Responsibility of nurses and midwives in clinical practice is much important and it should be evidence based. There is a wide benefit of using evidence-based nursing practice to improve and update clinical practice and to enhance the quality of care and outcomes for patients. However, despite a large body of research showing, that nurses and midwives have positive attitudes towards evidence-based practice, its implementation remains a considerable and significant challenge. As a way of improving them Health services and government agencies should make a concerted effort to make time for nurses and midwives to access, appraise and use evidence-based information.
Introduction: In every country of the world, nurses and midwives play an important role in national health care. The nursing and midwife profession face an increasing number of medical problems, such as an increase in fertility, an increase in the number of pregnant women over 40, higher rates of multiple births and cesarean sections, and social factors such as poverty and immigration. In addition, the fact of a shortage of midwives and the increasing age structure of midwives means that the profession is facing a shortage of staff, so learning and retaining them are priorities for obstetrics.
Purpose: analysis of scientific information on international experience in nursing in midwifery, based on evidence based nursing practice.
Search strategy: 45 English and Russian- language publications from the Cinahl, Google Scholar, PubMed, eLibrary databases were analyzed over the past 20 years, from January 1998 to December 2018. Inclusion criteria: publications, which contained a tool for analyzing of the problem of the formation and development of the nurse profession image. The following key queries were used: “Nurses”, “Midwives”, “Knowledge of evidence-based nursing practice”, “Obstetrics”.
Results and discussion. Turning to the statistics, it can be said that about 30 – 40% of patients do not receive medical care that is consistent with existing scientific data, and that about 20–30% of the medical care provided is unnecessary or even potentially harmful .A similar situation exists in nursing care .However, it is widely known that today in the Republic of Kazakhstan nursing practice based on evidence is being actively implemented and being developed. Speaking about the practice being implemented, one should take into account that the evidencebased practice (EBP) is a method that affects global public health .
Health authorities around the world recommend that medical professionals should make their decisions on the basis of scientific evidence. The same is true in nursing, because nurses and midwives are the largest in group of medical services and play an important role in providing effective care to patients, their competence and ability to use the results of scientific research in their daily practice were emphasized as emergence .
Evidence-based medicine is a section of evidence-based medicine that involves searching, comparing, summarizing, and widely disseminating evidence for use in the interests of patients. This is a new approach, direction or technology of collecting, analyzing, synthesizing and interpreting scientific information. Evidence-based medicine provides for a conscientious, explainable and common sense-based use of the best modern advances for treating each patient .The main goal of introducing the principles of evidence-based medicine into health care practice is to optimize the quality of medical care in terms of safety, efficiency, cost, and other significant factors. The term “evidence-based medicine” was first proposed in 1990 by a group of Canadian scientists from MacMaster University in Toronto. For example, Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., et al.  Describe EBP as two categories: the use of knowledge (use of evidence that underlies the practice, i.e., behavior change) and its influence (the result of using this knowledge, that is, the result for the patient, improvement, and profitability of medical care). In terms of evaluating the success of an EBP, this is an impact of the clinical outcome, differences in the use of health care resources, or changes in individual behavior based on evidence. Realizing that there is evidence-based medicine, a number of problems in nursing can be identified, the key of which is that many nurses and midwives in clinical practice do not understand the concept of evidence-based nursing care and how to apply this concept in general clinical practice . Indeed, at present, nurses and midwives are assisting patients from the point of view in their own experience and knowledge from textbooks, but due to the growth of internal and external expectations of higher quality nursing care, this is no longer acceptable. For a professional decision, it is expected that clinical nurses / midwives should use the best research results, extract data from nursing experience and consider patient preferences .
Evidence based nursing (EBN) is an approach that helps to make good quality decisions by the nurses and midwives regarding their case in accordance with most current, relevant research available on the same topic . The main aim of EBN is to improve the health of the patient and to improve the outcomes of both the patients and the health care system . Evidence-based practice (EBP) leads to the individual and professional development of nurses and midwives, inorder to increase the provision and reliability of the quality ofmedical care  as well as reducing healthcare costs and improving patient outcomes .
By studying further the relevance and application of evidence-based medicine, it can be clearly understood that nurses / midwives are largely responsible for evidence-based practice (EBP), as they are professionally responsible to provide the patients appropriate care based on the best evidence available . Overall, the implementation of EBP in the daily practice of nurses and midwives is difficult . As it is known, the study of Magda M. Mohsen, Nahla Ashour Safaan, and Omayma Okby  showed that 60% of practical nurses do not use the results of research in patient care procedures.
After the above-mentioned results, further studies were conducted, showing that one of the main problem preventing the introduction of evidence-based medical practice is the lack of time. Nurses believe that they are too busy to participate in evidencebased nursing activities .Along with this, nurses indicate that they lack the knowledge and competence to assess and analyze scientific data. As expected, a study by Majid, A., Foo, S., Luyt, B., Zhang, M., Theng, Y., Chang, Y., and Intan A. Found that many nurses in fact, they often do not understand the statistical terms and jargon used in research articles.
They have also found out that the nurses / midwives do not possess the principles of critical evaluation of publications, as they are frightened by the difficulty of mastering such skills. In today's scientific community, it is widely known that additional evidence and education is needed for evidence-based care for the sick. And in this case, nurses and midwives are no exception. The successful implementation of evidence-based nursing depends on the organizational plans and programs for empowering hospitals. Therefore, hospital management must formulate a comprehensive strategy for improving EBP. . And clinical nurses, in turn, need continuous educational programs to improve the competencies of research and evaluation as these skills are necessary for their clinical practice.  Indeed, many studies have shown that the current nursing culture, the belief of nurses, the lack of motivation to change one's habits are factors that prevent the introduction of EBP. In addition, many nurses do not bother whether their usual practice is the best practice. When they were asked, whether they found the answers to the questions arising in their daily practice, many responded that they had no questions or that they have asked the doctor about it . Pravikoff D.S., Pierce S. and Tanner A.  noted that nurses, as a rule, used data from their colleagues, and the library and research used as a last resort. Mc Caughan D., Thompson C., Cullum N., Sheldon T.A. and Thompson D. R. (2002, 23) called this cultural resistance to change, where, instead of active resistance, there is apathy and inaction.
Another problem that arises in the clinical setting is the lack of resources (limited access to literature and the Internet) to search for new knowledge . A study of Cheung N.F., Zhang L., Mander R., Xu X., and Wang X.  showed fundamental problem in Chinese obstetric education, since midwives do not have access to evidence-based materials. Thus, despite the growing volume of information sources, the reality of obtaining high-quality scientific evidence in practice remains problematic .
This is due to the following factors:
- - the absence of computers and medical libraries related specifically to evidence-based research in nursing, in an organization where nurses practice;
- - lack of knowledge to access the database and to find information in the database.
All of the above factors are which the society and public health representatives need to be aware of: an evidence-based approach can become a reality, only if nurses have access to current scientific resources and the Internet near clinical conditions .
Also, evidence-based practice is an environment for changing professional and clinical practice, but this requires the support of colleagues, managing directors, and management.
Moreover, eliminating the factors that impede the development of EBP requires medical organizations to take a structured and coordinated approach that allow nurses to practice using the evidence based. Therefore, hospital management should invest and develop comprehensive policies to strengthen EBP in treating the patients. The deliberate political stance on teaching more nurses to get a degree and postgraduate education will have a positive effect on the adoption of EBP.. Therefore, we suggest that evidence-based practice becomes more likely a reality when local health authorities and advanced training programs promote, support, and provide resources for its development in practice .
As all the previously mentioned, research by Krugman M. (2003) showed that changing attitudes and raising the level of nursing knowledge are the first step in EBP . As part of this concept, a study was conducted in Canada of 528 graduate students working in educational pediatric hospitals, and it was established that nurses' knowledge of EBP and their positive attitude towards it contribute to its introduction into the health care system .
At the same time, Melnyk B., Fineout - Overholt E., Stone P. and Ackerman M.  Argue that teaching nurses about research methods and the ability to critically evaluate the scientifically based data can overcome factors that impede application of research results, and thus lead to improved quality of health care.
In the study, in turn, conducted in Mashhad government hospitals in Iran, most nurses reported poor EBP knowledge or skills. The study found that nurses reported higher EBP knowledge, skills, and practices than midwives . And the experience conducted by Malik, G., McKenna, LG, and Plummer, VM  at Kenyatta National Hospital, Nairobi, Kenya showed that over 92% of respondents agree that EBP is not widely used and not taken into account in current practice. Similarly, a study conducted by Melnyk B.M., Fineout - Overholt E., Gallagher-Ford L., & Kaplan L.  Showed that only 34.5% of nurses reported that their colleagues have implemented EBP in patient care, 46.4% of respondents believe that EBP is used regularly in their institutes, 76.2% of respondents reported the need for additional knowledge and skills in EBP and 72.9% of EBP training.
Thus many researchers indicate that the use of EBP knowledge increases with the level of education and varies across the clinical specialty, which suggests that education and current professional practice influence the perception and familiarity with EBP. After all, it was found that nurses and midwives with master's degree showed more knowledge, skills and practices of EBP and more positive relationship than nurses with bachelor's degree .
In 2016 Belowska J., Panczyk M., Zarzeka A., Zmuda-Trzebiatowska H., Kot - Doniec B. and Gotlib J.  conducted an assessment of knowledge, attitudes and skills to use evidence-based practice (EBP) among midwives after completing specialized training organized by the center of postgraduate education for nurses and midwives (CKPPiP). They found that 66.6% of midwives knew about the importance and development of EBP in obstetrics and the benefits derived from using EBP, 37.5% of respondents never evaluated the methodological soundness of the scientific literature they used, 39.5% of them have never met the term “systematic review”, 56.2% of respondents said that they know how to search for information in electronic databases of scientific literature and 31.2% used it once a month.
This included knowledge, attitudes and practices of midwives in relation to evidencebased practice in the prevention of mother – to – child transmission of HIV in a hospital in Malawi. The results showed that the nurses had an average knowledge of evidencebased practice, although their attitude was favorable, their practice was very low. Certain socio-demographic variables influenced the respondent's knowledge, attitudes and practices. In addition, the results showed that evidence-based practice is mainly hampered by insufficient resources and difficulties in accessing research articles. The authors found that mentoring, learning, and access to literature can contribute to evidence-based practice . In Kazakhstan, however, only one study has been conducted, and the purpose of which was to describe and compare thecurrent state of EBP from the point of view of Kazakhstan nurses and nursing teachers. In particular, the goal was to obtain information about the knowledge of teachers in nursing and nurses about knowledge and attitudes towards EBP and to study the factors that influence the adoption of EBP in Kazakhstan. It was found that the majority of respondents did not understand the definition and meaning of the EBP concept. The research results showed that only 5.7% of respondents understood EBP, only subjective and objective patient data - 12.3% of respondents, as well as a combination of previous experience and research results of 20.8% of respondents. More than a third (36.8%) of teachers of nurses and nurses believed that EBP is a combination of patient's subjective and objective data, information from textbooks, previous experience of health workers and research results. A quarter (24.5%) of respondents identified EBP as consisting of patient data, previous experience of medical professionals, research results and patient values / preferences. This study found that the main obstacles to the implementation of EBP were lack of time, knowledge, skills and resources. Since Nursing Education traditionally does not support critical thinking, given that it was not expected in nursing practice, and it is difficult to change the culture of practice. In addition, the results of this study indicate a lack of confidence in evaluating one's own work and sharing experience in working with colleagues, which will be crucial in developing EBP . In the big picture, the experiences of spreading and implementing EBP among health workers showed that only a few were effective . The implementation of EBP is complex, multifaceted and multilayered, and interventions that must take into account context, culture, and promote its use. The assessment of EBP knowledge, attitudes and attitudes in the field of nursing is an important issue. The most common tool for determining EBP knowledge, attitudes and practices among clinical nurses and midwives are questionnaires / scales. The most famous are the following questionnaires / scales:
In order for nurses / midwives to work on the basis of evidence, they need to know how to implement, develop and evaluate evidence-based practices. In most developed countries, EBP nursing education has been transferred to universities and academic colleges, where nurses are trained in EBP thinking and use. After completing an EBP - oriented study, nurses will be able to search for research results, understand them and compare them with their clinical experience in practice. This has led to new challenges, such as the training of lecturers and clinical nurses .It is very important for EBP nurses to meet and study with nurses who believe in the importance of critical thinking and use the research findings in their daily work . Joanna Briggs Institute (JBI) , founded in 1996, the first and largest institution of EBP, focused mainly on nursing. So far, it has more than 70 organizations worldwide. Another organization for influencing EBP in nursing is the Registered Association of Ontario Nurses (RNAO). RNAO has developed over 50 best practice recommendations, each of which has been implemented in the clinical work of nursing  .
Speaking about periodic training, professional development and continuous self-education of nurses / midwives based on the latest research results are a prerequisite for the provision of effective and safe medical services and care for pregnant women .
As the Republic of Kazakhstan began to promote evidence-based medicine only after independence and to develop new national guidelines, despite the current reforms in health care, the key components of the health system in Kazakhstan is in need to be improved . Also in Kazakhstan there are significant changes in higher education of nurses. The country joined the European Higher Education Area in 2011. Although Kazakhstan universities are trying to harmonize the higher education system with the Bologna process, problems in the integration process remain. Nevertheless, Kazakhstan is striving to become one of the 30 most developed countries of the world by 2020, to strive to comply with European directives in the system of training specialists in caring for the sick at all levels (from technical education to PhD) .
Most people know that, at present, in the health care system, specialists of the nursing service remain the most important part, with significant human resources and real opportunities to meet the public in health services.
The entry of the Republic of Kazakhstan into the Bologna process dictates the need to bring the education system, professional standards, qualifications and positions in line with European directives and nursing care is no exception. On August 9, 2017, a pilot project launched by the Ministry of Health of the Republic of Kazakhstan in order to create a new nursing service management system in the health organizations of the Republic of Kazakhstan. The goal of the pilot project is to develop and implement a new model of nursing services based on appropriate international requirements for the nursing profession in practical public health organizations - clinical bases of higher medical colleges. For the Republic of Kazakhstan, the development of the nursing care system means, its development at all levels of education, monitoring the quality of education at the level of international standards, introducing the practice of the Nursing Institute with various positions depending on the level of education. Along with the reform of nursing education, it is planned to introduce new mechanisms for the functioning of medical organizations with equal medical and nursing organizational structures, introducing a roster of specialists in nursing and nursing documentation, introducing innovative medical technologies, developing modern practice of nursing evidence, fundamental and applied science of nursing, redistribution and clear differentiation of functional responsibilities between doctors and nurses of different levels.
A little-known fact: Kazakhstan is one of the countries in which the development of nursing practice and nursing education is currently developing rapidly. However, there is limited knowledge of barriers and evidence-based practice in post-Soviet countries. More focused research is needed related to the implementation of an evidencebased approach to nursing education, nursing practice and management in Kazakhstan .
Conclusion. Despite numerous studies on the issue of practice based on evidence (EBP), the knowledge of midwives and attitudes based on evidence-based obstetrics, many issues including those related with EBP in obstetrics in the Republic of Kazakhstan, remain open.
Therefore, we consider it is necessary to study in depth the knowledge of midwives and the attitude to the practice of obstetrics based on actual data in the Republic of Kazakhstan.
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