of the TDF and COM-B in other clinical environments. In their study of healthcare workers' perceptions of why patients were or were not assessed for rehabilitation after undergoing a stroke, Lynch et al (2017) employed the TDF to explore the factors that contributed to assessment and referral practices by healthcare workers in acute stroke units. Key factors in uencing practice were identi ed and mapped to the TDF domains (this included individual and organisational in uences and practitioner skill and knowledge de cits), which were then assessed by participants to determine the suitability of employing the TDF to improve rehabilitation and referral practices for patients. Key ndings highlighted the potential for using the TDF to identify factors that in uence clinician practices. Additionally, Lynch and associates articulated the value of using the TDF to enhance clinical outcomes of patients. Recommendations for further research focusing on strategies that integrate EBP into routine systems was also advocated to optimise the use of latest evidence in practice environments. Although this study provided relevant information on the usability of the TDF, the authors did not make reference to the use of behavioural theories to validate their ndings.
Flemming et al (Fleming, Bradley, Cullinan, & Byrne, 2014), in their study investigating healthcare professionals' views on antibiotic stewardship (over-prescribing) in long-term care facilities, combined the TDF with the COM-B and behaviour change technique taxonomy to map the in uential factors that contributed to the over-prescribing of antibiotics by doctors working in clinical areas. Participants (comprising doctors, pharmacists and nursing staff) identi ed several barriers that in uenced their prescribing practices: lack of knowledge, skills, inconsistency in individual practices, miscommunication and unsupportive workplace culture, all of which resonate with the ndings of our study. Combining the COM-B and TDF apparently proved useful in this study and the authors reported that the tools effectively "identi ed the challenges…along with many broad issues at play…on which to model future antimicrobial stewardship interventions' (p. 9). Further, these authors recommended future studies exploring behavioural change to include both the COM-B and TDF for more detailed analysis of the barriers and facilitators of change.
In the eld of dentistry, Asimakopoulou and Newton (Asimakopoulou & Newton, 2015)  research into what combination of theories, frameworks and other tools may produce the best outcomes for implementation efforts was highlighted in this study as a priority for future research.
It emerged that none of the participants had considered or used IS methods to support their implementation efforts. It is plausible this re ects the near absence of midwifery research relating to IS processes and offers an explanation for the persistent evidence-practice gap in midwifery practice settings. The core nding to emerge from this study clearly illustrate that fear, lack of con dence and knowledge about implementation processes, and time constraints obstruct midwives' capacity to implement new practices. When applied to the constructs of the TDF these ndings were further Finally, only two of the TDF domains were not identi ed in the ndings presented in this study: Intentions and Goals (TDF domains 8 and 9), which may offer some insight into why participants experienced the challenges they reported and provide direction for future implementation processes in midwifery.
Although all participants set broad goals to implement an evidence-based practice change, none speci cally spoke of the methods they used to plan, implement, evaluate and sustain their clinical innovations. This does not imply that these steps were not considered by participants, rather it highlights the need for change-leader midwives to consider goal setting and action planning (also termed 'intervention mapping') in their efforts to embed new evidence-based practices. Although ongoing audit and evaluation were reported by two of our participants, none articulated how they intended to address behaviour change or recognised the value of incorporating IS processes in their implementation efforts.
Research endeavours to identify, develop and re ne implementation processes have promised a way to . Although not context speci c, the ERIC implementation strategy compilation may be of use to midwives wanting to target intervention strategies speci c to the implementation hindrances and helpers explored in this study.

Limitations
Although the sample provided su cient data to generate signi cant ndings in this study, the authors acknowledge two limitations. Firstly, the participants represented a relatively small portion of experienced midwifery leaders and may have bene ted from including practicing midwives currently working within the service. Secondly, while participants were employed in all public sectors of Western Australian maternity services it is possible that data saturation may not have been reached as a result of the small sample size. Subsequently, it is possible the ndings of this study may not re ect the wider implementation issues midwives experience in other midwifery practice contexts.

Conclusions
The ndings of our study identify a disconnection between high level evidence, current midwifery practice and mechanisms known to promote the implementation efforts of midwives seeking to initiate evidencebased practice change. This prompts several recommendations by the authors. First, maternity service providers are advised to scale up their knowledge and con dence to introduce evidence-based practices, because it is the key to moving midwifery forward. Second, organisational commitment to the implementation of evidence-based practice and the introduction of implementation strategies that support midwives' efforts is strongly encouraged. This includes both interdisciplinary and organisational buy-in at both local and organisational levels. Third, the value of strong leadership and 'change champions' cannot be understated. Introducing senior leadership or champions of change, as part of a larger 'implementation team' within an organisation may improve the co-ordination and outcomes of change initiatives. Finally, providing midwives with the resources and time to implement change within their practice environments is central to the success of practice change initiatives. Midwives require builtin time to source, interpret and translate latest evidence into EBP, which should be incorporated into their daily workload.
This study is signi cant in that it con rms what is known about the challenges and successes of translating latest evidence into EBP. We also provide valuable insight into the use of behavioural theories and context assessment tools to both diagnose and develop intervention strategies targeted to the needs of change leader midwives working in clinical areas. Additionally, we tested the value of combining the COM-B with the TDF to diagnose the helpers and hindrances of implementing evidence-based practice change in midwifery for the rst time and found it to be extremely helpful. This process enabled an assessment of the effectiveness of these tools when combined and establishes the starting point for developing intervention strategies speci c to midwifery practice contexts and the midwives working in these areas. It is anticipated that the ndings of this study will lead to mechanisms that support midwives' efforts to translate latest evidence into evidence-based practices. Midwives are key stakeholders in this venture, thus should be consulted and included in future research designed to improve mechanisms that support their implementation efforts and address the evidence-practice gap in midwifery. The Human Research and Ethics Committee at XXXXXX in XXXXXX approved the study. No risks to the participants or the researchers were anticipated and none eventuated.

Consent for publication
This manuscript contains no individual data or personalised information of any persons involved in this study.
Availability of data and materials The data sets during and/or analysed during the current study are available from the corresponding author on reasonable request.
Competing interests