The Midwives ‘ Awareness of Evidence Based Midwifery

Background: Evidence-based practice is very useful in every profession, in midwifery exception. Lack of awareness about the use of evidence-based practice can lead to poor quality and fiduciary care of the client. Objective: To determine the awareness of Midwives of Evidence Based Midwifery, determine whether midwives are familiar with the concept of Evidence Based Midwifery and acronym EBM and whether they practice Evidence Based Midwifery in their work. Methods: Respondents were midwives working in the gynecological-obstetric wards and clinics in the Czech Republic selected by purposive sampling, there were 150 respondents. e research was carried out by a non -standardized questionnaire. Results: 100 respondents don ́t know EBM: 93 respondents are interested in the study material about EBMid and 110 respondents are interested in a training course. Conclusions: e objectives of the research were met. e level of Midwives`awareness of Evidence Based Midwifery was detected. Most of the respondents don ́t use EBMid, but their interest in cooperation is quite large.


INTRODUCTION
Evidence Based Practice (dále jen EBP) means a practice based on evidences.e implementation of EBP into nursing profession faces many obstacles, such as lack of knowledge about EBP and its strategy, poor understanding and negative view on the research and EBP, conservative approach to EBP and highlighting the results of the "traditional" care, unavailability of quality professional journals and databases, high number of patients allocated, administrative and organizational problems of the workplace, delay in the publication of research results and applications of these results into practice (1).
Author Greenhalgh (2) states that among the most significant barriers to the implementation of EBP in nursing and midwifery belong knowledge and skills of medical staff (general nurse, midwife), thus, to which level of "standard" they understand EBP and how can such evidences make the best use?
Nursing access to evidence-based practice is different from the standard biomedical model.Midwife provides holistic care, she works more "with the client" rather than "on the client", she must weigh in her clinical decision making not only the effectiveness of treatment, but also the choice of intervention, client acceptability and cost-effectiveness.She must use her own clinical experience and on its basis apply the evidences found in specific clinical situations -in her client.For this purpose there is a specially built clinical question in format of PICOT(S) (3).
e first component of clinical question is P -Patient (patient population), another part of question is I -Intervention, area of interest (intervention being considered for the patient, administration of a particular drug, surgical intervention and other), intervention to compare C -Comparision, which may be a conventional standard treatment.e fourth component is O -Outcome -the desired result (alleviation of pain, risk reduction, improved quality of life and more),through which will be evaluated the intervention or area of interest.e last element os the clinical questions is T -Time -the timeframe for which the question is prepared.Recently, another element already appears -S -Setting -environment (4).
ere are five sequential steps which are usually considered as the process of evidence-based practice: 0 -Critical approach to practice 1 -Formulation of clinical question 2 -Systematic search for the best available evidence 3 -Critical assessment of the evidence (validity, clinical relevance, usability) -Introduction, Methods, Results, Discussion 4 -Application of evidence (results) into clinical practice 5 -Evaluation of the results of implementation of the evidence (performance) (5) Evidence Based Midwifery (hereaer EBMid) can be defined as evidence-based practice relating to midwifery and guidelines for midwives.Among the most significant barriers to the implementation of EBP in midwifery practice belong: knowledge and skills of midwives, thus, to which level of "standard" they understand EBP and how can such evidences make the best use (6).
It is important that the midwife has not only sufficient knowledge of EBP and its strategy, but also properly understands and has a positive approach to research and EBP.Instead of sticking to traditional care, she should be flexible and have access to enough quality and professional journals as well as databases.
EBMid is presented by the RCM (the Royal College of Midwifery) -a research newspaper, which promotes the dissemination, implementation and evaluation of evidence of midwifery at national and international level.e magazine "RCM's research journal" publishes documents of qualitative and quantitative researches, philosophical analyzes and systematic reviews.
Practice guidelines for midwives, based on evidence and resulting in improving quality of care and work with clients, were created in May 2008.EBMid is supported not only by RCM, RCGP (the Royal College of General Practitioners), but also the National Child birth Trust and consultant for the development of the RCM (7).
Within the IGA UP grant competition, we focused on awareness of midwives about the EBMid and the use of evidence-based practice in the profession of midwife.

OBJECTIVE OF WORK
e main objective of the project was to determine the awareness of midwives about the EBMid.Among the sub-objectives of the project belonged determining whether midwives know the concept of EBMid and whether they work with EBMid in their practice.We were also interested whether the respondents are interested in the study material and the course dedica-ted to the evidence-based practice in midwifery.

e research problem was determined:
To identify the degree of knowledge of midwives about evidence-based practice with a focus on EBMid.e research questions were determined: 1. Do the midwives know the acronym EBM and are they able to define it?2. Do the midwives know the the concept of evidence-based practice in midwifery?3. Are the midwives interested in the study material dedicated to the practice of evidence-based practice in midwifery?4. Are the midwives interested in the course dedicated to the evidence-based practice in midwifery?

METHODOLOGY AND CHARACTERISTICS OF SUBJECTS
We created a non-standardized questionnaire designed for midwives, since the focus of the research was very specific and standardized questionnaire that meets the objectives of the research was not found so far.e questionnaire included 15 questions.In the beginning of the questionnaire, the respondents were informed about the intention of the research and signed an informed consent.
In July 2013, a pilot study was conducted, with the aim to verify the suitability of the proposed methods, which address the research problem.Subsequently, we adjusted the non-standardized questionnaire.Pilot study was conducted in midwives working at the Gynecology and Obstetrics Department of the Hospital in Valašské Meziříčí and at the Obstetrics and Gynecology Department of the University Hospital in Olomouc, in the number of 40 respondents (20 respondents in Valašské Meziříčí Hospital, 20 respondents in the University Hospital in Olomouc).
e survey was carried out in the months of September to November 2013.160 questionnaires were distributed.Questionnaires were distributed at departments together with the verbal introduction to the questionnaires, then personally collected.erefore, the return was relatively high.We expected to work with about 150 questionnaires, and so we distributed 160 of them.Altogether we excluded 10 questionnaires from research because they did not meet the criteria for evaluation.e return was 93.8%.Altogether, we have worked with 150 questionnaires.Questionnaires were distributed at following workplaces: Gynecology and Obstetrics Department of the Hospital in Valašské Meziříčí, Obstetrics and Gynecology Department of the University Hospital in Olomouc, Gynecology and Obstetrics Department of the Hospital in Nový Jičín, Gynecology and Obstetrics Department of the Hospital in Přerov.Aer submission of the survey, all departments agreed with a survey on the basis of informed consent.When evaluating the results, we used Microso Word 2007 and Microso Excel 2007.e resulting data were recorded in the contingency tables and subsequently the tables and graphs of the measured values were generated.In the pilot study, a substantive and constructive validation of research tools was conducted.
e respondents were midwives working at chosed outpatient clinics.e total number of respondents was 150.

RESULTS
A total of 50 (33.3%)respondents reported that they know what the acronym EBM means.Of these, only 19 (12.7%) reported the correct version.e rest of the respondents either did not the write the wording of shortcut, or wrote a wrong one.Very oen it was EBM -the practice of evidence-based medicine, which in itself is not inherently bad. 100 (66.7%) of respondents reported ignorance of shortcut EBM.Knowledge of the concept of evidence-based practice in midwifery was confirmed to us by 46 (30.7%) respondents.For 104 (69.3%) of respondents this concept is unknown (see Graph 1).
Graph 1 Knowledge of the concept of evidence--based practice in midwifery . .

No
In our research, we focused on respondents' interest in learning material dedicated to the evidence--based practice in midwifery.We assessed whether they had already been offered a similar study material.Total of 4 (2.7%) the respondents have had a high quality study material for 3 of them (2.0%), a study material which they have been offered in the past, was insufficient and 143 (95.3%) respondents have not been offered any study material about EB-Mid (Table 1).93 (62.0%) of respondents would be interested in a new study material dealing with the evidence--based practice in midwifery, 13 (9.0 %) respondents reported that they were not interested in this topic and 44 (29.0 %) respondents would not know what to do with such material.
In our research we focused on EBMid course that we offer to midwives.So far, 2 (1.3%) respondents completed a similar course, 2 (1.3%) would not be interested in this course.A total of 146 (97.4%) respondents have not been offered a course dedicated to the practice based on evidence in midwifery.
We wondered whether the respondents would now be interested in such training course.85 (56.6%) respondents would like to learn more about EBP, 25 (16.7 %) respondents would certainly use the knowledge from the course in practice.25 (16.6%)respondents did not match the purpose of the course and a total of 15 (10.0%) respondents are not interested in evidence-based practice in midwifery (Graph 2).

DISCUSSION
In our research we focused on the knowledge of the concept of evidence-based practice in midwifery.A total of 30,7% respondents reported that they know this concept,for 69.3% of respondents this term was unknown.
We compared the acquired knowledge with a survey by Hrstková, Tóthová (8).e research investigation of Hrstková, Tothová (8) was addressed to general nurses in South Bohemian Region and Central Bohemian Region.It was devoted to understanding the concept of evidence-based practice.Of the total number of 121 respondents (100.0%),43.0% of them have already met with the term "Evidence Based Practice", the same percentage (43.0%)have not yet encountered with this term and 14.0% of nurses said they did not know whether met with this concept.If we compare it with our results, we find that interviewed nurses are doing better in the knowledge of the concept of EBP, than our midwives.Nevertheless, it must be added that research of Hrstková, Tothová (8) applied only to nurses with bachelor degree, while our research was attended by midwives with different education, where a total of 50.6% of midwives completed an undergraduate diploma.
In 2010 there was performed a research which also dedicated to the practice based on evidence in midwifery.At that time, a total of 32.5% of respondents knew the concept of evidence based midwifery.
62.0% of respondents were interested in a new study material dealing with the practice based on evidence in midwifery, 9.0% of respondents reported that this topic is not interesting for them and 29.0% of the respondents would not know what to do with such material.e research of Hrstková, Tóthová (8) showed that 33.1% of respondents -nurses is interested in research and new information in nursing, 15.7% of respondents is not interested in new information about EBP and 51.2% of respondents is only partly interested in the latest information on evidence--based practice.
A total of 33, 3% of respondents reported that they know the meaning of acronym EBM, of these, only 12.7% said the correct version.e rest of the respondents either did not know the wording of the shortcut, or wrote a wrong one.Very oen it was EBM -the practice of evidence-based medicine, which in itself is not inherently bad.66.7% of respondents reported ignorance of shortcut EBM.ere is a possibility to submit a proposal to amend shortcut for evidence based midwifery from EBM to EBMid.At present, both variants of the shortcut are already beginning to be used.
e results of the survey were compared with the results of the research of authors Ježová, Pokorná (9).Addressed responders of the research by Ježová, Pokorná (9) were nurses from 11 clinics of the University Hospital in Brno -Bohunice, in the total number of 189 (100.0%).A total of 56.6% of respondents chose the answer that was considered correct-EBN is a nursing care based on evidence.A total of 43.4% of respondents answered incorrectly -26.5% of them said that EBN is a nursing care based on skills, 9.5% marked the answer that EBN is a care based on communication and 7.4% chose -EBN is a nursing care based solely on medical research.If we compare the results of both the research investigations, we find that respondent -nurses were better off with the knowledge of EBN.It is necessary to add that in the questionnaire they had a choice of the correct option, while respondents -midwives had to directly define the EBM without choice of the correct option.erefore, the results of the comparison can be considered inaccurate.
Training course about evidence-based practice in midwifery was not found.Usually this topic is taught in the Bachelor and Master programs at universities.As 2 respondents reported participation in such course, we believe that it was precisely a subject or topic in the study.ere is a high rate of interest in this course.Disinterest in 10.0% of the respondents may be due to the lack of awareness about the use of EBMid in the profession.
Training Course on EBMid was realized for of midwives of Gynecology and Obstetrics Department of the Hospital in Valašské Meziříčí.Feedback from the audience was positive.During the lecture, the midwives had available worksheets and a brochure dedicated to the practice based on evidence, with a focus on evidence-based practice in midwifery.

CONCLUSION
e objectives of the research were met.e level of awareness of midwives about the Evidence Based Midwifery was determined as inadequate.Respondents defined shortcut EBM either as Evidence Based Medicine, or Evidence Based Midwifery.Comparison was carried out in a discussion with selected surveys, completed by general nurses, because so far no research survey with respondents -midwives was relevant for the comparison.erefore, it was also mentioned the research, which was conducted by midwives in 2010.We found that the respondents -general nurses had better knowledge of the evidence-based practice than contacted midwives.e reason may be the age of the two disciplines -evidence-based practice in midwifery is a young field and in comparison with evidence-based practice in nursing,there are not as many material and resources, from which the midwives can profit.
Evidence Based Midwiferyis a relatively young field, guidelines for midwives to improve the quality of care and work with clients were created in May 2008 (7).
Most respondents do not work with Evidence Based Midwifery in their practice, but their interest in cooperation is relatively large.It would be appropriate to inform the midwives about the use of EB-Mid in practice and then undertake further research, thanks to which could evaluate the improvement of the situation.Contribution to the practice is very important, as cooperation with EBMid not only leads to more expert and professional care, but also to more individual approach to client and confidence in the chosen care and process, which is supported by research.
We currently offer a training course dedicated to EBMid.e training course is available for gynecologic and obstetric departments and clinics in the Czech Republic, if interested.ere was published a study material that provides basic information about EBMid and its use in the profession of midwifery.It is offered in the course as study material.

Graph 2
Interest in the training course dedicated to the practice based on evidence in midwifery (EBMid)

Table 1
Offered study material about Evidence Based Midwifery until now