The Relationship Between Restrictive Regulation of Midwives, Practice Environment, and Professional Burnout: A 7-State Mixed-Methods Comparison of Autonomous and Restrictive State Regulation.

PURPOSE: The purpose of the study was to investigate the relationship between state regulation of the midwifery workforce, practice environment, and burnout. BACKGROUND: Burnout threatens the US midwifery workforce, with over 40% of certified nurse-midwives meeting criteria. Burnout can lead to poorer physical and mental health and withdrawal from the workforce. Burnout in midwives has been associated with lack of control and autonomy. In the United States, midwives' autonomy is restricted through state-level regulation that limits scope of practice and professional independence. METHODS: A mixed-methods study was conducted using an explanatory sequential approach. Quantitative and qualitative data were collected by online surveys and analyzed in a 2-stage process, followed by data integration. RESULTS: State regulation was not found to be independently associated with burnout (n = 248; P = .250); however, mediation analysis showed a significant association between state regulation, practice environment, and burnout. Qualitative analysis mirrored the importance of practice environment and expanded on its features. CONCLUSION: For midwives, unrestrictive practice regulation may not translate to burnout prevention without supportive practice environments. IMPLICATIONS FOR PRACTICE AND RESEARCH: Interventions should focus on promoting job flexibility, realistic demands, and professional values. While midwives' commitment to patients and the profession can help bolster the workforce, it can also amplify negative experiences of the practice environment.

Midwifery Practice Leaders' Experiences of Practice Changes Early in the COVID-19 Pandemic: A Qualitative Exploration.

INTRODUCTION: The coronavirus disease 2019 (COVID-19) pandemic generated considerable upheaval in all sectors of the US health care system, including maternity care. We focused this inquiry on midwifery practice leaders' experiences and perspectives on changes that occurred in their practices early in the pandemic. METHODS: This was a qualitative descriptive study using thematic analysis. The data were responses to an open-ended question in a survey of pandemic-related employment and clinical practice changes. Findings are presented from a constructivist perspective, describing the experiences and perspectives of a group of US midwifery practice leaders during the initial phase of the COVID-19 pandemic. RESULTS: Two main themes emerged from the analysis: demands on midwives and driving forces. Demands on midwives were 3-fold: clients' needs, modification of care, and midwives' needs. These encompassed the psychological, physical, and emotional toll that caring for women during the pandemic placed on midwives. Driving forces were those entities that spurred and directed change and included regulations, institutions, financial logistics, and team dynamics. Survey respondents in community (home and birth center) practices reported substantial increases in inquiries and client volume, and many respondents expressed concern about withdrawal of students from clinical placements. DISCUSSION: Midwifery practices experienced profound changes in their work environments during the COVID-19 pandemic, with both positive and negative characteristics. These challenges in providing birth care were similar to those reported in other countries. Results indicated existing guidance for maternity care during emergencies did not meet clients' needs. Coordinated planning for maternity care in future prolonged health emergencies should incorporate best practices and include midwives in the process.

Midwifery Autonomy and Employment Changes During the Early COVID-19 Pandemic.

INTRODUCTION: The COVID-19 pandemic presented the midwifery workforce with challenges for maintaining access to high-quality care and safety for patients and perinatal care providers. This study analyzed associations between different types of professional autonomy and changes in midwives' employment and compensation during the early months of the pandemic. METHODS: An online survey distributed to midwifery practices in fall 2020 compared midwives' employment and compensation in February 2020 and September 2020. Chi-square analysis determined associations between those data and measures of midwives' autonomy: state practice environment, midwifery practice ownership, intrapartum practice setting, and midwifery participation in practice decision-making. RESULTS: Participants included lead midwives from 727 practices, representing 50 states and the District of Columbia. Full-time equivalent (FTE) positions and number of full-time midwives were stable for 77% of practices, part-time employment for 83%, and salaries for 72%. Of the remaining practices, more practices lost FTE positions, full-time positions, part-time positions, and salary (18%, 15%, 9%, and 18%, respectively) than gained (11%, 8%, 8%, and 9%, respectively). Early retirements and furloughs were experienced by 9% of practices, and 18% lost benefits. However, midwifery practice ownership was significantly associated with increased salaries (20.3% vs 7.1%; P < .001) and decreased loss of benefits (7.8% vs 19.9%; P = .002) and furloughs (3.8 vs 10.1%; P = .04). Community-based practice was significantly associated with increased FTE positions (19.0% vs 8.8%; P = .005), part-time positions (17.4% vs 5.1%; P < .001), and salary (19.7% vs 7.0%; P < .001), as well as decreased loss of benefits (11.5% vs 21.1%; P = .02) and early retirement (1.4% vs 6.6%; P = .03). State practice environment and participation in practice decision-making were not directly associated with employment and compensation changes. DISCUSSION: Policies should facilitate midwifery practice ownership and the expansion and integration of community birth settings for greater perinatal care workforce stability, greater flexibility to respond to disasters, and improved patient access to care and health outcomes.

Supervisor competencies for supporting return to work: a mixed-methods study.

PURPOSE: Line supervisors often play an important role in the return to work (RTW) process; whether they possess the competencies needed to carry out this work effectively is unknown. The aim of this research was to determine the competencies supervisors need in order to facilitate a worker's RTW following absence due to a mental health condition or a musculoskeletal disorder. METHODS: Supervisors from five Australian industries with high rates of compensable claims participated in focus groups to elicit the knowledge, skills, and personal characteristics required to support returning workers. From a multi-stage analysis of responses, RTW competencies were developed, allocated to clusters of related items, and incorporated into an online survey administered to rehabilitation professionals. RESULTS: 29 supervisors participated in 1 of 5 focus groups. Analysis of focus group data identified 84 generic competencies, eight specific to mental health conditions, and two to musculoskeletal disorders, arranged in 11 clusters. Survey respondents (n = 344) represented a variety of rehabilitation professionals and jurisdictions. Nearly all agreed that supervisors should receive training to support RTW. Over 50 % of respondents rated 90 of 94 competencies as very important or essential. The highest ratings were for competencies relating to personal attributes, knowledge of RTW processes, and empathetic support of the worker. CONCLUSIONS: Supervisors and rehabilitation professionals perceive effective support of RTW requires supervisors to have a range of knowledge, skills, and personal characteristics. Our competency model should undergo workplace testing to evaluate its validity.

The prevalence of work-related neck, shoulder, and upper back musculoskeletal disorders among midwives, nurses, and physicians: a systematic review.

With the global shortage of health care workers predicted to worsen, attrition from the work force must be minimized. This review examined the incidence or prevalence of neck, shoulder, and upper back musculoskeletal disorders, a possible source of attrition, among midwives, nurses, and physicians. Four electronic databases were systematically searched for publications meeting inclusion criteria. Reference lists of retrieved articles were hand searched for additional articles. After eliminating articles that did not meet inclusion criteria, the remaining articles were assessed for quality and prevalence or incidence data were extracted. Twenty-nine articles published between 1990 and 2012 were included and assessed for quality. Median annual prevalence rates were 45% (neck), 40% (shoulder), and 35% (upper back). Methodological concerns included small sample size, inconsistency of outcome measures, likelihood of non-response bias, and low response rates. Midwives, who have not been well studied, demonstrated prevalence somewhat lower than that of nurses and physicians.

Helping women but hurting ourselves? Neck and upper back musculoskeletal symptoms in a cohort of Australian Midwives.

OBJECTIVE: To determine the prevalence of neck and upper back musculoskeletal symptoms in a group of Australian midwives and explore individual characteristics and workplace exposures associated with these symptoms. DESIGN: cross-sectional, using data from the Nurses and Midwives e-Cohort Study, a longitudinal, electronic survey of midwives and nurses in Australia, New Zealand and the United Kingdom. SETTING: data were collected via an online survey in 2006-2008. PARTICIPANTS: qualified Australian midwives aged 23-70 years. MEASUREMENTS AND FINDINGS: We undertook descriptive analysis of the sample, calculated prevalence and examined associations between individual and workplace variables and neck and upper back musculoskeletal symptoms. Variables achieving p<0.1 in bivariate analysis were entered simultaneously into logistic regression models. Overall prevalence rates were 48.8% for neck and 28.2% for upper back musculoskeletal symptoms; work-related prevalence was 40.8% (neck) and 24.5% (upper back), comparable to reported rates among nurses and physicians. Presence of symptoms in the adjacent area was associated with greater than a fourfold increased risk for neck and upper back symptoms. Participants with care responsibility for an adult dependent were 36% more likely to report neck symptoms. Current shift work and total physical activity were associated with decreased likelihood of neck and upper back symptoms, respectively. Psychological job demands were only weakly associated with upper back symptoms, possibly because the survey tool could not capture a sufficiently broad range of psychosocial exposures to present a complete picture. A striking finding was that work in awkward postures conferred an increased risk of 35% for neck and nearly 50% for upper back symptoms. KEY CONCLUSIONS: neck and upper back musculoskeletal symptoms were prevalent in this sample. Both individual and workplace factors were significantly associated with neck and/or upper back symptoms. Psychological job demands and work in awkward postures are potentially modifiable exposures that deserve further examination. IMPLICATIONS FOR PRACTICE: midwives who are or may become carers for adult dependents should be aware of a possible increased risk for neck symptoms. It may be prudent for midwives and those who employ/supervise them to monitor and, where possible, jointly develop strategies to mitigate psychological job demands. The potential hazard posed by work in awkward postures warrants consideration of how midwives may minimize time spent working in these postures.

Functional consequences of work-related spinal musculoskeletal symptoms in a cohort of Australian midwives.

BACKGROUND: Early evidence suggests spinal musculoskeletal symptoms are as prevalent in Australian midwives as in samples of nurses. Functional consequences of these symptoms include sick leave and functional incapacity, which are costly at both individual and workplace levels. To date there have been no studies of these consequences in midwives. QUESTION: What risk factors are associated with sick leave and functional incapacity among midwives with spinal musculoskeletal symptoms? METHODS: We undertook a cross-sectional study of qualified Australian midwives who completed the baseline survey of the Nurses and Midwives e-Cohort Study. A comprehensive set of independent variables were examined for bivariate associations with the main outcomes of sick leave and functional incapacity due to work-related musculoskeletal symptoms in the neck, upper or lower back. Associations that achieved a p value<.1 were entered into multiple logistic regression models. FINDINGS: 729 midwives with a mean age of 46 years were eligible for inclusion. Functional incapacity was more than twice as common as sick leave. Severity of worst pain was the explanatory variable most strongly associated with each main outcome and the only one significant for both. Psychological job demands showed a significant association with sick leave, while several individual factors were associated with both outcomes. Only the association of poorer general health with functional incapacity remained significant in all three spinal regions. CONCLUSION: Our sample reported considerable work-related musculoskeletal pain and functional incapacity. Factors associated with sick leave and functional incapacity in midwives should be confirmed by longitudinal studies with the aim of developing tertiary prevention strategies.

Work-related upper quadrant musculoskeletal disorders in midwives, nurses and physicians: A systematic review of risk factors and functional consequences.

BACKGROUND: Given a worldwide shortage of primary health care workers predicted to worsen, it is vital to address sources of attrition among these professionals. One such source may be work-related musculoskeletal disorders. We aimed to identify risk factors for and functional consequences of work-related upper quadrant musculoskeletal disorders in midwives, nurses and physicians. METHODS: Eighteen of 87 studies identified from an electronic database search met the inclusion and quality criteria. RESULTS: Job demands, demanding work schedules and physical exposures have the strongest associations with work-related upper quadrant musculoskeletal disorders. Functional consequences included widespread use of prescription and over-the-counter medications and major negative impact on activities of daily living. No studies of midwives were located. CONCLUSION: High-quality studies of midwives as well as better-designed prospective studies of nurses and physicians are needed. Results of such studies could inform preventive strategies and reduce the contribution of work-related musculoskeletal disorders to attrition.

A workforce profile comparison of practising and non-practising midwives in Australia: baseline data from the Midwives and Nurses e-Cohort Study.

Existing workforce data, as an estimate of the current capability of the midwifery workforce to provide midwifery care, is confounded by systematic reporting issues that may overestimate the potential of the existing midwifery workforce. This paper reports the characteristics of qualified Australian midwives who responded to the baseline data collection in the Midwives and Nurses e-Cohort Study and compares those who are currently practising in midwifery with those who are not. Currently practising midwives represented only 52% of those respondents who identified as midwives and the profile of the typical midwife is female, aged over 40 years, Australian, married or in a de facto relationship. She has been registered for over 10 years, educated to postgraduate diploma level and currently works in a clinical midwifery role in a hospital for less than 35 hours per week. Specific deficits in the Australian midwifery workforce namely low numbers of indigenous midwives, independent practitioners and midwives suitably qualified to teach and undertake research in academia are identified. Drawing on the nationally representative e-cohort data, this cross-sectional analysis identifies for the first time the real face of the Australian midwifery workforce and provides an evidence-based foundation for future workforce planning and a methodology for other countries interested in accurately monitoring their actual and potential midwifery workforce.