Factors Explaining Nurses’ Implementation of Evidence-Based Practice for Postpartum Hemorrhage Management

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Jiranee Panyapin
Wannee Deoisares
Nujjaree Chaimongkol
Poonpong Suksawang


                The implementation of evidence-based guidelines for the prevention and appropriate management of postpartum hemorrhage significantly decreases maternal morbidity and mortality. However, postpartum hemorrhage evidence-based guidelines are not optimally adhered to. This study aimed to examine individual- and organizational-level factors and the interaction effects that explain the implementation of evidence-based practice for PPH management among nurse-midwives. A multi-stage sampling technique was used in this cross-sectional study to recruit 298 nurse-midwives from 50 delivery rooms of community hospitals in Thailand between March to June 2019. Data were collected through seven self-administered questionnaires including a Demographic questionnaire, Evidence-Based Practice Implementation Activity for Postpartum Hemorrhage Management scale, Organizational Support scale, Implementation Climate Scale, Individual Innovativeness scale, Perceived Characteristics of Guidelines scale, and BARRIERS Scale. Descriptive statistics and multilevel modeling analysis were carried out to analyze the data.
                The results revealed the factors that significantly influenced the implementation of evidence-based practice at the level of an individual nurse-midwife were years of experience, personal innovativeness, perceived barriers, and perceived characteristics of guidelines, and the organizational level factors were being a large community hospital and organizational climate. Individual nurse level factors significantly accounted for 68%of the variance in the implementation of evidence-based practice while organizational level factors accounted for 32% of the variance. There was an interactive effect between individual- and organization-level variables. The results of this study suggest that nurse administrators should develop a strategy to promote the adherence of evidence-based practice guidelines among nurse-midwives by decreasing their perceived barriers and establishing an organizational climate of evidence-based implementation.

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Panyapin J, Deoisares W, Chaimongkol N, Suksawang P. Factors Explaining Nurses’ Implementation of Evidence-Based Practice for Postpartum Hemorrhage Management . PRIJNR [Internet]. 2021Jun.15 [cited 2021Sep.27];25(3):421-36. Available from: https://he02.tci-thaijo.org/index.php/PRIJNR/article/view/240472
Original paper


1. World Health Organization. World health statistics 2017: monitoring health for the sustainable development goals [Internet]. 2018 [cited 2018 May 2]. Available from: http://www.who.int/gho/maternal_health/en/

2. Bureau of Policy and Strategy, Department of Health, Ministry of Public Health. Public Health Statistics 2016 [Internet]. 2017[cited 2018 May 2]. Available from: http://bps2moph.go.th/sites/default/files/kpimoph61.pdf

3. Bureau of Policy and Strategy, Department of Health, Ministry of Public Health. Public Health Statistics 2015 [Internet]. 2016 [cited 2018 May 2]. Available from: http://bps.moph.go.th/new_bps/sites/default/files/ stratistics60.pdf

4. Shields LE, Wiesner S, Fulton J, Pelletreau B. Comprehensive maternal hemorrhage protocols reduce the use of blood products and improve patient safety. Am J Obstet Gynecol. 2015; 212(3): 272-80. DOI:10. 1016/j.ajog.2014.07.012.

5. Woiski MD, van Vugt HC, Dijkman A, Grol RP, Marcus A, Middeldorp JM et al. From postpartum haemorrhage guideline to local protocol: a study of protocol quality. Matern Child Health J. 2016; 20(10):2160-8. DOI: 10.1007/s10995-016-2050-9.

6. Driessen M., Bouvier-Colle MH, Dupont C, Khoshnood B, Rudigoz RC, Deneux-Tharaux C. Postpartum hemorrhage resulting from uterine atony after vaginal delivery: factors associated with severity. JOGNN. 2011; 117(1): 21-31. doi:10.1097/AOG.0b013e318202c845.

7. Holleman G, van Tol M, Schoonhoven L, Mintjes-de Groot J, van Achterberg T. Empowering nurses to handle the guideline implementation process: identification of implementation competencies. J Nurs Care Qual. 2014; 29(3): E1-E6. doi: 10.1097/NCQ.0000000000000052.

8. Nienke OK, Gerrie WB, Jan PH, Gertrudis IJM K, Rixt Z. Feasibility of the Translating Innovations into Practice-toolbox (TIP-toolbox): a mixed-methods study for implementing activity innovations in nursing homes. Geriatric Nurs. 2017; 38(6): 498-504. DOI: 10.1016/j.gerinurse.2017.03.011.

9. Herr K, Titler M, Fine PG, Sanders S, Cavanaugh JE, Swegle J, et al. The effect of a translating research into practice (TRIP)-cancer intervention on cancer pain management in older adults in hospice. Pain Med. 2012; 13(8): 1004- 17. doi:10.1111/j.1526-4637.2012.01405.x.

10. Sanluang CS, Aungsuroch Y. Predictive factors for research utilization in nursing practice among professional nurses, regional hospitals, Thailand. J Health Res. 2015; 30(1): 25-31. doi:10.14456/jhr.2016.4.

11. Squires JE, Estabrooks CA, Gustavsson P, Wallin L. Individual determinants of research utilization by nurses: a systematic review update. Implem Sci. 2011; 6(1): 1-20. doi: 10.1186/1748-5908-6-1.

12. Suwanraj M. Current practice, perceived barriers, and perceived facilitators of Thai nurses on using the evidence-based practice on pain assessment and pain management in older adults. (3422198 Ph.D.), The University of Iowa, Ann Arbor, 2010.

13. Rogers E. Diffusion of Innovations, 5th ed. New York: Simon & Shuster; 2003.

14. Melnyk, BM, Fineout-Overholt, E. Evidence-based practice in nursing & healthcare: a guide to best practice. Lippincott Williams & Wilkins; 2011.

15. Estabrooks CA, Squires JE, Strandberg E, Nilsson-Kajermo K, Scott SD, Profetto-McGrath J, et al. Towards better measures of research utilization: a collaborative study in Canada and Sweden. J Adv Nurs. 2011; 67(8): 1705-18. doi.org/10.1111/j.1365-2648. 2011.05610.x.

16. Heydari A, Mazlom SR, Ranjbar H, Scurlock‐Evans L. A study of Iranian nurses’ and midwives’ knowledge, attitudes, and implementation of evidence‐based practice: the time for change has arrived. Worldviews on Evidence‐ Based Nurs. 2014; 11(5): 325-31. doi: 10.1111/ wvn.12052.

17. Funk SG, Champagne MT, Wiese CR, Tomquist EM. Barriers: the barriers to research utilization scale. App Nurs Res. 1991; 4(1): 39-45. doi: 10.1016/s0897- 1897(05)80052-7.

18. Kajermo KN, Boström A-M, Thompson DS, Hutchinson AM, Estabrooks CA, & Wallin L. The BARRIERS scale - the barriers to research utilization scale: a systematic review. Implem Sci. 2010; 5: 32-32. doi: 10.1186/1748- 5908-5-32.

19. Puttaruksa L, Subgranon R, Othaganont P. Factors leading to success in the implementation of evidence based nursing practice of professional nurses. J of Faculty of Nursing, Burapha University. 2016; 24(3): 94-103. (in Thai).

20. Cummings GG, Hutchinson AM, Scott SD, Norton PG, Estabrooks CA. The relationship between characteristics of context and research utilization in a pediatric setting. BMC Health Serv Res. 2010; 10: 1-10. doi: 10.1186/1472-6963-10-168.

21. Shuman C. Addressing the practice context in evidence based practice implementation: leadership and climate. (10670409 Ph.D.), The University of Michigan, Proquest, 2017.

22. Ehrhart MG, Aarons GA, Farahnak LR. Assessing the organizational context for EBP implementation: the development and validity testing of the Implementation Climate Scale (ICS). Implement Sci. 2014; 9: 1-10. doi:10.1186/s13012-014-0157-1.

23. Hox JJ. Multilevel analysis. Techniques and applications, 2nd ed. New York, US: Routledge/Taylor & Francis Group; 2010.

24. Brislin RW. Back-translation for cross-cultural research. J Cross-Cultural Psychol. 1970; 1(3):185-216.

25. Hurt HT, Joseph K & Cook CD. Scales for the measurement of innovativeness. Human Comm Res. 1977; 4(1): 58-65.

26. Edwards N, Davies B, Danseco E, Pharand D, Brosseau L, Ploeg J, et al. Evaluation of nursing best practice guidelines: organizational characteristics. Comm Health Res Unit Monograph Series. 2004; 04-02: 1-31.

27. World Health Organization. WHO recommendations for the prevention and treatment of postpartum haemorrhage [Internet]. Geneva: WHO; 2012 [cited 2018 May 2]. Available from: http://who.int/iris/bitstream/handle/ 10665/ 75411/9789241548502_eng.pdf

28. Royal Thai College of Obstetricians and Gynaecologists (RTCOG). Clinical practice guideline: management of atonic postpartum hemorrhage. In: Royal Thai College of Obstetricians and Gynaecologists (RTCOG), editor. Clinical management guidelines for obstetrician–gynecologists. 2nd. ed. Bangkok; 2012 (in Thai).

29. Aarons GA, Ehrhart MG, Farahnak LR. Sklar M. Aligning leadership across systems and organizations to develop a strategic climate for evidence based practice implementation. Ann Revof Pub Health. 2014; 35: 255-74. doi: 10.1146/ annurev-publhealth-032013-182447.

30. Bourgault AM, Hooper V, Sole ML, Waller JL. Factors influencing critical care nurses’ adoption of the AACN practice alert on verification of feeding tube placement. Nutr in Crit Care. 2014; 23(2): 134-44. doi: 10.4037/ ajcc2014558.

31. Zhou F, Maier M, Hao Y, Tang L, Guo L, Liu H, et al. Barriers to research utilization among registered nurses in traditional Chinese Medicine hospitals: a cross-sectional survey in China. Evid Based Complementary Altern Med. 2015: 1-8. doi.org/10.1155/2015/475340.

32. Leo A, Bayes S, Geraghty S, Butt J. Midwives’ use of best available evidence in practice: an integrative review. J Clin Nurs. 2019;28:4225–35. doi: 10.1111/jocn.15027.

33. Abuejheisheh A, Omar T, Qaddumi J, Almahmoud O, Darawad MW. Predictors of intensive care unit nurses’ practice of evidence-based practice guidelines. J of Health Care. 2020; 57:1-7. doi: 10.1177%2F004695802090 2323.

34. Quiros D, Lin S, Larson EL. Attitudes toward practice guidelines among ICU personnel: a cross-sectional anonymous survey. Heart Lung J. 2007 ; 36(4): 287– 297. doi: 10.1016/j.hrtlng.2006.08.005.

35. Ball K. Compliance with surgical smoke evacuation guidelines: implications for practice. AORN J. 2012; 30(1): 142-9. doi: 10.1016/j.aorn.2010.06.002.

36. Cho E, Lee N-J, Kim E-Y, Kim S, Lee K, Park K-O, et al. Nurse staffing level and overtime associated with patient safety, quality of care, and care left undone in hospitals: a cross-sectional study. Intern J of Nurs Stud. 2016, 60: 263-71. doi: 10.1016/j.ijnurstu.2016.05. 009.