Midwives’ Perceptions of Barriers to Implementing Evidence-Based Practice in Northern Jordan

Abstract

Introduction

Through evidence-based practice (EBP) implementation, midwives are critical in maternal care. However, there remain unrecognised barriers that they frequently experienced. Such barriers within Jordan perspective include insufficient managerial support, excessive workloads and limited resources.

Objective

To gain an in-depth understanding and facilitate the implementation of maternity care improvements, this study examines the perspectives of midwives concerning the barriers to implementing EBP in northern Jordan.

Methods

This study adopted a cross-sectional, descriptive design with the BARRIERS scale to investigate the barriers during the implementation process including adopter, communication, organisation and innovation. 191 midwives participated with the scale, all works from the gynaecology and obstetrics departments within seven government and university hospitals in Northern Jordan. Analyses were performed upon the data including descriptive statistics, analysis of variance (ANOVA) and linear regression.

Results

Midwives perceptions indicated that the top three barriers to the implementation of EBP are innovation, organisation and communication. The regression analysis revealed a negative correlation between perceived barriers and education level (F (2, 188) = 8.657, p < 0.001). However, there were no correlation between age and work experience.

Conclusion

The midwives revealed that the major obstacles to EBP utilisation are organisational factors. The key facilitator is proper support from the management. Therefore, the recommendation from this study is the implementation of robust strategies that reduces organisational barriers, strengthen staff training, managerial and police support as well as active engagement with leadership.

Despite the focus of this research is Jordan, the findings may not be specific to this region. As such, it is possible to assume that the recommendations can be applied to maternity care within healthcare contexts that have similar organisational attributes and challenges. However, cautious interpretation of the findings must be made due to the geographical limitations and reliance upon self-reported data within this study.

Introduction

Evidence-based practice (EBP) within healthcare refers to proven care practices that are safe and effective in the improvement of patient outcomes (Chrisman et al., 2014; Moreno-Casbas et al., 2011). Additionally, EBP within maternity care ensures patient-centred care delivery (World Health Organization, 2017).

Midwives that adopt EBP ensures that the maternity care they deliver is updated and supported by robust and latest scientific evidence and clinical expertise. Through decreasing the rate of maternal and neonatal mortality and recovering times, adoption of EBP results in service delivery improve maternal and new-born health outcomes and quality of life (DeLeo et al., 2019). EBP adoption within maternity care paves the way for midwives to comprehend and deliver specific care practices (identified as optimal by contemporary evidence) to ensure a consistent and standardised care delivery across the range of offered services.

EBP practices decrease variability, and improves both efficiency and patient safety (World Health Organization, 2017). Midwifes adoption of EBP has achieved efficiency including decrease of costs such as adopting proven interventions, improved resource allocation and increase healthcare efficiency due to the minimal tests, procedures or treatments that have no evidence (World Health Organization, 2017). The guidelines WHO (2017) prescribed can be used all over the world despite variability on international and intranational level during implementation. From Jordan's perspective, the major barriers are inadequate managerial support, insufficient staff and resource allocation (Abuhammad et al., 2020).

Literature Review

EBP decreases expenditure through evading any unnecessary treatments and complications, decrease the number of hospital stays for both mothers and neonates and ensuring care delivery that is of high quality and safe. Jiang et al. (2017) agreed with this notion through supporting restrictive episiotomy and intermittent auscultation through constant monitoring for low-risk pregnancies. Unsuccessful implementation of evidence-based practice may lead to higher expenditure and complications. Additionally, the purpose of EBP is to improve patient outcomes through verified and robust techniques.

Improved maternal and newborn health outcomes may minimise the need for additional interventions, treatments, or hospitalisations, resulting in cost savings (Cameron-Lawson, 2021; Meng et al., 2019;Williams, 2022)

Midwives play a key role in providing safe and effective care to high and low-risk patients in the obstetric unit, promoting maternal and neonatal health, and the avoidance of comorbidities (Catton, 2020). Therefore, to provide high-quality care for patients in obstetrics and gynaecology units, any proposed care should be based on research-based practice: patients must receive dependable and effective treatment and cost-effective services that minimise unnecessary treatment and medical errors (Phillips, 2015).

Despite several studies conducted across diverse healthcare systems, there is a limited understanding of midwives’ perceptions of the barriers to implementing EBP in Jordan. International studies report that midwives encounter numerous challenges while implementing evidence-based practice.

An example is midwives operating in Iran highlighted that the major barriers towards EBP implementation are insufficient facilities, inadequate literature resources focused in one location, time constraints, inadequate physicians cooperation and authority (Azmoude et al., 2018). Meanwhile, nurses and midwives in Australia highlighted four major barriers in maintaining EBP, which are organisational and management support, time constraints, education opportunities and difficulty in accessing evidence (Fry & Attawet, 2018).

Furthermore, nurses and midwives in Ethiopia also reported time constraints, insufficient research usage and inadequate skill to understand statistics within research articles; all of which are their major barriers to applying research (Dagne & Ayalew, 2020). Despite the studies focus upon diverse perspectives, the barriers that they stated are similar to the Jordanian healthcare system, which are both organisational and systematic.

However, there is insufficient research that focuses on midwives based in Jordan pertaining to barriers of EBP implementation, thus support the necessity of this study. Therefore, this research shall explore the healthcare staff in Jordan regarding their perception towards barriers of EMP implementation. This will establish knowledge pertaining to solutions to address the barriers, develop education programmes and to address the gaps between research and practice.

The majority of contemporary research has focused on the perspectives of nurses and physicians (Abuhammad et al., 2020; AlKhalaileh et al., 2016; Aljezawi et al., 2019; Shayan et al., 2019; Youssef et al., 2018). Only a limited number of studies have examined EBP in relation to midwives and other medical professionals; therefore, the current study is designed to specifically explore how midwives in northern Jordan perceive the barriers to implementing evidence-based practice.

Research Questions

RQ 1: What are the perceived barriers to implementing evidence-based practice (EBP) among midwives in Jordan?

Hypothesis 1: Compared to personal, research quality, and communication factors, organisational barriers are viewed as the major barriers to implementing EBP.

RQ 2: What is the association between social demographic characteristics (age, experience, and education level) and the perceived barriers to using evidence-based practices?

Hypothesis 2: A higher level of education is associated with fewer perceived barriers, whereas age and experience do not exhibit significant relationships.

Methodology

Study Design

This study adopts a cross-sectional design that could explore the correlation between variables upon a particular time period and to collect data from relevant group characteristics, variable occurrence frequency and situations (LoBiondo-Wood & Haber, 2017). Such method includes significant sample size that encompasses multiple locations and is also possible to achieve within a limited time and budget (Polit & Beck, 2021).

Longitudinal or mixed-methods designs could provide further insights; however, they were not practical for the present study. The study was conducted in accordance with the STROBE guidelines (see Appendix S1 for the STROBE Checklist)

Setting

Data were collected from the gynaecological and obstetric departments located in seven government and university-affiliated hospitals in northern Jordan. These hospitals were selected due to their status as major referral maternity centres in northern Jordan; therefore, they employ a significant number of practising midwives and provide maternity care for a substantial number of women. These features provide a suitable framework for examining the barriers to implementing evidence-based practice; however, the omission of private sector healthcare means that the findings cannot be generalised to midwives employed in the non-governmental sector.

Sampling

Convenience sampling was employed to ensure a sufficient number of participants were recruited from the seven hospitals. However, because convenience sampling is not random, it can introduce selection biases; therefore, the results must be interpreted with due caution and cannot be generalised to all midwives in Jordanian hospitals. At a 5% significance level, a minimum of 158 participants was necessary to identify a moderate effect with 80% power for comparisons among educational levels. The final sample of 191 midwives fulfilled this criterion, ensuring sufficient power for the planned analyses (Cohen, 1998). The selected participants were required to satisfy the selected inclusion criteria:

• ♣ Jordanian midwives employed in labour units, postnatal or antenatal wards.

• ♣ Have attained the minimum qualification of a diploma degree (three years).

• ♣ Have a minimum of one year of experience.

Study Instruments

Demographic Information

The researchers developed a characteristics checklist to obtain the following information from participants: age, experience, and education level.

The Barriers to Research Utilisation Questionnaire Scale

This study utilised the Barriers to Research Utilisation Questionnaire Scale Funk et al. (1991) Although initially created for health professionals, the BARRIERS scale has been utilised in nursing and midwifery research, including studies involving midwives (Azmoude et al., 2018), thereby affirming its relevance to the current study. The scale consists of twenty-eight items and the following four subscales:

• Personal/individual factors (8 items) - The characteristics of the individual are used to measure the values, skills, and awareness of research.

• Organisational Factors (8 items) - The organisation's characteristics are used to measure midwives’ perception of the existing limitations and barriers in a work setting.

• Quality of Research Factors (6 items) - The research characteristics are used to measure the midwives’ perceptions of the quality of research.

• Communication/Presentation Factors (6 items) - The communication characteristics are used to measure the midwives’ perceptions regarding the presentation and accessibility of the research.

The Barriers to Research Utilisation Questionnaire is based on a five-point Likert scale scoring system and the frequency of responses. The five-point scale is presented as 1 = strongly disagree, 2 = disagree, 3 = agree, 4 = strongly agree, and 0 = no opinion. Consistent with, Funk et al. (1991) any ‘no opinion’ responses were omitted from scoring because they do not reflect a quantifiable attitude toward barriers and could distort mean values if included.

The responses of the midwives are summed up within dimensions to provide subscale scores, and the final score is calculated by totalling the scores of all of the responses. Typically, the total score of the BRU scale fluctuates between 28 and 112; however, Funk et al. (1991) did not provide established benchmarks for interpreting total scores. Consequently, to enhance understanding, the range (84 points) was divided into three equal intervals: low (28–56), moderate (57–84), and high (85–112). Furthermore, the participants were asked to rank the three greatest barriers and suggest factors. The mean scores for each subscale were summed and divided by the number of items (any items receiving a “no opinion” response or left blank were removed). To identify the single largest barriers to research utilisation, the number of respondents who reported each barrier as moderate or great was calculated, and the items were ranked accordingly. According to Funk et al. (1991); (Kajermo et al., 2010), the questionnaire possesses good internal consistency (0.84–0.96) and reliability (r = 0.63–0.83). The instruments were translated into Arabic by a professional translator; subsequently, a second translator converted the instruments back into English. The original and back-translated tools were checked for discrepancies; however, no significant changes were identified.

In March 2022, the face and content validity of the instrument were confirmed via pilot testing conducted with five senior faculty members from nursing and midwifery. Following the faculty members’ recommendations, some minor phrase modifications were made to enhance the tool's clarity; however, no other modifications or structural changes were required.

Internal reliability was established with a Cronbach's alpha of .80, .80, and .72 for the first three subscales; however, the communication subscale exhibited low internal reliability (.65), which suggests only moderate internal consistency for the last subscale. For the present study, the Cronbach alpha reliability coefficient values for the scales were .825, which denotes that the tool has good reliability. For research purposes, the BRU scale is available in the literature and permission to use the scale for this study was granted by its author.

Data Collection Procedure

Ethical approval was obtained from the Institutional Review Board (IRB) based at Jordan University of Science and Technology, which approved the collection of data from the selected hospitals. After obtaining the necessary approval, a self-report questionnaire was employed to accumulate the data. A meeting was held with the hospital administrator of each selected site to discuss the required eligibility criteria, and a list of potential participants was created. The researcher met with the potential participants to introduce the study and provide a detailed description of its methodology.

Introductory sessions were conducted in various time period to ascertain all participants could access the information in addition to accommodate the working shifts of midwives as well as different hospital units, meaning midwives that work at various locations. Participants were required to sign the consent form prior to completing a questionnaire at their convenience before returning to the researcher. The researcher was present at the premise to collect the responses and to answer any enquiries related to the study or questionnaire. The next process was to analyse and report the data, which was collected from seven public hospitals located in Northern Jordan between March 2022 to June 2022.

Ethical Considerations

Ethical approval for this study was provided by The Institutional Review Board (Jordan University of Science and Technology). Participations was entirely optional and potential participants were fully informed regarding the study and questionnaire. Each participant must and has consented was provided with an information sheet and being informed that all their identification will remain confidential through the use of codes and numbers instead of actual information. All data were to be saved within an anonymous file within a computer that is password protected. Additional confidentiality protection includes enabling participants to complete the survey in a private area and at their convenience. No identifiable information to protect their anonymity.

Data Analysis

Upon the collection of participants’ responses, data analysis was conducted using Statistical Package for the Social Sciences (SPSS) v.25. The normality of the data was verified through descriptive statistics such as standard deviations, frequencies and means. Additional variables based upon analysis of variance (ANOVA) and demographics were used to reveal and disparities to the views of the midwives pertaining to barriers of EBP implementations.

Linear regression analysis was conducted to identify the correlation between the demographic variables related to midwives’ experience with challenges in EBP implementation. Results were deemed significant if p < 0.05. This study includes all the demographic variables within the analysis regardless of bivariate significance and fulfilling the methodological guidelines that complement variable selection in accordance to theoretical structure and previous research, which are crucial in decreasing confounding effects (Polit & Beck, 2021).

Prior to the analysis, assessment was carried out for ANOVA and regression. Shapiro-Wilk and distribution plots were conducted to assess normality. Levene's test was conducted to assess the variances homogeneity and residual analysis was carried out to assess the regression assumptions. Despite regression model take account into age, education and years of experience, it does not include other potential confounding variables such as type of hospital and workload intensity since such data is not available.

It should be noted that the exclusion of such factors may have altered the observed relationships; therefore, they should be considered while interpreting the data.

Results

Characteristics of the Study Sample

The sociodemographic characteristics of the participants are presented in Table 1. Data were collected from a total of 191 midwives. The age of the midwives ranged from 22 to 49 years (mean = 33.1, SD = 5.1): 48 (25.1%) were between the ages of 22 and 29, 115 (60.2%) were between the ages of 30–39, and 28 (14.7%) of the participants were aged 40 or over. 92 (48.2%) of the midwives had received a midwifery diploma, 84 (44.0%) had obtained a bachelor's degree in midwifery, and 15 (7.9%) of the participants had obtained a Master's in Nursing.

Table 1.

Description of Sample Characteristics (N=191).

Variable	n (%)	M (SD)
Age (years)		33.1 (5.1)
23–29	48(25.1)
30–39	115(60.2)
40≤	28(14.7)
Midwifery experience (years)		8.9 (6.8)
1–5	79(41.4)
6–10	54(28.3)
10<	58(30.4)
Education level
Diploma of midwifery	92(48.2)
Bachelor of midwifery	84(44.0)
Master of nursing	15(7.9)
Hospital
King Abdallah University Hospital	27(14.1)
Princess Badiaa Teaching Hospital	26(13.6)
Jerash Governmental Hospital	28(14.7)
Princess Iman Hospital	44(23.0)
Al Ramtha government hospital	15(7.9)
Obstetrics, Gynecology, and Children Hospital/ Almafraq	28(14.7)
Princess Raya Hospital	23(12.0)
Seeking for evidence-based practices
Never	38(19.9)
Seldom	73(38.2)
Occasionally	63(33.0)
Often	17(8.9)
Familiarity with evidence-base practice
Not familiar	38(19.9)
Little familiar	65(34.0)
moderate familiar	61(31.9)
To a great extent familiar	21(11.0)
Completely	6(3.1)

Perception of Barriers to Evidence-Based Practices

The distribution of barriers across the four subscales is presented in Table 2. The average total score of the participant's responses was 64.60 (SD = 15.49) out of 112. The mean scores for the subscales are as follows: personal factors (17.03 out of 32), organisational factors (20.10 out of 32), quality of research (13.89 out of 24), and communication (13.58 out of 24). The highest mean scores were obtained for the following statements: The facilities are inadequate for implementation (M = 2.64 out of 4); Physicians will not cooperate with the implementation (M = 2.58 out of 4); and There is insufficient time on the job to implement new ideas (M = 2.25 out of 4). The lowest mean scores were obtained for the following statements: The midwife does not see the value of research for practice (M = 2.05 out of 4), and The midwife is unwilling to change/try new ideas (M = 2.03 out of 4).

Table 2.

Midwives' Perceived Barriers to Implementing Evidence-Based Practices (n = 191).

Barriers Rank	Subscale	Item	Mean	SD	(%)
20	P	The midwife is isolated from knowledgeable colleagues whom to discuss the research	2.22	0.98	37.1
21	P	The midwife does not feel capable of evaluating the quality of the research	2.23	0.89	36.6
22	P	The midwife feels the benefits of changing practice will be minimal	2.2	0.93	35.1
24	P	The midwife is unaware of the research	2.09	0.94	35.1
25	P	There is not a documented need to change Practice	2.07	0.96	33
27	P	The midwife sees little benefit for self	2.14	0.9	32.5
28	P	The midwife does not see the value of research for Practice	2.05	0.92	30.9
29	P	The midwife is unwilling to change/try new ideas	2.03	0.96	27.7
Total personal subscale			17.03	5.04
1	O	The facilities are inadequate for implementation	2.64	1.01	57.6
2	O	Physicians will not cooperate with the implementation	2.58	0.98	54.5
3	O	There is insufficient time on the job to implement new ideas	2.52	1.02	53.4
5	O	The administration will not allow the implementation	2.61	0.98	49.7
6	O	Other staff are not supportive of the implementation	2.51	0.94	49.7
7	O	The midwife feels results are not generalizable to own setting	2.47	1	49.2
9	O	The midwife does not have time to read the research	2.44	1.01	46.6
13	O	The midwife does not feel she/he has enough authority to change patient care procedures	2.34	0.97	42.4
Total organization subscale			20.10	5.6
4	Q	The research has methodological inadequacies	2.47	0.88	51.8
8	Q	Research reports/articles are not published fast enough	2.38	1	48.2
14	Q	The midwife is uncertain whether to believe the results of the research	2.31	0.9	41.9
15	Q	The conclusions drawn from the research are not justified	2.3	1	41.9
17	Q	The research has not been replicated	2.27	0.92	40.8
26	Q	The literature reports conflicting results	2.17	0.92	33
Total quality of research subscale			13.89	4.16
23	C	Statistical analyses are not understandable	2.16	0.96	35.1
10	C	The relevant literature is not compiled in one place	2.36	0.96	45
11	C	Research reports/articles are not readily available	2.3	0.97	44
12	C	The research is not relevant to the nurse's Practice	2.25	0.99	43.5
16	C	Implications for practice are not made clear	2.3	0.9	41.4
19	C	The research is not reported clearly and readably	2.21	0.9	37.7
Total communication subscale			13.58	4.38
Over all BARRIER Scale			64.60	15.49

Note. Sub-scales: p, Personal subscale; O, Organization subscale; Q, Quality of research subscale; C, Communication subscale., %: rating item as high or moderate barrier, SD: standard deviation.

ANOVA of Sociodemographic Characteristics on Barriers Scale Scores

The differences in mean barrier scores according to age, experience, and education level are displayed in Table 3. Based on this data, it can be established that the only variable that significantly affected the total barriers score was the level of education: midwives with a master's degree identified the fewest barriers, followed by those with a bachelor's degree, whereas diploma-holders experienced the most significant obstacles. There was no significant statistical difference in the mean evidence-based practices total barrier score associated with age (F (2,188) = 0.431, p = 0.65) or years of experience (F (2,188) = 1.55, p = 0.22) (see Table 3).

Table 3.

Differences of Barriers Total Score and Demographic Characteristics (N = 191).

Variable	Mean (SD)	F	P-Value
Age (years)		0.431	0.650
23–29	63.10(14.91)a
30–39	64.77(16.32)a
40≤	66.46(13.00)a
Midwifery experience (years)		1.55	0.22
1–5	64.13(16.18)a
6–10	62.33(15.85)a
10<	67.36(13.96)a
Education level		8.657	≤ 0.001*
Diploma of midwifery	68.75(0.45)a
Bachelor of midwifery	61.94(17.19)a
Master of nursing	54.07(14.51)b

* Significant at p < 0.05. Diferrent subscripts indicate statistical difference across categories of each variable.

^aNo statistically significant difference between groups.

^bStatistically significant difference compared to diploma.

group (Benferroni post hoc test, P < 0.05).

Contrastingly, the total scores for the evidence-based practices barrier were statistically significantly different between education levels (F (2, 188) = 8.657, p ≤ 0.001). A post hoc comparison was run for statistically significant simple main effects with reported 95% confidence intervals and p-values (Bonferroni adjusted). Post hoc comparisons indicate that the mean evidence-based practices total barrier score for midwives who had a master's degree in nursing (M = 54.07, SD = 14.51) was significantly different from midwives who had a diploma of midwifery (M = 68.75, SD = 12.52). However, the mean evidence-based practices barrier total score for midwives with a bachelor's degree in midwifery (M = 61.94, SD = 17.19) did not significantly differ from midwives with a master's degree in nursing.

Regression Model for Barrier Subscales

The regression analysis results for the four subscales are presented in Table 4. All socio-demographic variables (age, midwifery experience, and education level) were entered into the regression model as the predictor variables for each subscale (personal, organisation, quality of research, and communication). Across all subscales (except education level), age and experience are not associated with the perception of barriers to EBP, which suggests that participants with a higher education level predicted fewer perceived barriers (p < 0.05 for all associations) (see Table 4). Midwives holding advanced degrees exhibited consistently lower scores in personal, organisational, quality of research, and communication barriers, confirming the patterns identified in the ANOVA results.

Table 4.

Results of Regression Analysis on the BARRIERS Subscales (n = 191).

	Unstandardized Coefficients		Standardized Coefficients	t	Sig.	95.0% Confidence Interval for B
	B	Std. Error	Beta			Lower Bound	Upper Bound
Personal subscale
Age	−.007	.104	−.008	−.069	.945	−.213	.199
Midwifery experience	.020	.090	.027	.226	.821	−.156	.197
Level of education	−2.598	.564	−.326	−4.610	.000*	−3.710	−1.486
Organization subscale
Age	−.025	.119	−.026	−.208	.835	−.260	.210
Midwifery experience	.035	.102	.042	.339	.735	−.167	.236
Level of education	−2.042	.642	−.232	−3.182	.002*	−3.308	−.776
Quality of research subscale
Age	.069	.090	.095	.759	.449	−.109	.247
Midwifery experience	−.040	.077	−.065	−.512	.609	−.192	.113
Level of education	−.969	.487	−.147	−1.990	.048*	−1.929	−.008
Communication subscale
Age	.144	.093	.190	1.543	.124	−.040	.328
Midwifery experience	−.042	.080	−.066	−.530	.597	−.200	.115
Level of education	−1.416	.503	−.204	−2.815	.005*	−2.408	−.423

Discussion

This research examined midwives’ perceptions of the barriers to implementing evidence-based practice in seven health settings located in the northern region of Jordan. This research should be considered significant because it is the first nationwide research conducted in Jordanian government hospitals to explore how midwives perceive the barriers to implementing evidence-based practice. Across all four domains (organisational, personal, research quality, and communication barriers), the findings of the current study indicate that organisational barriers were the most significant inhibiting factors. The prominence of this finding signifies that addressing systemic and managerial issues to facilitate the adoption of evidence-based practice should be prioritised.

This study's findings highlight that just under 50% of midwives that participated in this study perceived to have moderate level of EBP adoption. Such findings are in accordance to other regional studies such as by (Alqahtani et al., 2020; Dagne & Ayalew, 2020). However, discrepancies may reflect variances within the sample and setting. Abuhammad et al. (2020) findings however reported higher barriers by nurses in Jordan, and this highlight the differences in professional position and workplace environments.

This variance in results may be attributed to the fact that their study sample consisted of nurses (not just midwives) and occurred in different settings. To the best of this author's knowledge, nursing and midwifery education incorporates learning about evidence-based practice; however, the emphasis and scope of any individual curriculum may vary. Typically, pregnancy, labour, and postpartum care are the principal themes of midwifery education: Midwives are taught to provide holistic, individualised care throughout labour and delivery, alongside an emphasis on natural birth consisting of minimal interventions. In terms of evidence-based practice, midwifery education incorporates the most recent studies and contains directives concerning pregnancy, delivery, and the clinical application of such information. Furthermore, midwifery students receive comprehensive instruction concerning the critical analysis of research and making judgments concerning the reliability of the information.

Conversely, general nursing education encompasses a broad range of healthcare settings and patient groups: nurses are trained to deliver a broad spectrum of treatment in diverse clinical settings (such as hospitals, clinics, and community health settings). Nursing students receive tuition concerning evidence-based practice across all aspects of healthcare (including pregnancy and delivery); however, their training lacks the specialisation provided to midwifery students. Beyond pregnancy and childbirth, nurses may be involved in additional patient care activities (such as chronic illness management, wound care, and medication management). Training in evidence-based practice is a component of both midwifery and nursing education; however, midwifery education provides in-depth and specific knowledge concerning pregnancy, labour, and postpartum care.

According to the results of the four BARRIERS subscales, when compared to the other areas (personal, quality of research, and communication), the organisation subscale received the highest score (P-value < 0.001). Research conducted in the Middle East and other countries (Abuhammad et al., 2020; Shayan et al., 2019) has identified similar organisational barriers to EBP implementation, which implies that such challenges are not specific to particular healthcare contexts.

The midwives in this study considered insufficient facilities to be the primary barrier to effective EBP implementation, a factor which has been identified by several other studies (Abuhammad et al., 2020; Bosch et al., 2011; Williams et al., 2015). The lack of resources, infrastructure, and required tools can all contribute to the difficulty of integrating evidence-based strategies in healthcare contexts (Bosch et al., 2011; Williams et al., 2015). The barriers to incorporating the best practices (as identified by earlier research) are more acute in countries where healthcare environments are constrained by limited resources, such as Jordan (Hweidi et al., 2017).

The third most significant barrier to EBP implementation concerns the lack of available time during the working day, a finding which aligns with the results of AlKhalaileh et al. (2016) and Shifaza et al. (2014.) Midwives’ workloads are fully occupied with patient care; therefore, it is extremely challenging to allocate the time required to evaluate and implement any evidence-based care practices advocated by the most up-to-date research (Alqahtani et al., 2020; Brown et al., 2009). Furthermore, midwives typically work shifts, provide care for multiple patients simultaneously, and may be called to assist with emergencies without notice. Such pressures severely restrict their ability to review, reflect on, and implement EBPs (Ejebu et al., 2021).

In agreement with, Abuhammad et al. (2020) only education level showed a significant relationship with the BARRIERS score total, and neither age nor experience showed any association. Midwives with the highest level of education identified fewer barriers to EBP implementation, which suggests that they were more capable of overcoming barriers. Additionally, they are more likely to be familiar with research and appreciate its value; therefore, they may demonstrate a positive attitude towards research findings and recognise the importance of their implementation. According to the theory of planned behaviour (Ajzen, 1991), higher education can influence subjective norms, while increasing perceived behavioural control, both of which may enable midwives to perceive challenging aspects of the working environment as barriers. Therefore, education is a crucial facilitator of EBP, while age and experience appear less relevant.

Unlike a diploma-level education, students studying for a master's degree are required to actively engage in the research process, conduct data analysis, and critically examine theories and research findings; therefore, their proficiency in conducting research is inclined to escalate with increased exposure to research and data analysis. Furthermore, such students have access to a wider range of academic materials (such as publications and conferences), via which they are exposed to new approaches and current research trends (Moeti et al., 2016; Rogal & Young, 2008; Urhan et al., 2022). Midwives with comparable education levels (regardless of their age and level of expertise) may have similar capacities to understand and implement the practices recommended by contemporary research. Correspondingly, the organisational culture (particularly those aspects related to research) may exert considerably more influence on midwives’ behaviour than their age or experience.

Other studies (Al-Maskari & Patterson, 2018; AlKhalaileh et al., 2016) have observed a negative relationship between education level and the BARRIERS subscale scores. Higher education students are accustomed to appraising the research presented by journal articles; therefore, they recognise that claims concerning, for example, specific interventions, must be supported by references to credible sources. Such students have a greater appreciation of the importance of empirical evidence and the overall scientific process. Furthermore, higher education provides an environment wherein intellectual integrity, enquiry, and scholarship are promoted and valued. When engaged in high-level scholarship, students gain an in-depth knowledge of scientific subjects by reading first-hand (primary) sources.

Implications for Practice

This research provides significant contribution towards organisational managers and primary healthcare professionals. The participants, which are midwives highlighted that organisation barrier is the main obstacle towards EBP implementation. Therefore, organisation management need to develop strategies to address these barriers. Additionally, healthcare institutions should create a work culture that appreciates and values care practices that are based on research. Solutions include the provision for staff to have the opportunity to engage in case discussion, shared decision-making and interdisciplinary meetings. This will create a work environment that encourages collaboration thus EBP implementation.

Furthermore, hospital managements need to encourage EBP implementation through introducing tangible initiatives such as provision for midwifes to have scheduled opportunities to practice activities related to EBP and easy access to up to date research. Additionally, organisation should have full support and encouragement for all level staff to implement EBP. However, work pressures, budget constraints, resources, infrastructure and time will be the barriers towards EBP integration.

Strengths and Limitations

Strengths

There are several strengths in this study that reinforce the research credibility and quality. Firstly, this is a first significant research that explores midwives’ perspective pertaining to EBP implementation across several hospitals in the north of Jordan. The second advantage is the sample size at n = 191 cemented the study's reliability and generalisability. The final advantage is the adoption of BARRIERS scale, which is a recognised and renowned tool within literature related to nursing and midwifery, reinforces the study's consistency and methodological rigour.

Limitations

Limitations must be highlighted and the following are such for this study. This research has a geographical limitation in terms of limited to northern region of Jordan, thus impacting the generalisability for the entire country and globally. Another limitation is related to the sample size since the participants consists only of midwives that are employed within government hospitals thus limited the findings towards just this sector and could be generalised over to the private hospitals. Additionally, there is a completely different culture, particularly research-related culture between private and public hospitals, thus this may influence the perceptions of the participants in the importance of EBP implementation. Further limitations include the adoption of convenience sampling method and restrictions to only seven hospitals at the north of Jordan.

Although these decisions were made to ensure the inclusion of the required number of participants, they limited the generalisability of the results to other hospitals, regions, and midwives.

The questionnaire was completed by the participants themselves, meaning biases may be included such as social desirability. Such biases may not be excluded during data triangulation. Therefore, the scores are not a total objective representation of the midwives’ perception. Further limitation that shall be highlighted include the low reliability of communication subscale at r = .65, which means that the conclusions pertaining to communication factors should be considered in a cautious manner.

However, for exploratory studies, the insights obtained remain valuable, and the coefficient itself should be considered acceptable when utilising a research instrument in a cultural context that differs from the one in which it was developed (Nunnally & Bernstein, 1994).

Furthermore, no assessment was made regarding the correlation between personal subscale BARRIERS scores and practical clinical behaviours. These scores, despite being informative are not inclusive of objective clinical practices. Future research could assess the midwives’ other aspects including personal values, competencies and their awareness of the impact of research upon their clinical practices. The scores were categorised into equal scale intervals, despite being logical was random and with insufficient empirical validation. Future studies could explore the application of specific thresholds and the wider range of BARRIERS scale. Lastly, the regression analysis only takes account into key demographic variables as predictors while other variables such as individual, contexts and demographic may be presented as confounders and not present during the analysis.

With the exception of the aforementioned limitations, this study provides significant contribution towards knowledge pertaining to barriers to EBP implementation within north Jordan's healthcare institutions. The information is deemed critical in terms of formulating improvement strategies.

Conclusion

This research shows that midwives that are working in northern Jordan experience significant barriers toward EBP implementation within their clinical practice. The major barriers based on the evidence-based findings of this study were organisational related factors and subsequently insufficient resources, time constraints and limited managerial support. Additionally, midwives’ education level determines the perceived barriers by them and has nothing to with their age or experience. Full EBP integration within healthcare and midwives’ care practices necessitate the managers and policymakers to provide organisation-wide and structural support, and these means providing access to continuous education and research resources to the staff.