From stress to support: an ethnographic journey of a staff-led wellbeing intervention in maternity services

Abstract

Background

Addressing occupational distress in maternal services is imperative to ensuring staff retention and patient safety. Interventions to promote wellbeing among healthcare staff are urgently needed. However, little is known about the implementation of such interventions in hospital maternity services. This study aimed to explore the workplace demands and stressors experienced by healthcare staff in hospital maternity services and identify how these demands and stressors affect engagement in workplace wellbeing activities.

Methods

This qualitative study employed an ethnographic approach in maternity services in regional Australia. Data were collected through observations over a 12-week period before and during the implementation of a wellbeing program called SEED. Participants included healthcare staff and leaders employed in maternity services. Key themes and insights from the observational data were identified through reflexive thematic analysis. The study followed COREQ guidelines to report key aspects of the research team, methods, context, findings, and analysis.

Results

Six themes were identified, depicting both the challenges and opportunities for implementing workplace wellbeing activities in maternity services. The first three themes highlighted pre-existing challenges that affected staff engagement in wellbeing activities: (1) Disconnection Across the Service; (2) Balancing Role Expectations and Wellbeing at Work; and (3) Leaders Trusting in Wellbeing but Staff not Trusting in Leaders. The subsequent three themes described opportunities for engagement: (4) Staff are the Experts of Their Own Wellbeing and Work Environment; (5) Fostering Connection through Conversations; and (6) Cultivating Camaraderie within the Service.

Conclusion

By identifying challenges such as disconnection and lack of trust, alongside opportunities like collaboration and camaraderie, the findings provide actionable insights for designing effective wellbeing activities. Gaining leaders’ trust and commitment, followed by engaging staff in collaborative decision-making, is crucial for successful implementation. This research contributes to the global clinical community by providing a nuanced understanding of workplace wellbeing implementation in maternity services, offering a blueprint for similar interventions in healthcare settings worldwide.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-025-13239-x.

Background

The significance of staff wellbeing in the healthcare workforce has been established in literature and has received increased recognition following the COVID-19 pandemic [1–3]. Increasing workloads, new guidelines, and continuous changes in healthcare provision have placed immense pressure on the workforce and explain the high rate of occupational distress and high turnover amongst the health staff [2]. The World Health Organisation defines occupational distress as “emotional exhaustion, cynicism, and loss of meaning and effectiveness in work” ([1]p. 163). The profound negative impact of occupational distress on patient care and safety [4] has emphasised the need for health organisations to prioritise staff wellbeing in the workplace.

Feelings such as hopelessness and helplessness have been described by healthcare staff working in demanding workplaces, complicated by working conditions, and a lack of faith in leaders and managers to take action [5]. To address these concerns there has been a growing interest in workplace wellbeing interventions. As a condition caused by the work environment, addressing the impact of occupational distress on the workforce requires healthcare systems to improve the practice environment itself [1, 6]. Moving from a reactive to a more proactive approach to workplace wellbeing requires organisations to step away from an individual lifestyle approach, which places the responsibility on the person experiencing signs of occupational distress, to a focus on collective responsibility, optimising team-based care [3, 6–8].

Although the terms ‘wellness’ and ‘wellbeing’ are often used interchangeably, they are indeed different. The National Wellness Institute defines wellness as, “an active process through which people become aware of, and make choices toward, a more successful existence” ([9]p. 983). Wellness encompasses the physical, mental, and social domains of health, and the exhaustion of adequate resources can prevent one’s ability to attain wellness [9]. Wellbeing is considered a step towards wellness, described as “the balance-point between an individual’s resources and the challenges he or she faces” ([10]p. 14). The term ‘wellbeing’ will be used throughout this article to refer the organisational factors that either facilitate or impede the holistic health of staff.

One area in health, where occupational distress and job dissatisfaction is of great concern is among staff in maternity services [11, 12]. Exposure to vicarious trauma through maternal and neonatal morbidity and mortality, and emotionally fraught circumstances involving family violence, termination, and reproductive loss are common workplace encounters for staff in maternity services [13]. High rates of burnout, low morale, and staff shortages have been reported as widespread experiences of maternity staff in the hospital setting [11, 13]. While it is known that exposure to repeated trauma impacts the ability of healthcare staff to provide safe and sufficient care [12, 13], little is known about how healthcare organisations manage the signs and symptoms of burnout and low morale amongst maternity teams.

The Australian Institute of Health and Welfare [14] reports that nurses and midwives are the largest group of registered health professionals in Australia. However, the number of registered midwives is reported to be declining, resulting in staffing shortages [13]. Findings from a national cross-sectional study of registered midwives in Australia found that 64.9% of midwives experienced burnout [15]. Studies conducted in Australia reported that the COVID-19 pandemic significantly impacted on the nursing and midwifery workforce, contributing to increased levels of occupational distress and job dissatisfaction [13, 16, 17]. However, there remains limited research carried out in maternity services in Australia, with most studies conducted overseas [13, 17]. A deeper understanding of the workplace experiences of maternity staff in Australia is needed to provide targeted recommendations that can address the long-term effects of occupational distress.

Maternity services across the globe have acknowledged a need to improve the working conditions for nurses and midwives, recognising that improved emotional wellbeing, mental health, and teamwork can contribute to improved quality of care [18–20]. Findings from the international WHELM (work, health, and emotional lives of midwives) survey and emotional wellbeing scales conducted in Western Canada found that midwives who experienced burnout required access to no or low-cost counselling, time off work to focus on self-care, and mentorship through peer support [21]. Similarly, an international scoping review on the prevalence of and factors associated with burnout in midwifery found that burnout could be minimised by reducing inter-professional conflict and creating safe practice environments where self-care is valued [20]. Findings from an Australian study identified that “taking short breaks outdoors, or at a minimum ensuring green views, lowers stress” and improves overall wellbeing, however work to date with healthcare staff and nature are generally small scale ([22]p. 4214). Despite organisational awareness for the need to mitigate occupational distress among staff in maternity, there are no published reports about the implementation of workplace interventions that aim to improve the wellbeing of staff in hospital maternity services during worktime.

Although there has been an increased recognition of the need for interventions to minimise occupational distress and promote wellbeing amongst the healthcare workforce, research on the implementation of such activities in hospital maternity services is needed. The research questions for this study were: (1) How are workplace demands and stressors experienced by healthcare staff in maternity services? and (2) How did staff engage in workplace wellbeing activities in maternity services?

Methods

Study design

This exploratory qualitative study employed an ethnographic approach to examine the workplace demands, stressors, and wellbeing opportunities within maternity wards in a large regional hospital in New South Wales, Australia. The study was conducted in two phases: (1) documenting the workplace demands and stresses faced by healthcare staff, and (2) describing the opportunities to provide support through the implementation of a wellbeing program called SEED. Ethnographic methods were used to provide a nuanced understanding of how workplace wellbeing is experienced and enacted in practice, particularly within the complex and high-pressure environment of maternity services.

Ethnographic observations are increasingly used in healthcare research as they offer rich, contextual insights into behaviours, actions, and perspectives of staff, as well as the institutional environments they work within [23]. By closely observing the interactions and routines, and listening to informal conversations, the researcher was able to explore the relational and organisational dynamics of that shape staff wellbeing [23].

Observations were conducted over a 12-week period and included fieldnotes, informal conversations, and participation in key events related to the SEED Program. Ethical approval was granted by the Human Research Ethics Committee of New South Wales (NSW) Health and the University of Wollongong (2023/STE00269). The study adhered to the COnsolidated criteria for REporting Qualitative research (COREQ) guidelines to report key aspects of the research team, methods, context, findings, and analysis [24].

Study setting

This study was conducted in a public health service on the south coast of New South Wales, Australia. The health service is one of the region’s largest employers, with a workforce of more than 8,500 staff across hospitals and community services. The maternity service in this district provides pregnancy and after birth care to community members in three local government areas, covering approximately 250 km.

For several years, the maternity service in this public health service has faced systemic challenges that have critically impacted service delivery and patient care [25]. Staffing shortages, high workloads, difficulties with workforce retention and recruitment, and overall negative workforce attitudes have been brought to community attention through several campaigns facilitated by the NSW Nurses and Midwives Association (NSWNMA) [26]. In response to this, a committee established in June 2023 found a high percentage of birth trauma reports from the region [25]. This study was conducted prior to the Parliamentary Inquiry into Birth Trauma, which aims to inform policy makers understanding of the issues related to birth trauma.

Description of The SEED program

SEED (Stability, Encompassing, Endurance and Direction) is a workplace wellbeing program developed and implemented by a small team of healthcare staff [27, 28]. Initially designed to promote wellbeing and a sense of belonging among staff in a rural hospital impacted by the 2019–2020 Australian bushfires, SEED expanded across the health service through a strengths-based approach [27]. This approach involved identifying staff needs and supporting the implementation of staff-led wellbeing activities [27]. Further information on different iterations of the SEED Program can be found in previously published studies [27–31].

SEED is made up of four key strategies that together promote workplace wellbeing through collaborative, strengths-based, and staff led-approaches. These include:

1. Strengths-Based Workshops: Interactive sessions tailored to specific needs of staff, including reflective practice, peer connection, and strengths-based approaches to wellbeing.

2. Staff-Led Wellbeing Initiatives: A bottom-up model where trained staff lead initiatives within their own teams or departments, promoting ownership, relevance, and sustainability.

3. Team-Driven Wellbeing Activities: Informal and accessible onsite activities that enhance connection and self-care.

4. Tangible Wellbeing Tools: Practical, accessible tools that support wellbeing in the workplace.

In this study, Team-Driven Wellbeing Activities were introduced into the maternity service as part of the research and were co-designed with staff during implementation. These activities were not pre-existent but were developed in response to staff feedback and engagement with the SEED process.

SEED implementation in maternity services

In response to the ongoing and increasing challenges across the maternity service, management requested support from the SEED team, expressing their desire to enhance staff wellbeing and connection across the service. Table 1 provides an overview of the implementation activities facilitated by SEED in maternity services.

Table 1.

Phases of SEED implementation in maternity services

Phases	Description
1. Pre-Implementation Meetings with Leaders	Before the implementation of SEED, regular meetings were conducted between the SEED team and management in maternity to learn about the workplace demands and stressors and discuss the opportunities for workplace wellbeing activities.
2. SEED In-Services	To ensure that the service was aware of the implementation of SEED, four in-services were facilitated with a select group of staff appointed by management. The four groups included managers, educators, and staff. The SEED in-services were conducted over two hours during worktime. The purpose of the in-services was to introduce SEED and discuss the opportunities and challenges for implementing wellbeing activities in maternity.
3. SEED Discussions	The SEED team conducted two weeks of informal discussions with managers and staff, capturing their suggestions for workplace wellbeing activities in the maternity service. Managers and staff across all shifts were consulted.
4. SEED Soft-Launch	As part of the inauguration of SEED in maternity services, a soft-launch was facilitated by the SEED team over two days. The term soft-launch was used to describe the start of SEED implementation in maternity. Staff were encouraged by their managers to attend a short 20-minute presentation about SEED and participate in a discussion about the opportunities and challenges for implementing workplace wellbeing activities. Staff from various disciplines attended the soft-launch, including nurses, educators, doctors, allied health, administration, and support services.
5. SEED Wellbeing Activities	As a final step before the implementation of SEED wellbeing activities in maternity, the SEED team analysed all the staff suggestions that were collected during the meetings, in-services, discussions, and the soft-launch. Five wellbeing activities were identified from this process and are described in more detail in the study findings.

Sample approach

Purposive sampling was used to recruit healthcare staff who were employed in the maternity wards participating in the study and who had engaged in the SEED Program. Participants were selected based on their direct involvement in, or exposure to, the SEED Program, including those who attended SEED workshops, in-services, or participated in wellbeing activities. The sampling approach ensured that a diverse range of professional roles (e.g. midwives, nurses, doctors, allied health staff, and managers) and perspectives were included to capture the varied experiences of workplace demands, stressors, and engagement in wellbeing activities.

Recruitment strategy

The SEED Program Lead (PP), who is also the first author’s (AK) PhD field supervisor, facilitated several pre-implementation meetings with managers. During these meetings, the managers were informed of the study and provided permission to meet with staff. Both virtual and in-person meetings were held with staff to inform them of the study and that their participation was voluntary. To ensure that participants felt comfortable with the observations, the first author attended SEED pre-implementation activities prior to data collection to explain the study. Informed consent was obtained prior to observations taking place on any given day and the researcher kept a list of staff who consented to be part of the study. The researcher explained to all participants that the observations did not include any clinical aspect of their job and only focused on work demands and if, when, and how wellbeing activities were being implemented on the ward. Any information that was collected in field notes during observations from staff who did not consent was removed through the process of data cleaning prior to analysis.

Data collection

Ethnographic observations were conducted in maternity services between August 2022 and November 2022. As an outsider of the service, the first author (AK) was a non-participant during observations, watching workplace interactions as they occurred from a distance [32]. The observation guide was developed by the research team to document potential workplace demands and stressors; opportunities and challenges for implementing wellbeing activities in the workplace; the key stakeholders involved; and the participation in wellbeing activities, e.g. according to shift and staff roles. The observation guide (see Supplementary file) included prompts to document daily demographics, a description of the ward and staff interactions, and the researcher’s critical reflection at the end of each day guided by De Bono’s six modes of thinking [33]. Participant quotes were documented through the process of prolonged engagement, persistent observation, thick and rich description, and member checking of fieldnotes with the SEED team who were present during the observations [34]. As the first author was a non-participant, their focus was on recording observations in the form of field notes as opposed to participating in group interactions and activities. Fieldnotes were captured both manually in a notebook and electronically on a laptop, depending on the environment that the observations were taking place in.

Observations were conducted between two to three times a week for 8-hours each day for a total of 224 h. The maternity wards were observed at different times on the same day. The first author (AK) also attended all SEED activities and conducted observations when consenting staff from the participating wards attended. The time each ward was observed was determined by the Nurse Unit Manager or nurse in-charge on the day. At the beginning of each week of observations, the researcher would contact the Nurse Unit Manager to provide suitable times to attend the ward. Nineteen consenting participants were observed on multiple occasions, depending on their availability and involvement in SEED activities, with some observed once or twice and others more frequently across the study period. A log of consent and observation frequency was maintained to ensure ethical compliance and data integrity.

Data analysis

Observational field notes and researcher reflections were analysed using reflexive thematic analysis [35] supported by the NVivo 12 software [36]. The NVivo 12 software allowed the first author AK to organise, code, and visualise the data [36]. As identified by Braun and Clarke [35] reflexive thematic analysis involves “a six-phase process for data engagement, coding, and theme development” (p.331). The six-phases include: (1) data familiarisation and writing familiarisation notes; (2) systematic data coding; (3) generating initial themes from coded and collated data; (4) developing and reviewing themes; (5) refining, defining and naming themes; and (6) writing the report [35].

Phase one, data familiarisation was approached by reading and re-reading the field notes and utilising the memo tool on the NVivo 12 software [36] to write familiarisation notes. An inductive approach was used in phase two to systematically code the data, developing two broad codes, which represented the opportunities and challenges of implementing workplace wellbeing activities in maternity services. Several discussions then took place between AK, JA and JC in phase three to generate initial themes. The research questions were reviewed and refined during this phase, allowing AK to merge similar codes to form higher order themes. As part of phase four these themes were reviewed by JA and JC, collapsing existing codes, splitting into new themes, and discarding other codes all together. Phase five was approached by reviewing and re-defining the definitions that AK initially wrote for each node in the NVivo 12 software [36] using the node properties description tool. This was followed by naming each theme in a way that told a story and answered the research questions. Once the final themes were reviewed by the team a report of the final analysis was prepared by AK, weaving together the narrative and data extracts contextualising the analysis.

Reflexivity

To enhance the trustworthiness of the study, reflexivity was embedded throughout the research process. The first author (AK) maintained a reflexive journal and used NVivo’s memo tool to critically reflect on how her positionality, as a social worker and PhD candidate familiar with the SEED team influenced data interpretation and theme development. Regular reflexive discussions were also held with the broader research team (KO, JC, JA and PP), who brought diverse disciplinary backgrounds and varying familiarity with the SEED Program. This collaborative approach helped challenge assumptions and mitigate individual bias.

Results

Six themes were identified in the data depicting the opportunities and challenges for implementing workplace wellbeing activities in maternity. The first three themes represent the challenges observed in the maternity service before and during to the implementation of SEED wellbeing activities: (1) Disconnection Across the Service; (2) Balancing Role Expectations and Wellbeing at Work; and (3) Leaders Trusting in Wellbeing but Staff not Trusting in Leaders. The subsequent three themes describe the opportunities identified for staff to engage in SEED wellbeing activities: (4) Staff are the Experts of Their Own Wellbeing and Work Environment; (5) Fostering Connection through Conversations; and (6) Cultivating Camaraderie within the Service. Study participants will be referred to as Leader (L) or Staff (S), with participants quoted by their assigned number. The sample was predominately female and included staff from various roles, wards, and shifts (see Table 2 for details).

Table 2.

Sample characteristics

Gender	Work Role	Ward	Shift
Female 18 Male 1	Nurse/Midwife 6 Nurse Educator 3 Manager/Executive (L) 7 Allied Health 1 Administration 1 Doctor 1	Clinical Governance Unit 2 Maternity Services Stream 4 Inpatient Maternity Services 5 Neonatal Unit 8	Morning 11 Afternoon 8

While the six themes were relevant across all maternity ward locations, variations in how these themes manifested were observed. For instance (1), Disconnection Across the Service was more accurately felt in wards that operated more independently from one another, particularly those with fewer shared staff or overlapping rosters. Similarly, engagement with SEED activities and leadership support varied slightly depending on the level of managerial buy-in and staffing pressures. However, despite these contextual differences, all themes were present to some extent in each ward, reinforcing their significance as shared experiences within the broader maternity service.

Disconnection across the service

This theme focuses on the different layers of disconnection amongst and within the maternity service. Disconnection was observed both in the physical layout of the service and through the interpersonal relationships between staff in the service. The disregard between professional disciplines and the general indifference among staff to instances of disrespect and unkindness, was prevalent across wards. This resulted in negative staff attitudes and tension between striving to provide optimal patient care and dealing with a suboptimal work environment.

Although close in proximity, the wards operate almost as separate entities. There is a welcoming artwork in front of the birthing unit of a pregnant woman greeting the visitors in various languages. To find the neonatal unit, however, one must walk down an uninviting long corridor to reach a single closed door, and a little further down two large doors lead into the maternity inpatient ward. The antenatal clinic, also part of the maternity service is located on a different level of the hospital. As staff enter each ward at the beginning of their shifts they do not interact with or acknowledge their colleagues in the other wards. One staff described the disconnection between the service, stating that “we hardly see each other or know each other’s names” (S7).

Another example of the disconnection across the service was described by staff as disrespect and disregard between disciplines. During the first SEED in-service, the six staff who attended (representing educators, nurses, midwives, and administration) were invited to describe the opportunities and challenges for implementing wellbeing activities in maternity. Without hesitation the staff began to unveil the challenges in the service, avoiding discussion of the opportunities. One staff spoke about the “siloed nature of maternity services” (S11), emphasising that “nurses, doctors and other staff do not know one another, although they are often caring for the same patient” (S11). Another staff said:

“There is little respect between doctors and nurses. They [doctors] are often dumping patients into wards without consulting the nurses … which is adding to the chaos on the ward. We [nurses] feel disrespected by the doctors, they don’t smile when they enter the ward and disregard our greetings” (S7).

The other staff sighed and shook their heads in agreement as they listened to their colleague. A senior staff described the workplace culture as “poor”, stating that “the morale is really low, much lower than it should be, and it is really hard to deliver good care when staff don’t want to talk to one another” (S1). Another senior staff discussed her role as a midwife, reflecting on her position in the service as the “middleman between doctors and nurses” (S13). She said:

“Midwives have a better relationship with doctors, and I think it is because of their [doctors] perceived superiority, which midwives have learnt to acknowledge but nurses not so much. I think that this is what leads to the poor relationship between us [midwives and doctors] and them [nurses]. But I guess it is up to all of us [midwives, doctors, and nurses] to do something about it because our patients are suffering” (S13).

Interactions between staff at the nurse’s station echoed the negative workplace attitudes in the ward with the repeated disclosure of “disconnection amongst teams and across maternity services as a whole” (S8) and an emphasis on “staff being unkind to one another, particularly during handovers from one ward to another” (S4). The observations confirmed that the maternity wards operate separately, with nurses and staff not knowing one another, although they are often caring for the same mothers and babies. One staff perceived the disconnect across the service as “a lack of care and appreciation for one another, leading to poor outcomes for our patients” (S14).

Balancing role expectations and wellbeing at work

This theme highlights the challenges faced by healthcare staff and leaders in balancing their professional roles with self-care needs. It emphasises the internal conflict stemming from the fear of vulnerability and perception of right or wrong practice in a particular role, which hinders staff from slowing down and taking breaks. The uncertainty and unpredictability of working in maternity services appeared to prevent staff from engaging in SEED activities while at work. The conversations with staff on the ward revealed the fast pace and the constant fear of something going wrong in maternity. For example, one staff explained:

“Yes, there are things we can predict in our day, like the time a woman might give birth if we have a planned caesarean, but we can’t predict the baby will be healthy or that there won’t be any complications and that’s really hard when we keep getting thrown expectations like doing wellbeing” (S15).

Aware of the uncertain and unpredictable environment in maternity, the SEED team facilitated two-weeks of pre-implementation discussions with staff on the ward. The purpose of these discussions was to establish a presence on the ward, ascertain staff needs, and capture their suggestions for wellbeing at work. The first discussion was facilitated in the staff tearoom, where managers requested staff to meet with the SEED team. Sitting around the table, the SEED team asked staff for their suggestions for wellbeing activities in maternity. One staff loudly exhaled, saying in an ambivalent tone “I don’t think that wellbeing exercises are practical in maternity or that they would be used often by the staff, because we just don’t get the time” (S9). Another staff with three decades of experience in the service nodded, agreeing with her colleague, and stated that “there is simply not the time to leave our patients to do wellbeing because there is not enough staff” (S14). She then smiled at the SEED team and in a more optimistic tone suggested facilitating activities that would not require staff to leave their patients, such as “anything that could be done at the desk for about 5 or 10 minutes, something we can do when we sit down to write our notes” (S14). The other staff in the group nodded, with one staff saying:

“Understanding our working conditions is the only way something like this could work, and it has to come from the staff because they won’t trust it or participate in it otherwise. What might sound like a great idea on paper just won’t work if staff aren’t on board. We’ve seen it too many times and I think that’s why we are all fed up with wellbeing” (S13).

This exemplifies the work stress maternity staff face – finding a balance between caring for patients and for themselves. This was observed during another SEED in-service that was facilitated with managers and educators. As the staff walked into the room, they were asked to pick up two pictures from a pile in the middle of the floor, one picture representing a “good day” at work and another “a bad day”. A senior staff shared the picture that she chose for a bad day, which she described as “a puppy with depleted eyes” (S1). With tears coming down her face and a trembling voice she described the work demands maternity staff face: “we [nurses and midwives] are so used to working at a fast pace when it comes to birthing babies or resuscitating babies and so on that we forget to slow down” (S1). Another staff responded, “I agree with you, we have a terrible culture of not slowing down and it makes me think whose responsibility, is it?” (S5). A silence filled the room, some staff looked down at the floor and others turned their heads to each other and sighed. Contributing to the discussion of responsibility, a senior staff asked the group “what are the drivers of resistance when it comes to wellbeing in our workplace?” (S6). Before others had a chance to answer, the same staff answered her own question, “I think it might be that I am too busy, or I am afraid of being exposed because it is scary to be vulnerable when we are all taught the opposite in our roles” (S6). This seemed to surprise the group, as if they did not know how to respond. It appeared that this was the first time many of the staff had considered thinking about their own wellbeing as they were confronted by the demands of their caring roles.

Leaders trusting in wellbeing but staff not trusting in leaders

This theme captures a potential disconnect between leadership wellbeing rhetoric and commitment to addressing staff concerns in maternity. It reveals a notable discrepancy between leaders investing and trusting in wellbeing with staff mistrusting their leaders’ intentions to promote wellbeing interventions such as SEED. While leaders were seen to advocate for wellbeing in maternity, staff expressed concern regarding the inconsistencies in leadership behaviours and actions.

The implementation of SEED in maternity services was initiated by the management who believed SEED to be “the key for addressing staff wellbeing in the service” (L16). Despite leaders communicating their support for SEED during staff meetings or in email announcements, staff appeared apprehensive about their intentions. When sitting in the nurse’s station during a quiet afternoon shift, staff gathered around talking about their perceptions of leaders and whether their commitment to SEED was genuine. One staff expressed her concern with the implementation of SEED in maternity, saying “this [SEED] is coming from management and will not work” (S9). The discussion then shifted from SEED to concerns with leadership, with staff stating, “we don’t feel heard … it [SEED] is just lip service” (S9) and “we don’t feel trust” (S6).

A disconnection between staff and leaders was observed when leaders were absent during SEED activities, which seemed to create an even greater sense of mistrust between the groups. One staff said, “we need someone to model the way and promote a sense of connection in the team, because without that this [SEED] won’t work” (S8). Although leaders appeared to be disengaged in SEED implementation, the SEED team facilitated weekly meetings to inform leaders of progress and any barriers they encountered. The SEED team informed staff that regular meetings were taking place with leaders, but a lack of physical presence on the ward resulted in leaders appearing invisible to staff who work on the frontline.

Despite outward appearances of disengagement and disinterest in wellbeing, conversations with leaders in private settings revealed a contrasting perspective. Discussions with leaders about SEED uncovered that they were passionate about wellbeing, sharing personal experiences of how they implement wellbeing strategies into their own lives through “morning walks and reading” (L16), and “meditating, yoga, and attending weekend workshops” (L2). All these activities, however, occurred outside of work hours. When asked about engaging in workplace wellbeing activities, one leader said, “I don’t have the support from those [managers] above me” (L2) and “others just don’t believe in this [SEED]” (L2). This indicates a systemic issue where managers themselves lack support from higher levels of the hierarchy and may feel hesitant to engage in SEED due to concerns of potential repercussions.

During a discussion between a leader in maternity and the SEED Program Lead, the leader shared her experience of being perceived as “the boss” by her own staff and how she believed this inhibited the team from seeing her as “human” (L2). She elaborated by adding:

“My leadership style had to change since entering this role as I started off trying to improve the culture myself, using innovative ways such as hosting yoga, having lunches, and facilitating team building days, but I was slandered by the staff” (L2).

The position of leaders in maternity services was described by one leader as “lonely”, stating that “in these positions you’re not always liked, so I need to be the person that allows staff to take part, and build this [SEED] from the ground up” (L16). Despite leaders believing that operating out of sight was of benefit to the staff, the perception of staff was that it was poor leadership, resulting in staff feeling unsupported and resentful. When discussing the implementation of SEED in maternity, a senior staff said, “you don’t have hope or trust when you don’t feel safe or supported” (S6). A paradox thus emerges as leaders demonstrate trust in wellbeing interventions, yet staff lack trust in leadership, resulting in a reluctance to participate in SEED.

Despite the workplace demands and stressors observed in maternity, there were also several opportunities for healthcare staff to engage in workplace wellbeing activities during the implementation of SEED.

Staff are the experts of their own wellbeing and work environment

This theme highlights the pivotal role of staff engagement in shaping the trajectory of workplace wellbeing interventions in healthcare. The SEED team describes staff as “the experts of their own wellbeing and work environment” (L19), actively engaging teams in decision making processes. The initial six-weeks of SEED implementation in maternity consisted of building rapport and establishing trust with staff, followed by six-weeks of implementing workplace wellbeing activities. The process of engaging staff at each stage of SEED implementation appeared to be a critical component of bringing SEED into maternity. This process included identifying staff needs, gathering staff suggestions, and co-designing and co-facilitating wellbeing activities.

During the initial six-weeks of SEED implementation, a two-day soft launch was facilitated for all staff in the service. Managers arranged rosters for staff to be able to take time off work to attend. Although there was a reluctance for staff to participate in wellbeing activities at work, the attendance was high across the two-days, with 65 staff from different disciplines across the service taking part. Of these, 19 staff members gave informed consent to be observed during the 12-week data collection period. No staff explicitly refused to participate; however, many attended SEED activities without formally consenting to be part of the study so were not included in observation records. As part of the soft launch, the SEED team asked all staff to write their suggestions for SEED implementation in maternity on sticky notes. Some of the suggestions included: team building activities, building connections between wards, more support for students, improving communication between doctors and nurses, creating a comfortable outdoor space and mindfulness sessions on the ward. In discussing the challenges of working in maternity, one staff suggested some opportunities for wellbeing:

“There is a real need for nurses to start taking breaks. For me, taking a break and going to the tearoom doesn’t feel like a break when someone is constantly coming in asking questions. There is the communal outside space for the whole hospital, but if the weather is bad, you can’t access it. It would be great to transform the outdoor space we look onto from the ward, so that we can at least get a breath of fresh air” (S5).

Another staff mentioned the value that an outdoor space would bring to the service, stating that “we need fresh air and sunlight after being indoors all day” (S6). She said:

“We don’t have the capacity to leave the ward most of the time, because of the staffing and patient ratios, so having a space to go outside that is close to the ward is important to us. I think it could really boost the low morale” (S6).

The soft launch along with SEED in-services and discussions provided staff with a platform to be involved in decision making about workplace wellbeing implementation on their ward. One staff described the SEED team as “being the enablers for putting staff suggestions in place” (S4). The concept of an outdoor space was discussed by several staff across both wards, particularly when providing suggestions to improve their own wellbeing at work.

Another example of the collaborative decision-making in maternity was observed during an interaction between the SEED team and two young staff. The interaction took place as part of a SEED activity away from the ward, in a communal outdoor space in the hospital. Sitting outside and overlooking the mountains on a warm spring day, the SEED facilitator asked the staff about their thoughts around creating an outdoor space in maternity. Both staff turned their heads to one another and smiled. One staff said:

“An outdoor space is exactly what we need in maternity. I think it will not only improve the low morale, but also connect us with staff we might not see otherwise. Most of us have breaks at different times on the same ward, so we are usually eating alone. Having an outdoor space to go during our breaks might bring us closer to staff from other wards” (S17).

Recognised as a recurring suggestion for wellbeing in maternity, the SEED team collaborated with the staff, leaders, and the facility management department to create a comfortable outdoor space located outside the maternity service that is accessible to all staff. This process allowed the maternity service to decide their own approach, while being provided with the support to implement a tangible initiative in a timely and efficient manner.

Fostering connection through conversations

This theme encapsulates the process and the outcome of listening to and sharing personal stories by creating a supportive environment within maternity services. It highlights the significance of building connections between staff, particularly in demanding and stressful work environments exacerbated by the pandemic. SEED provided opportunities for staff to come together, forming bonds and boosting teamwork.

An example of connection through conversations was observed during one of the SEED wellbeing activities that was co-designed with staff in maternity, called ‘break buddies’. The SEED facilitator initiated a group conversation by asking the staff “Why did you start nursing or midwifery?” (L19). Many of the responses were around “wanting to care for people” (S4) or family members being in hospital or being healthcare staff themselves. Others mentioned “falling into the profession by chance” (S5). Listening to their colleagues’ stories, many staff expressed being able to draw on parallels between their own experiences. One staff said, “I never knew that so many of us had family members that were nurses” (S4). The SEED facilitator then asked the group about their “first place of employment in healthcare” (L19). Three of the staff spoke about their experience of being trained in the United Kingdom, describing a positive and empowering work environment that was heavily focused on “women-centred care” (S5). This generated conversations between the group with one staff stating:

“It is sad that many of us have worked together for months or even years and don’t know anything about one another. It is like we come to work, get the job done and leave, forgetting that we work in a team. Nursing wasn’t like this before, we were always connected, but over the years I’ve noticed that things have changed. I remember when I started nursing, we were like sisters-in-arms” (S4).

The conversation then shifted to the impacts of the disconnection in the service and a negative attitude spread across the group. The tone of voice of many staff increased, while the posture of some staff became stiff, and others started to use more hand movements to convey their points to the group. Mindful of the conversation spiralling, the SEED facilitator pulled the conversation back to SEED by asking the staff to discuss one highlight in their career. There was a lot of discussion about nurses and midwives moving hospitals, states, and countries to gain more work experience. This was another connection point in the group conversation. One staff said, “I started nursing in locally, I then moved to Sydney, and then the United Kingdom before coming back here” (S8). Another staff smiled and said, “my journey is quite similar, but I didn’t start here, I decided to apply when my partner got a job locally” (S9). This group conversation seemed to be an opportunity for many staff to connect on a deeper level, which they may not have had an opportunity to do before.

Another example of a group conversation that fostered connection was observed during a different ‘break buddies’ session, where two staff were reunited. Asked by the SEED facilitator to share their past work experience, the two staff shared a similar story and recognised only once their masks were removed that they worked on the same ward in a different hospital several years ago. One of the staff said, “you look so familiar, but I just can’t put a finger on where I have seen you before” (S6). The other staff said, “I used to work at [name of a hospital in another district] but moved down during the pandemic” (S7). Working during the COVID-19 pandemic meant that staff were required to wear masks and additional protective equipment, which made it difficult to recognise the person underneath. Observing these two staff reconnect after months of working together stressed the disconnection on the ward that had been exacerbated by the pandemic with masks making it difficult to read people’s expressions or even recognise who you are talking to.

This theme highlights the significance of group conversations as a tool to create a supportive, understanding, and interconnected team. It emphasises the power of personal narratives in building bridges between people, fostering compassion and connection, and nurturing a sense of belonging and solidarity.

Cultivating camaraderie within the service

This theme conveys the intent of creating a unified and supportive work environment by building strong bonds and mutual respect among colleagues. Healthcare staff across wards shared a common goal for the maternity service, centred around building connections and positive relationships at work. During the two-weeks of pre-implementation discussions facilitated by the SEED team, one leader spoke about the current absence of camaraderie within the service and a need to improve the relationship between all staff and leaders:

“It would be nice to see more camaraderie within the service, between different wards and disciplines. What I think could support this is validating one another’s work and giving each other acknowledgements” (L10).

In an optimistic tone she concluded by saying that “by knowing each other and having those relationships, people will understand each other better and that will then support our ability to deliver best patient care” (L10).

As an attempt to cultivate camaraderie within the maternity service, the SEED team collected suggestions for workplace wellbeing from staff and leaders across all wards and shifts over the course of six-weeks. By gathering suggestions from both staff and leaders, the SEED team identified that there was a collective longing for connection within the service.

The SEED team captured over 50 staff suggestions from across the service to form five overarching wellbeing activities that would be implemented in the maternity services. The five wellbeing activities included: (1) Break Buddies (a planned lunch or coffee break with a colleague as a form of collective care); (2) Gathering Together (designated time during work hours to get to know work colleagues, connect and have some fun); (3) Wellbeing Exercises (scheduled exercises that promote mindfulness and connections), (4) Outdoor Spaces (an accessible and inviting outdoor space for staff to use during their breaks) and (5) Celebration (celebrating achievements and acknowledging milestones). In the final weeks of observations, the SEED team supported both staff and leaders in maternity to implement three of the five wellbeing activities. Although the wellbeing activities were intended to be implemented during work hours, a group of four staff that participated in a ‘break buddies’ session discussed the idea of ‘gathering together’ outside of work. While getting to know one another on a deeper level during the ‘break buddies’ session, a young nurse spoke about being new to the hospital and the local community. In a quiet tone she said:

“I moved to [name of region] recently and it’s been hard to adjust. I was wondering if anyone would be keen to meet up outside of work? We could bring our partners, kids or pets and meet for a walk or hike” (S17).

The rest of the group smiled with one senior staff responding immediately, “I love that idea; it is something we used to do before COVID, catch up outside of work, and it was such a good way to get to know each other” (S14). Another staff contributed to the conversation by asking the SEED facilitator whether this could be something the whole maternity service can participate in. The SEED facilitator contacted the leaders and with their approval asked them to spread the word across the service. That weekend a bushwalk took place at a local lookout, with three staff and their partners and pets attending. The following week, staff shared their photos from the bushwalk and the young nurse who initiated the get together described the experience as “an awesome opportunity to get to know one another, talking about our upbringing, where we are from and the hobbies we like” (S17).

Another example of strategies for connecting staff and leaders was observed towards the end of the 12-weeks of SEED implementation. During an informal conversation between the SEED Program Lead and one of the leaders, the leader expressed her commitment to building connections across the service after SEED. In an enthusiastic tone she shared an idea with the SEED team:

“I have thought of a way of increasing my own connection with staff across the wards, by allocating designated time each week in 2023 to sit with different staff and work together to mindfully colour in a mural. Once the mural is complete, I am hoping to hang it up in the common area as a reminder of togetherness and connection” (L2).

In response, the SEED team designed four murals with different themes, asking both staff and leaders to choose the one that resonated most with the service. Following the leader’s suggestion, the SEED team had created another opportunity to staff to spend some time together and build connections.

Discussion

This study explored the workplace demands and stressors experienced by healthcare staff in hospital maternity services and subsequently how these demands and stressors affected their engagement in workplace wellbeing activities. Ethnographic observations captured how a regional maternity service responded to workplace environment challenges through the implementation of a workplace wellbeing program called SEED. We found that despite several systemic challenges present in maternity services, the SEED wellbeing program provided an opportunity for staff to engage in wellbeing activities during worktime. The challenges in maternity included strained staff relationships and a lack of respect between units and across disciplines, work distress and perceptions of wellbeing as yet another demand, and limited confidence in, and connection with, leadership. While the opportunities identified were staff generated ideas for improving the environment and fostering connections and relationship building. The human and financial resources of SEED were able to implement staff ideas facilitating some take-up of the wellbeing program during the observation period.

Although the implementation of SEED was intended to support staff in prioritising their own wellbeing, participants in this study reported difficulties in engaging in wellbeing activities at work, due to the unpredictable nature of maternity care and internal conflicts between patient care and their own self-care needs. Staff expressed feelings of frustration with workplace wellbeing programs due to time constraints and staffing shortages affecting their ability to participate. Discussing the concept of slowing down in a high-pressure environment proved challenging for many participants. Despite these challenges, staff are expected to prioritise their own wellbeing to ensure the provision of optimal care to their patients [17]. Some shifted the responsibility for wellbeing onto themselves, questioning whose responsibility it truly is. While others shifted the responsibility onto leaders. Despite leadership’s outward support for SEED, many participants expressed scepticism and distrust, perceiving leaders’ intentions for wellbeing as disingenuous. Previous studies investigating the role of leadership in implementing SEED identified that successful implementation was associated with leaders valuing and supporting wellbeing, whilst also participating in the intervention [28–30]. However, as opposed to the previous implementation of SEED in other healthcare settings [29, 30], leaders did not participate in wellbeing activities in maternity services. Leaders behind-the-scenes involvement and lack of participation in SEED appeared to have a destructive impact on their relationship with staff who felt that their leaders were removed from the frontline. Research shows that organisational-level strategies, particularly those that prioritise leadership engagement and cultural change, are significantly more effective in reducing burnout and occupational distress than individual-focused interventions [6, 17]. However, exactly what leaders should do is unclear. The interplay of organisational and individual factors requires future investigation.

In our exploration of opportunities for staff to engage in workplace wellbeing activities, we discovered promising avenues despite the various challenges identified. Activities such as peer support, team building events, mindfulness, and accessible outdoor spaces emerged as key strategies to promote wellbeing in this context. Most of these strategies were consistent with recommendations from international studies on reducing burnout in maternity services through peer support, inter-professional team building and self-care strategies [6, 20, 21]. As the implementation of SEED commenced in maternity, staff were active participants in the decision-making of the wellbeing activities that would become part of the service. Despite increasing recognition of the value of involving staff in decision-making processes [6, 37], previous studies have not reported on the collaborative development of wellbeing activities. Instead, emotional support and wellbeing resources were often predetermined and delivered through external services such as the Employee Assistance Program (EAP) [17, 38].

Recommendations for future research

Future research should evaluate the effectiveness of novel strategies, such as creating outdoor spaces, in promoting wellbeing among healthcare staff in maternity services. While strategies like peer support and mindfulness activities have been previously recognised and studied, our research highlights the importance of considering additional approaches tailored to the specific needs and preferences of staff. Future studies could investigate the impact of outdoor spaces on reducing stress and enhancing wellbeing, as well as explore other innovative strategies that may have been overlooked in previous research. Moreover, our findings emphasise the significance of involving staff in the decision-making process of wellbeing activities, suggesting that collaborative approaches may lead to more tailored and effective interventions. Therefore, future research could focus on examining the outcomes of collaborative decision-making in implementing workplace wellbeing activities, including its effects on staff engagement, satisfaction, and overall wellbeing. By addressing these areas, future research can contribute to the development of more comprehensive and evidence-based strategies for promoting wellbeing in maternity services.

Strengths and limitations

This study offers several notable strengths that contribute to its value and impact. Firstly, the use of an ethnographic methodology allowed for an in-depth exploration of the unique dynamics within maternity services. By immersing in the day-to-day activities and interactions of healthcare staff, the study was able to capture nuanced insights and firsthand accounts of their experiences. This approach provided a rich, contextual understanding of the complex dynamics and stressors present in maternity services, which would be difficult to achieve through more detached research methods.

By focusing specifically on maternity services, the study addressed a critical but often underexplored area within healthcare. The findings shed light on the unique stressors and demands faced by maternity healthcare staff, providing valuable insights that can inform targeted interventions. This focus also contributes to the broader literature on healthcare worker wellbeing by highlighting the specific needs of those working in high stakes, emotionally charged environments.

One of the limitations of this study is its context-specific nature, as the findings are derived from an ethnographic approach focused on the dynamics of maternity services at one large regional hospital. As a result, the strategies and approaches identified for implementing wellbeing activities may not be universally applicable across all healthcare settings. The unique relationships and dynamics between staff and leaders within each institution may require tailored interventions to effectively promote wellbeing. Thus, the generalisability of the study findings to other healthcare contexts may be limited, and further research in other health setting is warranted to validate the effectiveness of these wellbeing strategies.

Another limitation of the study is the relatively short duration of observations, spanning 12-weeks. Due to this timeframe, only three out of the five SEED activities were initiated and observed during the study period. Consequently, the sustainability of the SEED wellbeing activities in maternity was not fully captured in the study findings. This limitation suggests the need for future research to assess the ongoing impact and sustainability of workplace wellbeing activities over an extended period to provide a more comprehensive understanding of their effectiveness.

Conclusion

In conclusion, this study sheds light on the intricate landscape of opportunities and challenges for implementing workplace wellbeing activities in maternity services. By identifying challenges such as disconnection and lack of trust, alongside opportunities like collaboration and camaraderie, the findings provide actionable insights for designing effective wellbeing activities. Gaining leaders’ trust and commitment, followed by engaging staff in collaborative decision-making, is crucial for successful implementation. This research contributes to the global clinical community by providing a nuanced understanding of workplace wellbeing implementation in maternity services, offering a blueprint for similar interventions in healthcare settings worldwide.

Biographies

Andrea Knezevic

is a PhD Candidate at the University of Wollongong who holds a Bachelor of Social Work (Honours). One of the highlights of her career was volunteering in the aftermath of the 2019/2020 Australian bushfire crisis, providing immediate crisis support to staff at a small rural hospital. She is a young researcher with a passion for staff wellbeing in healthcare. Her current research is exploring the opportunities and challenges for healthcare workers to engage in wellness activities in the hospital setting.

Dr. Katarzyna Olcoń

is a Senior Lecturer Social Work in the School of Health and Society, University of Wollongong, Australia. Her research centres on community mental health, workplace wellness and cultural humility in health and social service provision.

Dr. Jacqui Cameron

is a social worker, bringing over 20 years’ research and practitioner experience in ‘real world’ research and knowledge translation in a variety of settings including substance use, mental health, worker wellbeing and domestic violence. She is an Associate Professor and Academic Program Director for the Bachelor Social Work at the University of Wollongong.

Dr. Padmini Pai

has 30 years of experience as a social worker, service manager, and program lead for many district-wide initiatives. Her publications have been in positive, strength-based ways of working in healthcare. Padmini has a unique way of balancing ‘people and process’ in equal measure.

Prof. Julaine Allan

is a social work researcher specialising in mental health, substance use and service user healthcare experience. Prof Allan specialises in qualitative and mixed methods research in healthcare settings and with vulnerable groups.

Authors’ contributions

AK was involved in the research design, ethics application, data collection and data analysis, writing of the manuscript and dissemination of findings. KO was involved in the research design, facilitated PhD supervision, and contributed to preparing and reviewing manuscript. JC provided project oversight, was involved in PhD supervision, assisted in data analysis, and contributed to preparing and reviewing the manuscript. PP provided assistance with the project design, was involved in the project oversight, participated in PhD supervision and reviewed manuscript. JA contributed to the research design, was involved in the project oversight, participated in PhD supervision, contributed to data analysis, and provided support in preparing and reviewing the manuscript. All authors read and approved the final manuscript.

Funding

This project was funded by the Research Training Program Scholarship awarded by the Australian Government.

Data availability

The datasets generated and/or analysed during the current study are not publicly available due to ethics committee requirements regarding confidentiality and the potential risks of participant identification. Given the nature of the ethnographic data collected in a specific maternity service, full anonymisation is challenging, and sharing raw data could compromise the privacy of healthcare staff and leaders involved. However, the data are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

This study was conducted in accordance with the principles outlined in the Declaration of Helsinki. Ethical approval was obtained from the Human Research Ethics Committee of New South Wales (NSW) Health and the University of Wollongong (2023/STE00269), and all participants provided informed consent prior to participation. Participants were informed of their right to withdraw at any time without consequence, and confidentiality was maintained throughout the study.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.