Exploring the usability of the COM-B model and Transtheoretical Domains Framework (TDF) to dene the underlying helpers and hindrances of evidence-based change in midwifery

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 reticence towards implementing 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 practice, and test the usability of the Capability, Opportunity, Motivation and Behaviour model and Transtheoretical Domains Framework to analyse the barriers and facilitators to evidence-based change. Methods

Exploring the usability of the COM-B model and Transtheoretical Domains Framework (TDF) to de ne the underlying helpers and hindrances of evidence-based change in midwifery These ndings provide empirical evidence of the helpers and hindrances of EBP in midwifery and the use IS tools to accelerate the timely adoption of EBP in midwifery.

Background
The bene ts of adopting Evidence-based Practice (EBP) in healthcare are well reported in the literature (Friesen-Storms, Moser, van der Loo, Beurskens, & Bours, 2015). However, after more than two decades of Implementation Science (IS) research and the development of over 60 implementation theories, models and frameworks, the evidence-to-practice gap remains an issue in healthcare (Gallen, Kodate, & Casey, 2019;Heydari, Mazlom, Ranjbar, & Scurlock-Evans, 2014).
The implementation of behaviour change interventions (such as implementing EBP) are recognised to be more effective when based on theory, compared with those that lack a philosophical approach (Glanz & Bishop, 2010;Hanbury & Wood, 2018). One such behavioural theory, the 'Capability, Opportunity, Motivation and Behaviour' model ('COM-B'), also recognised as the 'Behaviour Change Wheel' ('BCW'), identi es systems that motivate behaviours at both individual and organisational levels (Michie, van Stralen, & West, 2011). The key premise of the COM-B model is in understanding that Capabilities (an individual's capacity to engage in behaviour modi cations), Opportunity (factors in the environment that in uence individual behaviours) and Motivation (the willingness to change) generate behaviours that can be leveraged to in uence Behaviour change interventions (Handley, Gorukanti, & Cattamanchi, 2016). In essence, the COM-B model highlights that in order to adopt new behaviours an individual needs to be capable of change, have the opportunity to change and be motivated to engage in new behaviours.
Context assessment frameworks derived from IS research may also provide valuable insight into the challenges of implementing EBP. The Transtheoretical Domains Framework (TDF) builds on the systems identi ed in the COM-B model to further breakdown the underpinning individual-level barriers and facilitators of evidence-based change, and enhances the development of tailored intervention strategies by facilitating the practical use of IS in clinical environments (Cane, O'Connor, & Michie, 2012).
Comprising 14 theoretical domains, the TDF is a well-validated, comprehensive framework that can be used to assess the barriers and enablers of behaviour change and 'diagnose' the contextual factors that may in uence the change implementation process (Michie et al., 2005). The domains cover three broad elements: individual-level variables, social-cultural variables, and system-level variables that can be mapped to the COM-B systems (Table 2). When combined, the COM-B model and TDF offer IS strategies that maybe useful for midwives wanting to optimise the e ciency and outcomes of EBP initiatives in clinical areas. Implementation Science knowledge is; however, not commonly taught in midwifery education and although literature on the topic continues to inform midwives' of the evidence-to-practice problem, it fails to provide clear direction on how to facilitate practice change initiatives (Nilsen, Neher, Ellstrom, & Gardner, 2017). Although there is an established body of literature on the barriers and facilitators of EBP in healthcare, there little is known about midwives' use of IS resources to facilitate the process (Bayes, Fenwick, & Jennings, 2016). The purpose of this study was to address this uncertainty by exploring midwives' experience of implementing EBP and testing the usability of the COM-B and TDF in midwifery contexts.

Study design and population
This study forms part of a broader Participatory Action Research (PAR) project that aims to improve the processes by which midwives implement EBP in clinical areas. Eight midwifery leaders with experience in leading practice change were nominated by their managing Directors to participate in the study. The study involved a focus group discussion and ve in-depth interviews, all of which were underpinned by the methodological reasoning of Action Research (Kemmis & McTaggart, 1988). This design enabled authors to gain an insider's perspective of the implementation challenges midwives' experience when trying to initiate evidence-based change, which led to discussion about the challenges and uncertainty of how to implement evidence-based change. The focus group and interviews were guided by four discussion points, which were designed to elicit participants' views on initiating practice change, the factors that helped or hindered the process, what information or IS tools midwives' used to implement EBP and what midwives require to how these should be packaged for midwives working in clinical areas.

Data collection
The Nominal Group Technique (NGT) was used during the focus group discussion to achieve group consensus on four key discussion points. The NGT aligns with the constructs of qualitative research, proving to be more effective in obtaining participant responses in greater depth and breadth when compared with traditional focus group discussions (Langford, Schoenfeld, & Izzo, 2002). The focus group was facilitated over three hours by authors 1 and 2, wherein discussions were audio-recorded and additional eld notes taken. All participants were ascribed pseudonyms and consented to participating in the discussion.
Due to work commitments, three participants consented to an audio-recorded interview, which focused on the same discussion points explored at the focus group. Each interview lasted approx. 60 minutes and no follow-up interviews were conducted. The interviews were conducted by author 1 and data saturation was discussed with authors 2, 3 and 4 following the nal interview. The transcripts were not returned to participants' for comment or correction.

Data analysis
The audio-recordings and eld notes from the focus group and semi-structured interviews were transcribed and 'coded' through a process of thematic analysis as described by Braun and Clarke's approach to qualitative research (Braun & Clarke, 2006). A structured categorisation matrix was developed to code the data, which was based on the transcripts from the focus group and interviews. All transcripts were reviewed for content relating to the following data sets: experience of implementing EBP, helpers and hindrances of implementing EBP, information midwives require to implement EBP and how to package this information for midwives working in clinical areas. Content relevant to the data sets were extracted from the transcripts and labelled as codes. These codes were grouped into major categories and mapped to the COM-B model (also recognised as the 'Behaviour Change Wheel' or 'BCW') (Michie et al., 2011) and the TDF (Cane et al., 2012). The codes validated the categorised ndings and demonstrate consistency between the data presented and the core nding (See table 1

Results
There was unanimous agreement by all 8 participants that midwives' are passionate about EBP, yet reticent towards change. According to participants, the reasoning behind this was midwives' limited knowledge of implementation processes and their expressed reticence towards evidence-based change.
This was derived from 72 codes and 4 major categories that described the various personal, contextual and operational challenges midwives' experienced when trying to implement evidence-based change. In addition to these challenges, 5 participants expressed various leveraging factors that facilitated the implementation process: inter-disciplinary buy-in, well de ned implementation processes and support from midwifery 'change-leaders' were considered key components to successfully embedding EBP in clinical areas.

Comparison of the ndings when mapped to COM-B and TDF domains
The ndings of this study were mapped to a matrix that combined the COM-B model with the TDF to further breakdown the underlying individual-level barriers and facilitators of evidence-based change (see Table 2). These are presented below using the Capability, Opportunity and Motivation systems of the COM-B model.

Capability
Within the Capability system of the COMB-B model, three of the TDF domains: Knowledge, Skills and Behaviour Regulation (TDF domains 1, 2 and 4) were described by participants' when sharing their experience of implementing EBP. Participants' recognised that most midwives' have limited skills in sourcing, interpreting and translating best available evidence into everyday care. With regard to Behaviour Regulation (TDF domain 14), all participants acknowledged the challenges of implementing evidencebased change during work hours, with the general consensus being "change takes time and you also need to be present with women…you've got to manage both and that's sometimes not easy" (MW7). Additionally, two participants acknowledged the importance of ongoing audit and evaluation to ensure change initiatives were sustained.
Opportunity Two of the TDF domains (Environmental Context and Resources and Social In uences) were identi ed in the codes and major categories as being suited to the Opportunity component of the COM-B model. Participants articulated local and organisational hindrances (TDF domain 11) that hindered midwives' efforts to introduce EBP. Social In uences were explored by MW5 who recalled conversations with a midwife who said: "that sounds like a great idea, and in a perfect world if I didn't need sleep, have my family and need to pay the bills I would [initiate practice change]…let's wait till next year" (MW5). The resistance experienced by all participants not only delayed the prospect of initiating evidence-based change but also lengthened the time it took to embed new practices. This resulted in inconsistency in both uptake and longevity of implementation projects.

Motivation
When mapped to the COM-B model, the TDF domains identi ed in this system included: Beliefs about capabilities (4), Beliefs about consequences (6), Social/professional role and identity (3), Emotion (13), Optimism (5), and Reinforcement (7). Signi cantly, participants expressed reticence towards practice change. This led to aversion by some midwives who felt challenged by the problems associated with initiating evidence-based change. 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). Participants also reported that many midwives' were driven by automatic (emotional) responses to change, which often related to their personal view towards EBP and how practice change would affect their workload and professional responsibilities. One midwife quoted "I didn't say I don't believe it (the evidence), I just want to know how it's going to affect my workload and income?" (MW4). Domain 13 of the TDF (Emotion) provided a platform for participants' descriptions of increased stress, fatigue and anxiety in relation to implementing evidence-based change, and their mixed feelings towards initiating EBP in clinical areas. Another signi cant nding reported by participants' was that fear stops midwives capacity to initiate change. The TDF proved valuable in deconstructing this further to highlight that many midwives feel reticent towards practice change and implementing new 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." No participants reported the use of other reinforcement techniques as articulated within the constructs of domain 7.
Feelings of Optimism (TDF domain 5) resonated in the views shared by the majority of participants, 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), which captures the professional responsibility of midwives' to lead change initiatives in maternity care settings. MW3 re ected on these issues and commented "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." (Please insert

Discussion
The widespread implementation of EBP in maternity care remains inconsistent and uncertain, despite best efforts by midwives (Bayes, Juggins, Whitehead, & De Leo, 2019). This study aimed to establish midwives' views on the helpers and hindrances of EBP, and tested the suitability of the COM-B model and TDF to further explore the underlying factors that contribute to the timely adoption of EBP in clinical areas. Signi cantly, none of the participants had considered or used IS tools to support their implementation efforts. This perhaps re ects the near absence of midwifery research relating to IS and offers an explanation for the persistent evidence-to-practice gap in midwifery practice settings. The ndings of this study resonate with Bayes et al. (2016) who tested the usability of the Consolidated Framework for Implementation Research (CFIR) in midwifery contexts. Authors reported the CFIR to be broadly helpful; although inappropriate in its original form for midwifery contexts. Seemingly, there has been no other work exploring the usability of either the COM-B model or TDF in midwifery contexts; however there are publications that report on the use of the COM-B model and TDF in other healthcare contexts outside the discipline of midwifery (Asimakopoulou & Newton, 2015;Lynch, Luker, Cadilhac, Fryer, & Hillier, 2017).
In regard to this study, only two of the TDF domains were not identi ed in the ndings: Intentions and Goals (TDF domains 8 and 9), which offers some insight into why participant's experienced the challenges they reported and may provide direction for future implementation processes in midwifery. Although all participants set broad goals to implement evidence-based change, none speci cally spoke of the processes they used to plan, implement, evaluate and sustain their implementation efforts. We do no assume these steps were not undertaken, rather highlight the need for midwives to consider goal-setting and action-planning (also termed 'intervention mapping') when implementing EBP. Although ongoing audit and evaluation were reported by two of our participants, none articulated how they intended to address behavioural change or recognised the value of incorporating IS processes in their implementation projects.
The ndings of this study con rm the usability of the COM-B model and TDF in midwifery contexts, and suggest evidence implementation tools would improve implementation processes for timely evidencebased change. The Expert Recommendations for Implementing Change (ERIC) project has developed a compilation of 68 implementation strategies that provide a foundation for constructing intervention strategies (for example: Education, Training and Environmental restructuring). These are multidimensional and useful for targeting change innovations at both individual and organisational levels (Powell et al., 2015). 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 helpers and hindrances explored in this study.
This study must be considered within the context in which it was conducted. Although the sample provided su cient data to generate signi cant ndings in this study, the participants represented a relatively small portion of experienced midwifery leaders from the public health sector and may have bene ted from the inclusion of practicing midwives. Thus, it is possible the ndings of this study may not re ect the wider implementation issues of practicing midwives in all maternity care contexts.

Conclusions
This study is signi cant in that it provides valuable insight into the use of behavioural theories and context assessment frameworks to diagnose and develop intervention strategies for the needs of midwives wanting to initiate EBP in clinical areas. This process enabled an assessment of the effectiveness of the COM-B model and TDF, and establishes the starting point for developing intervention strategies speci c to midwifery practice contexts. It is anticipated this will lead to the development of new processes that will facilitate closure of the evidence-to-practice gap in midwifery. Inter-disciplinary buy-in and strong midwifery leadership is a huge advantage

Supplementary Files
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