Resilience strategies against working pressures in midwives: A qualitative study

Abstract

INTRODUCTION:

The lack of experienced midwifery in obstetrics and gynecology centers would have harmful consequences. Resilience could increase midwives’ endurance while caring for women and neonates in the maternity hospitals. Research on resilience of midwives is rare. The purpose of this study was to explore and describe resilience strategies against working pressures in midwives in Sabzevar, Iran.

METHODOLOGY:

The qualitative study was conducted using content analysis method. Twelve midwives, who had at least 1 year of work experience, were selected by purposeful sampling. Data collection was conducted using semi-structured deep interviews on midwives’ resilience strategies. The analysis was carried out using conventional content analysis method.

RESULTS:

The five main categories of data were extracted, including self-management, supporters in the workplace, sense of usefulness and reassuring, the nature of creation, and life dynamic in the workplace, and accountability. Reading recitation and recourse, obtaining decision-making power, and problem-solving were subcategories of the self-management. Intimate the communication, peer support, physician support, and family support were subcategories of supporters in the workplace. The subcategories of sense of usefulness and reassuring were work autonomy, satisfaction of applying the knowledge in practice, the feeling of energy evacuating with much work, and trying to reassuring mothers.

CONCLUSION:

All extraction factors were related to the midwife and did not relate to the therapeutic system and management. However, hospital managers can provide their supporting and facilitating role to reduce the risk of depreciation and burnout in midwives.

Introduction

Midwives work in an emergency environment. They care for two people at the same time, one of them is a mother, who is not only the mother of a new-born baby but also the mother of other children of the family; with damage to her incur uncompensated lesion of the health of the community.[1] In this regard, providing health care for mothers has great importance.[2] Working in the midwifery environment is very stressful. Therefore, that we can compare work in maternity care units with nursing in emergency and intensive care units, or it may be more stressful than nursing in these departments.[3] The other person who needs care at the same time is a neonate. The smallest fault in a particular situation can lead to neonate death or irreparable injuries. Because the mission of midwife is to health promotion of mothers and infants, it is one of the most important careers. Therefore, midwives’ mental health and well-being can be effective in the health of mothers and neonates.[4,5] Midwives who work in the maternity wards suffer from tragic scenes, such as maternal and neonatal death, which are called secondary traumatic stress. This detrimental consequence incurs serious injury to midwives’ mental health and their capacity for providing care.[1,6]

Midwives’ job stress can affect their job satisfaction. In a study, midwives’ job behaviors were directly related to their job satisfaction and had a negative relationship with occupational stress. In this study, 59% of midwives were satisfied with their job; however, 61.5% of them reported moderate occupational stress levels.[7] Moghaddam et al. showed that only 14% of midwives had mental health, and 86% had some psychosocial disorder. In addition, 54% had moderate and 46% had severe stress. He showed a significant and inverse relationship between mental health and occupational stress, which can indicate the effect of stress on midwives’ mental health.[8] Hashemi–Nejad et al. study showed that 60.7% of midwives suffered from the psychosocial disorder and hence that 81.8% and 17.6% had moderate and severe occupational stress, respectively.[9] In another study, about two-thirds of midwives (60.7%) experienced high levels of emotional exhaustion, and one-third of them (30.3%) reported experiencing personality, deprivation, and decreased self-efficacy.[10]

Resilience is the ability to successfully adapt to the hardships and frustrations that person experienced.[11] Resilience is necessary to overcome daily problems and also a major change in life.[12] The qualities of getting well and going forward in life are the symptoms of resilience.[13] Resilience refers to the ability to discover and using all internal and external capabilities to address the underlying challenges and evolutionary development.[14]

Many British midwives have experienced escalation in workload and displacement in the workplace. For this reason, the midwives shortages are seen at the national level. Midwives reported an increase in the number of deliveries and an increase in the number of pregnant women requiring complex care. Studies show that workload pressures, emotional needs of the job, and experience high-stress, along with the immorality in the workplace, can lead to illness and leave a job in midwives.[15]

Different sources of pressure lead to diverse reactions in different people. Some people can overcome these factors better than others. They can face the environmental struggle; while many people are totally susceptible to psychological stresses due to their individual characteristics. They cannot cope with the stressful factors. These individual characteristics include age, sex, health status, patterns of exercise, and even nutrition, which leads to different responses in stressful situations. In addition to individual characteristics, other variables that affect personal behavior, includes work schedules and rest hours can be listed as sources of pressure.[16]

As seen, a variety of studies have been done on the midwives’ work pressures. However, studies on midwives that indicate how they acquire resiliency in high-pressure maternity wards are rare. In Hunter's study, which evaluated the resilience of midwives qualitatively, thematic analysis identified four themes that included challenges of resilience, management and adaptability, self-awareness, and resilience building.[15]

Literatures review revealed that few studies have been done on the resilience of midwives in dealing with the different work situations. The concept of resilience in other fields of health has been studied, but there is no study on this issue in midwifery in Iran. Therefore, there is a gap in the midwifery body of knowledge.

The role of the midwife as a supporter of pregnant mothers is always considered, whereas attention to the mental health of midwives who responsible for the care of mothers and neonates has been neglected.[11] As mentioned, moderate-to-high levels of stress, psychosocial problems, job burnout, and emotional exhaustion exist in the midwives.[8,9,10] Such problems are due to leave work on midwives. The aim of this study was to identify factors that lead to resilience in the face of work pressure. Thus, using the results of this research, it is possible to identify the facilitators and modulators of work pressure. Furthermore, it is possible for workload management strategies can be developed. Since, few studies have been done, especially in Iran regarding the resilience of midwives. This research was conducted with the aim of discovering resilience strategies against working pressures in midwives in Sabzevar's maternity wards.

Methodology

Regarding the purpose of the research, the discovery of resilience strategies was used qualitative approach to understand human emotions and discovering hidden meanings in daily experiences. Using this research method may able researcher to extract the main themes and discover the patterns in the data. Moreover, this qualitative approach is proper method for achieving valid and dynamic results that shape the new knowledge, emerge the reality, and prepare clinical guide in practice. In fact, this method attempts to explore some of the meanings in the data by qualitative reduction and categorizing.[17]

In this qualitative study, content analysis was used. The participants were midwives working at Mobini Hospital in Sabzevar. At first, 12 midwives were enrolled in the study with purposeful sampling. Semi-structured deep interviewing method was used to collect data. To select the samples, the maximum variance was used. So that midwives with a minimum of one to maximum 25 years of work experience, different ages and educations, as well as with and without shift responsibilities were selected to obtain data. For this purpose, midwives who encountered severe stressful situations were also selected using the snowball method.

The sampling continued up to data saturation, it meant that with more interviews, no new information was available for developing a new category about resilience. So that, no new information was received in the past three interviews. The study lasted from March to July 2018. Midwives should have at least 1 year of work experience and feel the pressure on the workplace. Participants should be willing to participate in the interview and be able to express their experiences. The age of the participating midwives was 23–47 years. Whose work experience ranged from 1 to 23 years. In qualitative research, the number of samples is not constant and sampling continues until no new idea is obtained.[18]

First, the researcher, while introducing himself, stated the purpose of the study for the participant. Then, explaining the ethical issues and commitment to compliance it. If the participant agrees, the interview began with warming questions such as “introducing yourself please?, including the age, work experience, level of education, management experience, wife's job, number of children, and etc.” Then, the interview continued with a general question about the experiences of the workplace pressures. After that gradual introduction of more detailed questions, such as the feeling of individual in that situation. The questions continued with asking to express their response to the work environment stresses, and how to resilient in that situation. If needed asked more probing questions such as “can you explain more about this, then what happened, what was your mind busy with, and how was your feeling.” Each interview ended with the following two questions: “In your opinion, is there another question that I have to ask and if you have any question.” In this study, data collection method was in-depth and semi-structured interviews on midwives’ experiences of work environment stress and resilience. The duration of the interview was 60–90 min with each contributor, and after repeated listening and data analysis, if there was a need for further information, it would be arranged another time for an interview. The time and the place of interviewing were agreed upon between the participants and interviewer. Interviews were conducted at the midwifery workplace in Mobini Hospital, in the educational supervisor room. Interviews were recorded with the permission of the participants, and after each interview, it was listened to several times and then transcribed. After each interview, data analysis was carried out and the next interview was conducted after an accurate analysis.

After several listening, data mining, reading, and drowning in the data, a general picture of the data was obtained and the meanings were extracted, key ideas were highlighted, and the codes were categorized accordingly relating to each other.

Different strategies were used to authenticate data such as peer-check techniques and member check. In member check, the interview codes were returned to five participants, and they verified the codes extracted by the researcher. In peer-check technique, two researchers performed the coding and categorization independently, and in the event of disagreement with the codification or categorization, to reach the consensus, the discussion, and clarification were made. The MAXQDA10 Software (MAXQDA is a registered trademark of VERBI Software. Consult. Sozialforschung. GmbH, Berlin/Germany) was used to maintain, better sort, and analyses of qualitative data.

The proposal was approved at the ethics committee of Sabzevar University of Medical Sciences (code IR. MEDSAB.REC.1396.123). For participants, the goal of the study was explained before the interview. Participants were told that they could leave the project at any step of research. All participants were informed that their data are confidential. Then, the informed consent form was completed by the participants.

Results

Data were being compiled from the 20-h interview tapes and the verbatim transcription of the interviews. The number of participants was 12, of which 10 had bachelor's degrees and two had master's degree. The age range of the participants was 23–45 years. Their work experience ranged from 1 to 20 years with an average working experience of 8 years. By analyzing the data of the interviews, 600 initial codes, 46 subcategories, 16 subcategories, and finally five major categories were developed. In this study, five main categories included self-management, the presence of supporters at work, the sense of usefulness, the nature of creation and life, and accountability. Each category contains the subcategories that are listed in Table 1.

Table 1.

Resilience factors of midwives in high-pressure work environment

Categories	Sub categories
Self-management	Reading recitation and recourse
	Obtaining decision-making power
	Problem-solving
Supporters at work	Intimate communication
	Peer support
	Family support
	Physician support
Sense of usefulness and reassuring	Work autonomy
	Satisfaction of applying knowledge in practice
	Feeling of energy evacuating with much work
	And trying to reassuring mothers
The nature of creation and life dynamic in workplace	The nature of life in the maternity unit
	Importance of neonate
	Sharing in mother’s happiness
Accountability	Responsibility for patient follow-up
	Attention to the patient

Self-management

Reading recitation and recourse, decision-making power, and problem-solving skills were considered to be subcategories of the self-management factor, which is described below.

Reading recitation and recourse

One of the self-management methods used by midwives to increase the resilience was to reading recitation and recourse. By reading recitation and recourse, they obtain supernatural powers that able them to achieve energy in work environment. Furthermore, by recourse and trust to that power, they achieved a sense of calmness and inner happiness that accompanied them until to the end of their work shift. Furthermore, some of them put up reading recitation and giving charity as a prerequisite for entry into the maternity unit. They began to work with comfort achieved by of reading recitation and confidence in the heart.

I always pray before entrance to the maternity unit, and then I start my work. And when I’m reading ayatalcorcy, I want God to come out from hospital with a smile and happiness, and I call it every shift with myself. Thanks God, I think this helped me a lot and gave me some extra energy (fourth participant).

That is, if I won’t read that recitation in changing room,…. I do not get calmness, and I always said It (second participant).

Decision-making power

From the perspective of midwives, confrontation with diversity of decision-making is unavoidable in an emergency, risk, and unpredictability situations. Therefore, midwives considered decision-making power in serving patients to be their necessary skills and thereby, by increasing the decision-making power in a moment, they tried to overcome the stress caused by these situations in different ways. Midwives stated that gaining experience led to increased decision-making power, consequently, improved system satisfaction and trust in them. As a result, the system give midwives more responsibilities. Which all of these conditions reinforce self-management in the midwives and increased their resilience.

These days midwives are more supervisors and in charge, and the reason they (matrons) are so pleased is that they say midwives ongoing decision making is very high. You must learn this (decision making) as a midwife. It's hard but you learn (first participant).

Its hard in the high-pressure situation, for example, in night shift, very clam, patients delivered, you are busy to recording, at once door of elevator's opened with a high intensity, patient come with brancard, with high bleeding, high-blood pressure, very terrible conditions. Now, at that moment, what do I do, I go to care patient, or I call the doctor first, or I first go to care to baby, or first get to mother,…(seventh participant).

Problem-solving skills

Midwives used skills such as problem-solving in different situations to self– management. So that, before they are present in the shifts, they identified their colleagues and doctors who were in the shift and prepared their minds to cooperate with them. On the other hand, before the start of each shift, especially the night shift, which is taken more responsibility and difficult access to the doctor, they were preparing their minds for an uninterrupted effort until the next morning. They also adapted themselves to high workload and increased their capability to work in the field. Some midwives, who were in charge of shifting, had learned to manage their stress with early presence in the hospital and obtain information about hospitalized patients. Subsequently, they could apply proper interactions with other colleagues and avoid double-stress on them. Novice midwives gradually have realized that they had to defend themselves against the pressures of the workplace and protected themselves by emphasizing the truths.

I learned that I should not remain silent in my workplace anymore, and after that, I changed my behaviors and moods, I should never be silent. I have to defend myself. Anyone who wants to be, I must always write the reality (fourth participant).

I also say to my husband. I always go early. At least, 4–5 min earlier, because I’d been shifting in charge. I go 5 min earlier to lower my stress a little. Why that my obedient do not understand that I’m under stress. On the other hand, I give readiness to myself to go walking from night to morning (sixth participant).

Supporters at work

Sub-categories of supporters at work included intimate communication, peer support, family support, and support of physician.

Intimate communication

Midwives believed that it was hard to tolerate extreme working shift in the absence of intimate communication and mild jokes. They were considered laughing, calling with a small name, and creating an intimate environment in the workplace as a means of repelling the pressure.

We are in a closed environment that we live here with each other, if we deal with a very formal offensive, then we get choked, so we call a very intimate one with a small name (twelfth participant).

What our kids (colleague) are joke about, they say and laugh, especially in the crowded working shift or the long night, all them (jokes) related to work, because they know if it does not get destroyed until the morning (ninth participant).

Peer support

Helping experienced colleagues in the special and emergency situations was one of the factors that increased resilience of low-work experience and new employee. Sense of support by the in charge gave them a self-confidence in facing high-risk. Therefore, they were less tolerated stress-induced work.

My patient bled; I was having a severe stress indescribable, I was very scared, until mother's womb comes back up. Until I called shift in charge, she helped me, and we did the best, until her bleeding was controlled; she stays beside me (third participant).

Family support

Some midwives said that the family, especially their husband, understand the mental pressures after completing the work shift, they would have played a supportive role and helped them to address their concerns by meeting the patient out of working shift or by a telephone.

I say this about patients in our house a lot, that my husband, God bless him, calls me stand up and make a call to hospital until your worry lessened. Sometimes, he brings me to the hospital to ask for my patient (second participant).

Physician support

All midwives stated that the physician, as in authority person, reduced their stress-induced as a result of a complicated or unpleasant condition, with his supporting role. The confidence and support of physicians increased the resilience of midwives during many years of work in the maternity unit.

That night,… one thing that got rid me of pressure was the doctor's behavior. She (physician) said: “I’m sure You do not steal from work, and do the maximum effort; it took me out of the pressure on me, not even frown me at all, he did not even ask me at once that why such things happen,… (First participant).”

Sense of usefulness and reassuring

The sense of usefulness and reassuring included the subcategories of work autonomy, satisfaction of applying the knowledge in practice, feeling of energy evacuating with much work, and trying to reassuring mothers.

Work autonomy

The sense of practical autonomy and uniqueness in the midwifery career increases midwives sense of inner satisfaction, which this satisfaction-induced by the work autonomy facilitates toleration of work pressure and the sense of usefulness. Ultimately, work autonomy increases their spirit of resilience.

Because of the independence of the operation that we have, the independence of the action is a pleasure to ours, you feel that you are doing something independently, you’re a professional. You have a job that only you can do. this makes you feel a bit satisfied (tenth participant).

Satisfaction of applying knowledge in practice

Midwives stated that when they used their knowledge in practice and the care of patients. Moreover, they experienced the sense of usefulness, they proficient sense of satisfaction. Especially, when they tried to take care of a high-risk mothers or effort in facilitating and speeding up the process of delivery and reducing the patient's ailment.

I’m very pleased to work with a sick person, especially when working with a high-risk patient. I feel I’m using what I’ve learned …(Eleventh participant).

When my work ended with goodness and happiness. I’m happy to be there. I’m saying that she is well. I think that's good. At this time, I forget the work pressures, I overlook all of it (sixth participant).

Feeling of energy evacuating with much work

From the midwives’ point of view, working with mothers in the maternity unit is more energetic and satisfying more than anything else. The reason for this, they depicted the bold role of midwifery in their mind. Moreover, they knew that maternity environment is good for energy evacuation and service to the people.

It's a great place to evacuate energy. As a midwife, I may be able to work in an emergency in a health facility or clinic, but I do not know why I feel better to play my role in maternity unit (second participant).

Trying to reassuring mothers

Midwives expressed when they care of pregnant mothers, they feel completely usefulness, that they are reassuring agent for mothers. They try to reduce pain and increase the satisfaction of pregnant mothers. Therefore, sense of usefulness and helping agent form in their mind.

When I go to the examination, I think of something, that I do something for her. I try to talk to her to make it easier to tolerate pains and to hope that she will soon end up, get her desire, and when my work get to result in my happiness is grate.…(seventh participant).

The nature of creation and life dynamic in the workplace

The nature of creation and life dynamic in the workplace included the following subcategories: The nature of life in the maternity unit, importance of neonate, and sharing the moments of happiness.

The nature of life in the maternity unit

The common point of view of all participants was that there is permanent and extraordinary flow of life in the maternity unit. Mothers are not sick and come on with full of hope. Midwives said they received the energy of mothers who are full of hope for the birth of their baby, and its positive effects increase the resilience and facilitate work pressures.

The reality is that creation is here. We see creation there that human is adding to this world (first participant).

I think the nature of the maternity unit is nature of life. It's the only one that makes it possible to endure (fifth participant).

Importance of having a baby

Midwives believe that trying to give birth is unanimous between the midwife and client. This makes both midwives and mother maximize their efforts to achieve this common goal, (the birth of a healthy baby along with mother's health). The importance of having a baby was in the midwives’ mind, which, despite the difficulty of working in the maternity unit, could increase their tolerance.

It's always in my mind that how many she/he (baby) is important, how many it is important to what's in her belly, and then she gives birth, how much we are happy (seventh participant).

Sharing in mother's happiness

The midwives stated that seeing the mother's happiness after childbirth is an extraordinary opportunity that other clinical caregivers less benefit from that. Sharing to this happiness after labor and delivery can cover a large part of the stress. Perhaps, midwives consider their role to be effective in this joy as the cause of childbirth.

I really love patients. I like to give birth health, I like to give birth a good baby. I like to see her (mother) happiness; when I see my result, I am excited, and forget all of my hardiness (eighth participant).

Accountability

Responsibility for patient follow-up and attention to the patient were in the subcategory of accountability.

Responsibility for patient follow-up

Responsibility was a common sense among all the participants caused made their efforts to increase the quality of care in spite of high-workload and the multiplicity of high-risk patients. Even midwives stated that, in a more difficult situation, sense of responsibility caused they have had much more effort and less complaint of work.

When I feel responsible, I can’t lower the quality of the patient due to the fact that if we lower the quality of care, injury to patient increased immediately. hence, we decide to work more and less talk (ninth participant).

Even on the next day, you go back and follow your patient at the other ward. You go to see her (seventh participant).

Attention to the patient

From the midwives’ perspective, the sense of responsibility motivated for patient attention and care in the case management. Attention to the patient-reduced worries after the working shift. On the other hand, this attention to the patient gave mutual satisfaction, which allowed them tolerated difficult conditions of work. Midwives responsibility increased their accuracy even in documented medical records, which ultimately led to a tranquility after working shift.

When I get into the block (maternity unit), I think that I do my best to make the case uncomplicated and they’ve had a very good delivery. I do my work very precise, even my file recordings are very tidy and accurate (fourth participant).

Discussion

The findings of the study showed that midwives use self-management approaches to achieve resilience that include reading recitation and recourse, gaining decision-making power, and increasing the problem-solving skills. In addition, they believed that supporters in the workplace, such as intimate relationships, peer, physicians, and family support have had role in adapting resilience in the workplace. Another factor effective in resilience was the sense of usefulness and reassuring. The role of the work environment, which was the nature of creation and dynamism, was considered effective in resilience. Because midwives believed that nature of life, the baby is important and sharing the joy of mothers exist in the maternity unit. Sense of responsibility was another factor that led to patient following and attention to him. Eventually, all these factors lead to develop resilience in midwives. In a study by Clompus et al. who assessed the paramedics resilience. They received four themes from the participant, experiences that included formal support methods such as management and search and referral to foreign organizations, and informal support including support of colleagues, family and friends’ support, and use of humor, and laughter.[19] As seen informal support, including peer, and family support, and using jokes and laughter, are consistent with the results of this study.

Gayton and Lovell showed that resiliency was significantly related to health and well-being. Their findings reinforce the need for increased resilience interventions for paramedics to protect their well-being.[20]

The results of the present study were self-management and sense of usefulness, indicating the maintenance of midwives’ mental and function integrity, and protecting happiness in the work environment. In the same way, Streb et al., with a study in the paramedic group, found that good integration and high flexibility reduced the risk of post-traumatic stress disorder (PTSD) in paramedics.[21]

Hunter and Warren showed that resilience is a process to be learning that includes a range of adaptive strategies, including access to support, development of self-awareness, and self-protection. Participants emphasize the importance of a strong sense of professional identity to establish resilience.[15] The results of this study are in line with the recent study. Because midwives tried to overcome the workplace pressures by gaining the power of decision-making, problem-solving skills, reading recitation and recourse (self-management), and the use of support from peers, doctors, and the family (supporters at work).

Crowther et al. have studied the sustainability of midwifery and their resilience and identified themes including their own decision-making, self-care, the development of professional relationships with the women and family, and passion and love for midwifery.[22] As can be seen, the experiences of the participants in this study are somewhat referred to above findings and in line with them. Hence, midwives try to overcome high-pressure workload with self-management, the power of decision-making, problem-solving, reading recitation and recourse, and using advocates to protect themselves.

Hart et al. described that factors facilitated to resilience include the challenges of the workplace, psychological evacuation, reduced mental balance, and unpleasant patches. Moreover, they expressed examples of intrinsic characteristics include hope, self-efficacy, and adaptability. They find that factors such as cognitive modification, hardening, connection to the field, work-life balance, and reconciliation are strategies for creating flexibility[23] which are different from the findings of this study. It seems that Hart's study has focused on the factors that lead to resilience, but the present study addresses resilience strategies against working pressures in midwives.

The results of a study showed that three main factors necessary for resilience the ability to develop in the work environment and organizational health-including network support, personality traits, and the ability to organize work.[24] This results also are in line with the present study.

The limitations of this study were to examine midwives’ resilience strategies using their own experiences. Therefore, the therapeutic systems and managers strategies were ignored in this regard.

Conclusion

Since midwives play an important role in maintaining and improving the health and welfare of women in society. Therefore, one of the priorities is providing optimal and low-pressure environment to reduce physical, emotional, and psychological stress. Midwife's experiences showed that self-management, workplace, and family supporters, have a sense of usefulness, the nature of creation, life dynamic in the workplace, and accountability are for resilience strategies. All these factors go back to the midwife. In this study, midwives do not refer to the role of the system in their resilience. Thus, this result indicated that resilience-a concept returns to a state of equilibrium in difficult circumstances-occurred by the person himself, and the system plays a minor role.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.