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Is caseload midwifery a healthy work-form? – A survey of burnout among midwives in Denmark
Sexual & Reproductive Healthcare 11 (2017) 102–106
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Sexual & Reproductive Healthcare journal homepage: www.srhcjournal.org
Is caseload midwifery a healthy work-form? – A survey of burnout among midwives in Denmark Ingrid Jepsen a,b,c,⇑, Svend Juul d, Maralyn Foureur e, Erik Elgaard Sørensen b,c, Ellen Aagaard Nøhr f a
University College of Northern Denmark, Selma Lagerløfs Vej 2, 9220 Aalborg Øst, Denmark Clinical Nursing Research, Aalborg University Hospital, Sdr. Skovvej 15, 9000 Aalborg, Denmark c Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark d Section for Epidemiology, Department of Public Health, Bartholins Alle 2, Aarhus University, 8000 Aarhus C, Denmark e Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Australia f Research Unit for Gynaecology and Obstetrics, Institute of Clinical Research, University of Southern Denmark, Sdr Boulevard 29, 5000 Odense C, Denmark b
Introduction In recent decades, there has been a strong focus on the planning of care during pregnancy and labour investigating how different models of care are evaluated or experienced by the woman and her family [1–7]. During the last ten years, there has also been an increasing interest in how models of care impact the wellbeing and working conditions of midwives with qualitative as well as quantitative studies undertaken in this area [8–11]. The wellbeing of midwives was also the focus of this study. Health-care professionals may be at risk of work-related stress [12,13] leading to high attrition rates as is evidenced in a tendency towards midwives leaving the midwifery profession before retirement age [14–17]. In England, Curtis found that dissatisfaction due to role conflict, inadequate staffing, and unsupportive management were reasons for leaving midwifery [14], and Hunter claimed that high job demands stressed midwives and contributed to low morale, high sickness, and high attrition [17]. In Australia, Pugh found that a shortage of midwives was partly due to midwives retiring prematurely because of high attrition [15]. Paying attention to the well-being of midwives is important to prevent work-related stress. To obtain measurable information about working conditions and well-being, several studies have investigated the level of burnout among midwives [18–23]. A Swedish survey of 978 midwives with a response rate of 48.6% (475 midwives) found more than one third reporting some level of burnout [19]. A similar study from the UK, with a 54% response rate (128 midwives) among 238 surveyed midwives, showed that working hours were positively associated with burnout [18]. Interestingly, community midwives (working in teams or group practices) when compared to hospital midwives, had a higher score on stress recognition, but were more likely to feel in control, and had a higher degree of job satisfaction [18].
⇑ Corresponding author at: University College of Northern Denmark, Selma Lagerløfs Vej 2, 9220 Aalborg Øst, Denmark. E-mail addresses: [email protected] (I. Jepsen), [email protected] (S. Juul), [email protected] (M. Foureur), [email protected] (E.E. Sørensen), [email protected] (E.A. Nøhr). http://dx.doi.org/10.1016/j.srhc.2016.12.001 1877-5756/Ó 2016 Elsevier B.V. All rights reserved.
A large Danish population survey, the PUMA (Danish acronym for Project of Burnout, Motivation and Job Satisfaction) conducted in the human services sector, found that midwives had the highest levels of personal and work-related burnout and the second highest level of client-related burnout of all professions in the study [13]. As part of the PUMA study, The Copenhagen Burnout Inventory (CBI) was developed, validated, and evaluated to be able to measure burnout [24]. CBI is translated into eight languages and has been used worldwide [19,21,22]. In Denmark, midwives were authorised 300 years ago and midwifery led practice has been the standard model of care for all women during all pregnancies and labours since then [25]. Danish midwives are authorised to be in charge of managing uncomplicated childbirth. If complications arise, midwives will refer to obstetricians, but will continue to provide care for these women throughout labour [26]. Since the PUMA study in 1999–2005, different models of care such as team midwifery and caseload midwifery have been implemented. It is of interest to examine whether the level of burnout differs across the models of care and to compare the present level of burnout to the level of burnout ten years ago. Caseload midwifery is a model of care focusing on continuity, ensuring that childbearing women receive their antenatal, intrapartum, and postnatal care from one or only a few, known caseloading midwives with whom the women can develop a relationship [1]. This model of care has been increasingly popular in Denmark as 16 out of 26 (61%) public maternity units have implemented some kind of caseloading practice for a smaller part of their births. In the North and Central Denmark Regions, around 24% of childbearing women are offered caseload midwifery. The typical work-form for Danish midwives is to work 37 h per week in 8–12 h shifts, including one day in the antenatal clinic. The midwife will care for any women who may require care during the midwife’s working hours. In caseload midwifery, this rostered work pattern for a full-time midwife is replaced by being on call for her/his own caseload of women for up to seven days including a day in the local antenatal clinic, followed by six days of leisure time. The caseload for these midwives is 60 women per year. At
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present, caseload midwives in Denmark have chosen this workform themselves by applying for vacancies. Internationally, several studies have shown caseloading practice to have a positive influence on midwives as they are able to work autonomously, and experience high job-satisfaction [8,11,22]. At the same time, midwives working in caseloads experience their job as challenging because of the great impact on their personal lives [22,23,27,28]. This study is situated in Denmark in a tertiary level maternity hospital, defined as a maternity unit with specialist obstetric, anaesthetic and paediatric services onsite. The population in this maternity unit’s catchment area is predominately Caucasian and encompasses a wide range of socio-economic classes. The aim of this study was to investigate burnout among midwives – including a comparison of the level of burnout in caseloading midwives and midwives working in other models of care who do not provide continuity of care. Methods Design A cross-sectional survey using the Copenhagen Burnout Inventory (CBI) was carried out to measure the level of burnout among Danish midwives. Definition of burnout Burnout is a complex concept. Fatigue and exhaustion are coreconcepts of the PUMA burnout definition, but the additional key feature is ‘‘the attribution of fatigue and exhaustion to specific domains or spheres in the person’s life” [24] p. 196–197. These domains or spheres are personal burnout, work-related burnout, and client-related burnout. This definition of burnout is supported by some authors [29] whereas others define ‘‘burnout” as a severe psychosocial diagnosis [30]. In the PUMA study, the questionnaire was posted by mail to people who were working; this means that burnout was not regarded as a severe psychosocial diagnosis that would result in sick leave. In the PUMA study, the metaphor of ‘‘flat batteries” or ‘‘feeling exhausted according to the three different spheres in a person’s life” was used to describe burnout [24], thus covering a wide range of expressions of fatigue. Procedure Permission to use the Danish version of the Copenhagen Burnout Inventory Scheme (CBI) was obtained from the National Research Centre for the Working Environment. The applicability of the CBI questionnaire was discussed in a small project group including the first author and three volunteer midwives. Questions asking about ‘‘work-form” and ‘‘years since graduation” were added to the CBI to be able to assess the association between these variables and burnout. To ensure anonymity among the midwives, who knew each other well, the answers according to ‘‘years since graduation” were recorded in four groups. In this way, no individual midwife was recognisable. An information letter to the midwives was mailed to their home address but was also distributed via workplace ‘pigeon-holes’ to ensure a high response rate. The questionnaires were distributed using the midwives’ ‘pigeon-holes’ and the midwives returned the questionnaires in a post-box. To measure the response rate, the questionnaires were numbered but randomly distributed. A reminder was sent out a week after distribution.
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Participants and study setting This study focused on the level of burnout among midwives working in a tertiary unit with approximately 3200 births a year. In this unit, the midwives work in one of four models of midwifery practice: (1) Caseload midwifery, (2) Standard care, (3) Rotating between different departments of the maternity unit and (4) Only working at the labour ward. (1) Caseload midwifery is the only model focusing on continuity of care where an individual midwife (and/or her midwife partner) follows an individual woman throughout the duration of her care. In this unit full-time caseloading midwives most often work in pairs succeeding each other with one week on call, one day in the ante-natal clinic and six days of leisure time. Some work in a threesome which means working part-time (equivalent to 30 h a week), being on call for 3.5–4.5 days including a day in the antenatal clinic and followed by six days of leisure time. The midwives conduct consultations in small, local antenatal clinics and attend the women during childbirth, mainly in hospitals. Each full time midwife attends 60 all-risk pregnant women a year but here it should be noted that they have only one contact with the couple after birth because health care nurses provide postnatal care. Further elaboration of this model of care is available in a previous study [31]. (2) In standard maternity care, midwives are rostered to work 37 h a week per full time midwife. Besides working in the labour ward, the midwives undertake antenatal visits one day a week, but they do not follow individual women through the duration of care. Women can ask for a meeting with the delivery midwife after birth. (3) Midwives who rotate between the department for hospitalised pregnant women, the postnatal maternity ward for uncomplicated birth and the labour ward. They work in the labour ward for about 40–50% of their working hours. (4) Only working in labour ward means that the midwives are rostered to solely work in the labour ward attending any women giving birth. All midwives employed in these models of care received the questionnaire (n = 61). If they completed and returned the questionnaire this was regarded as implied consent to participate.
Ethical considerations Approval for the study was granted by the chief-midwife at the hospital. The Committee on health research ethics in the North Denmark Region saw ‘‘no obstructing ethical issues in this study” and the study was reported to the Danish Data Protection Agency (j.nr. 2014-41-2928) who rated the study to not include sensitive data.
The Copenhagen Burnout Inventory (CBI) In CBI, the three domains of burnout: personal, work-related, and client-related burnout are described by nineteen subquestions (Table 1). Personal burnout consists of 6 sub-questions, work-related burnout of 7 sub-questions, and client-related burnout of 6 sub-questions. Each sub-question is assessed on a Likert scale with five levels ranging from ‘‘Never” = 0 to ‘‘Always” = 100 points. [32]. The average score for each of the three domains was used in the analysis.
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The normal distribution of data was checked by using histograms, Shapiro-Wilk test for normality and normality-plots. Proportional difference was used to compare the dichotomized burnout score. Unpaired T-tests were used to compare mean scores of burnout across the four work-forms: ‘‘Caseload midwifery”, ‘‘Standard care”, ‘‘Working in different departments of the maternity unit” or ‘‘Only working at the labour ward”. A two-sided probability of P-value <0.05 was considered statistically significant, and 95% confidence intervals were provided when relevant. Stata 13 was used for all statistical analyses.
Table 1 The three domains of burnout and the nineteen sub-questions [32]. Personal burnout
Work-related burnout
How often do you feel tired? How often are you physically exhausted? How often are you emotionally exhausted? How often do you think: ‘‘I can’t take it any more”? How often do you feel worn out? How often do you feel weak and susceptible to illness?
Do you feel worn out at the end of the working day? Are you exhausted in the morning at the thought of another day at work? Do you feel that every working hour is tiring for you? Do you have enough energy for family and friends during leisure time? Is your work emotionally exhausting? Does your work frustrate you? Do you feel burnt out because of your work?
Client-related burnout Do you find it hard to work with clients? Does it drain your energy to work with clients? Do you find it frustrating to work with clients? Do you feel that you give more than you get back when you work with clients? Are you tired of working with clients? Do you sometimes wonder how long you will be able to continue working with clients?
Results
Analysis Two midwives had not answered one of the sub-questions. As specified in the English version of the inventory [32] we calculated the average domain score from the remaining responses. The midwives were categorized according to the four different work-forms and grouped in years since graduation (Table 2). The level of burnout among the midwives in the present study was compared to the level of burnout among midwives in PUMA and to the general score from all participants in PUMA (Table 3). As caseload midwifery was our main focus, we wanted to compare ‘‘high burnout score” between caseloading and not caseloading midwives. The burnout scores were divided into high or low scores by using a cut-point of 50 points. According to the CBI, a score higher or equal to 50 means that a respondent has burnout symptoms that one ‘‘should react to” or ‘‘immediately seek help for” A score below this cut-point means: ‘‘no signs of burnout” or ‘‘be aware of some signs of burnout” [33].
Out of 61 midwives, 50 (82.0%) completed the CBI questionnaire. Six of the midwives were working in caseload midwifery, twenty in standard care, twelve midwives worked in different departments, and twelve in the labour ward only (Table 2). The caseloading midwives’ level of education varied but none of the caseloading midwives had more than 15 years since graduation. Standard care midwives were almost evenly distributed among the grouped years of education although only two midwives had more than 16 years since graduation. Among midwives rotating between different departments, nine out of twelve had from 0 to 5 years since graduation. Of the twelve midwives working only at the labour ward, six midwives had16 or more years since graduation. Burnout in the present study compared to PUMA The level of burnout among all midwives was calculated and compared to the results from the PUMA survey in 2005 (Table 3). For all three domains, the mean score for midwives in the present study was lower than the mean for the 41 midwives participating in PUMA, but similar to the average mean for all participants in PUMA. Proportion of high burnout among midwives The proportions of high burnout scores (a score P50) among all participating midwives were 22% (95% CI: 12–36%) in personal burnout, 20% (95% CI: 11–34%) had high scores in work-related
Table 2 Midwives (n = 50) according to work-form and years since graduation. Work-form
Years since graduation
Caseload midwives (n = 6) Standard care midwives (n = 20) Different departments midwives (n = 12) Only labour ward midwives (n = 12)
Number of midwives (n)
0–5
6–10
5–15
16P
2 5 9 2
2 7 2 1
2 6 0 3
0 2 1 6
6 20 12 12
18
12
11
9
50
Table 3 Mean burnout score in each domain according to midwives in the present study, midwives participating in PUMA and all participants in PUMA.
* ** ***
Domains of burnout
All midwives in the present study (n = 50) Mean (SD)
Personal burnout Work-related burnout Client-related burnout
37.6 (16.2) 35.0 (15.7) 26.5 (16.4)
Ref. [24]. Ref. [13]. Standard deviations not reported.
95% CI
Midwives PUMA 2005* (n = 41) Mean***
All participants results from PUMA 2005** (n = 1914) Mean (SD)
95% CI
(32.6–41.8) (30.5–39.5) (21.8–31.2)
44.7 43.5 38.4
35.9 (16.5) 33.0 (17.7) 30.9 (17.6)
(35.2–36.6) (32.2–33.8) (30.1–31.7)
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I. Jepsen et al. / Sexual & Reproductive Healthcare 11 (2017) 102–106 Table 4 Caseload midwifery compared to other work-forms in the three domains of burnout.
Personal burnout Work-related burnout Client-related burnout
Caseload midwifery (n = 6) Mean (SD)
Not caseloading midwives (n = 44) Mean (SD)
All midwives (n = 50) Mean (SD)
P value
25.7 (12.0) 19.2 (9.8) 10.3 (6.0)
39.3 (16.1) 37.2 (15.1) 28.8 (16.2)
37.6 (16.2) 35.0 (15.6) 26.5 (16.4)
0.04 0.004 <0.001
burnout, and 10% (95% CI: 4–22%) had high scores in client-related burnout. Among caseloading midwives, we found that none had high scores of burnout in any of the measured domains. Among the remaining ‘‘not caseloading” midwives, 25% (95% CI: 14–40%) had high burnout scores in personal burnout, 23% (95% CI: 12– 38%) had high scores in work-related burnout, and 11% (95% CI 5–25%) had high scores in client-related burnout. Burnout and work-form When comparing average burnout scores across work-forms, caseloading midwives had lower burnout scores for all three domains compared to midwives in other models of care (Table 4). When comparing each of the four work-forms to the remaining work-forms combined, we only observed one statistically significant difference (p-value = 0.03) as midwives working in standard care had a higher level of personal related burnout (mean 43.5) compared to the rest of the midwives (mean 33.7).
Discussion We used the CBI questionnaire to investigate whether the organization of care may influence the level of burnout among midwives. For all three domains: personal, work-related and clientrelated burnout, we found that midwives working in caseloading practice had a significantly lower level of burnout than midwives working in other models of care. These results are in accordance with the findings of Newton et al. [22], who also used the CBI for measuring burnout among Australian midwives. Newton and colleagues found that two years after establishing caseload midwifery, the midwives had a significantly lower burnout score compared to standard care midwives. Comparison of the burnout scores from our Danish study to the Australian study suggest that Danish caseloading midwives felt less burnout than the Australian caseloading midwives on each domain: personal burnout (25.7 (DK) vs 35.7 (AUS)), workrelated burnout (19.2 (DK) vs 27.3 (AUS)), and client-related burnout (10.3 (DK) vs 11.3 (AUS)). On the other hand, ‘‘not caseloading midwives” in Denmark resembled the Australian scores for standard care midwives. The observed lower level of burnout among caseloading midwives confirmed the findings from a qualitative study in the same geographical area where caseloading midwives experienced less burnout when they compared their present work in caseloads to their former job in standard care [31]. In fact, standard care midwives in the present study had a significantly higher level of personal burnout than all other midwives combined. To get an overall assessment of burnout in this maternity unit, we initiated our analysis by investigating the level of burnout among all midwives (caseloading and not-caseloading combined). Compared to the midwives participating in PUMA in 2005, all midwives (caseloading and not-caseloading combined) in our study had lower scores of burnout for all three domains; a score that resembled the scores for all health professionals in PUMA. The midwives participating in PUMA were all working in maternity units in Frederiksborg’s county in Denmark. The organizations par-
ticipating in PUMA were self-selected [33] and we do not know why the maternity unit in Frederiksborg chose to participate. Because of these unknown circumstances and the different time points for the surveys, we cannot put too much emphasis on this comparison. The scores on burnout range from 0 to 100 and a high burnout score was in CBI defined as a score equal to or more than fifty. The proportion of all midwives with a high burnout score (caseloading and not-caseloading combined) in the present study was compared to a Swedish [19] and an Australian study [21] that also used the CBIs definitions of high burnout score and included all registered midwives in the respective study settings. The comparison indicated than fewer Danish midwives had high scores in personal burnout (22% (DK) 40% (SWE) 57% (AUS)). Work-related burnout was slightly lower in Sweden but very much higher in Australia (20% (DK) 16% (SWE) 57% (AUS)), whereas the proportion of high scores in client-related burnout was low in all three countries compared to personal and work-related burnout (10% (DK) 15% (SWE) 9% (AUS)). These findings suggest that the level of high burnout among all midwives in this study was moderate but the widths of our confidence intervals reveal a lack of information. Still, it is problematic that every fifth midwife in our maternity unit reported high levels of personal or work-related burnout since these midwives might leave the midwifery profession as reported in other studies [14,15,17]. The Swedish and the Australian study also provided mean scores. These were higher than the scores for caseloading midwives in the present study, but tended to resemble the mean scores for all midwives combined: Personal burnout (37.6 (DK). 43.0 (SWE) 52.1 (AUS)), work-related burnout (35.0 (DK) 33.85 (SWE) 50.9 (AUS)), and client-related burnout (26.5 (DK) vs. 30.42 (SWE) 23.9 (AUS)). Still, the Danish results are equal to or better than the results from Sweden and Australia suggesting that the level of burnout among all midwives in this maternity unit is not high when compared to other countries. Study limitations To the authors’ knowledge, no studies on caseloading midwifery or burnout have studied midwives randomly selected to work in different models of care and therefore the causal relation is difficult to assess. Midwives who choose caseloading midwifery may be different to other midwives, and in the present study, the significantly lower score on personal burnout among the self-selected caseloading midwives compared to other midwives might illustrate this. Newton and colleagues found that midwives choosing to work in caseload midwifery were very supportive and passionate about this model of care [22]. They note that the midwives might have had a vested interest in seeing this work-form succeed which might have introduced an information bias because of their positively skewed responses. This might also be the case in the present study. It is notable that midwives working in standard care in the present study had a significantly higher level of personal burnout than midwives working in ‘‘caseloading”, ‘‘only labour ward”, or ‘‘different departments”, combined, but the absolute difference was
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small. Based on information from a previous qualitative study in the same region [31] the caseloading midwives were on average 39 years old and had been working in caseloads for 4 years, which in itself might lead to a lower level of burnout. Therefore the clinical relevance is doubtful. The high response rate indicates that for this maternity unit, the results are valid. However the number of participants in the study was small and only one maternity unit was examined which may limit the generalisability. When comparing the level of burnout among midwives in the same setting, we believe that the observed difference reflects comparable experiences of burnout as the midwives share workingculture, language, and education, and live in the same society. When comparing the scores of burnout across countries, you may question whether the CBI reflects the level of burnout with the same high reliability. We note that the same questions are used world-wide but we do not know how midwives apprehend the questions and how different societies and different values might influence the working- as well as the private-life of health carers. Conclusion Caseload midwifery in a Danish setting was associated with lower burnout scores compared to the scores of midwives working in other models of care. The findings are in accordance with results from other countries and support the conclusion that caseloading midwifery is a healthy work-form for midwives who choose to and actually work in caseloads. When all midwives were analysed together and the proportion of high scores of burnout was compared to findings from Sweden and Australia, the midwives in our setting reported lower levels of burnout suggesting that the level of burnout in Denmark is not high. Still, every fifth midwife reported high burnout level in person and work-related burnout and this needs considerations. Implications for practice This study should be repeated among all midwives in Denmark taking into account the type of maternity unit and the years since graduation age of the midwives. Health care planners within midwifery should focus on how burnout among midwives could be reduced and examine whether the expanding of continuity of care models influences the well-being of midwives. Acknowledgement The authors wish to acknowledge the chief-midwife at this hospital for facilitating this study. We gratefully thank the midwives who participated in the project group and the midwives who returned the questionnaire. References [1] Homer C, Leap N, Brodie P. Midwifery continuity of care: a practical guide. Chatswood, N.S.W. Churchill Livingstone Elsevier (NSW, Sydney): Elsevier Health Sciences; 2008. [2] Beake S, Acosta L, Cooke P, McCourt C. Caseload midwifery in a multi-ethnic community: the women’s experiences. Midwifery 2013;29:996–1002. [3] Jenkins MG, Ford JB, Morris JM, Roberts CL. Women’s expectations and experiences of maternity care in NSW–what women highlight as most important. Women Birth 2014;27:214–9.
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Is caseload midwifery a healthy work-form? – A survey of burnout among midwives in Denmark Ingrid Jepsen a,b,c,⇑, Svend Juul d, Maralyn Foureur e, Erik Elgaard Sørensen b,c, Ellen Aagaard Nøhr f a
University College of Northern Denmark, Selma Lagerløfs Vej 2, 9220 Aalborg Øst, Denmark Clinical Nursing Research, Aalborg University Hospital, Sdr. Skovvej 15, 9000 Aalborg, Denmark c Department of Clinical Medicine, Aalborg University, Sdr. Skovvej 15, 9000 Aalborg, Denmark d Section for Epidemiology, Department of Public Health, Bartholins Alle 2, Aarhus University, 8000 Aarhus C, Denmark e Centre for Midwifery, Child and Family Health, Faculty of Health, University of Technology Sydney, Australia f Research Unit for Gynaecology and Obstetrics, Institute of Clinical Research, University of Southern Denmark, Sdr Boulevard 29, 5000 Odense C, Denmark b
Introduction In recent decades, there has been a strong focus on the planning of care during pregnancy and labour investigating how different models of care are evaluated or experienced by the woman and her family [1–7]. During the last ten years, there has also been an increasing interest in how models of care impact the wellbeing and working conditions of midwives with qualitative as well as quantitative studies undertaken in this area [8–11]. The wellbeing of midwives was also the focus of this study. Health-care professionals may be at risk of work-related stress [12,13] leading to high attrition rates as is evidenced in a tendency towards midwives leaving the midwifery profession before retirement age [14–17]. In England, Curtis found that dissatisfaction due to role conflict, inadequate staffing, and unsupportive management were reasons for leaving midwifery [14], and Hunter claimed that high job demands stressed midwives and contributed to low morale, high sickness, and high attrition [17]. In Australia, Pugh found that a shortage of midwives was partly due to midwives retiring prematurely because of high attrition [15]. Paying attention to the well-being of midwives is important to prevent work-related stress. To obtain measurable information about working conditions and well-being, several studies have investigated the level of burnout among midwives [18–23]. A Swedish survey of 978 midwives with a response rate of 48.6% (475 midwives) found more than one third reporting some level of burnout [19]. A similar study from the UK, with a 54% response rate (128 midwives) among 238 surveyed midwives, showed that working hours were positively associated with burnout [18]. Interestingly, community midwives (working in teams or group practices) when compared to hospital midwives, had a higher score on stress recognition, but were more likely to feel in control, and had a higher degree of job satisfaction [18].
⇑ Corresponding author at: University College of Northern Denmark, Selma Lagerløfs Vej 2, 9220 Aalborg Øst, Denmark. E-mail addresses: [email protected] (I. Jepsen), [email protected] (S. Juul), [email protected] (M. Foureur), [email protected] (E.E. Sørensen), [email protected] (E.A. Nøhr). http://dx.doi.org/10.1016/j.srhc.2016.12.001 1877-5756/Ó 2016 Elsevier B.V. All rights reserved.
A large Danish population survey, the PUMA (Danish acronym for Project of Burnout, Motivation and Job Satisfaction) conducted in the human services sector, found that midwives had the highest levels of personal and work-related burnout and the second highest level of client-related burnout of all professions in the study [13]. As part of the PUMA study, The Copenhagen Burnout Inventory (CBI) was developed, validated, and evaluated to be able to measure burnout [24]. CBI is translated into eight languages and has been used worldwide [19,21,22]. In Denmark, midwives were authorised 300 years ago and midwifery led practice has been the standard model of care for all women during all pregnancies and labours since then [25]. Danish midwives are authorised to be in charge of managing uncomplicated childbirth. If complications arise, midwives will refer to obstetricians, but will continue to provide care for these women throughout labour [26]. Since the PUMA study in 1999–2005, different models of care such as team midwifery and caseload midwifery have been implemented. It is of interest to examine whether the level of burnout differs across the models of care and to compare the present level of burnout to the level of burnout ten years ago. Caseload midwifery is a model of care focusing on continuity, ensuring that childbearing women receive their antenatal, intrapartum, and postnatal care from one or only a few, known caseloading midwives with whom the women can develop a relationship [1]. This model of care has been increasingly popular in Denmark as 16 out of 26 (61%) public maternity units have implemented some kind of caseloading practice for a smaller part of their births. In the North and Central Denmark Regions, around 24% of childbearing women are offered caseload midwifery. The typical work-form for Danish midwives is to work 37 h per week in 8–12 h shifts, including one day in the antenatal clinic. The midwife will care for any women who may require care during the midwife’s working hours. In caseload midwifery, this rostered work pattern for a full-time midwife is replaced by being on call for her/his own caseload of women for up to seven days including a day in the local antenatal clinic, followed by six days of leisure time. The caseload for these midwives is 60 women per year. At
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present, caseload midwives in Denmark have chosen this workform themselves by applying for vacancies. Internationally, several studies have shown caseloading practice to have a positive influence on midwives as they are able to work autonomously, and experience high job-satisfaction [8,11,22]. At the same time, midwives working in caseloads experience their job as challenging because of the great impact on their personal lives [22,23,27,28]. This study is situated in Denmark in a tertiary level maternity hospital, defined as a maternity unit with specialist obstetric, anaesthetic and paediatric services onsite. The population in this maternity unit’s catchment area is predominately Caucasian and encompasses a wide range of socio-economic classes. The aim of this study was to investigate burnout among midwives – including a comparison of the level of burnout in caseloading midwives and midwives working in other models of care who do not provide continuity of care. Methods Design A cross-sectional survey using the Copenhagen Burnout Inventory (CBI) was carried out to measure the level of burnout among Danish midwives. Definition of burnout Burnout is a complex concept. Fatigue and exhaustion are coreconcepts of the PUMA burnout definition, but the additional key feature is ‘‘the attribution of fatigue and exhaustion to specific domains or spheres in the person’s life” [24] p. 196–197. These domains or spheres are personal burnout, work-related burnout, and client-related burnout. This definition of burnout is supported by some authors [29] whereas others define ‘‘burnout” as a severe psychosocial diagnosis [30]. In the PUMA study, the questionnaire was posted by mail to people who were working; this means that burnout was not regarded as a severe psychosocial diagnosis that would result in sick leave. In the PUMA study, the metaphor of ‘‘flat batteries” or ‘‘feeling exhausted according to the three different spheres in a person’s life” was used to describe burnout [24], thus covering a wide range of expressions of fatigue. Procedure Permission to use the Danish version of the Copenhagen Burnout Inventory Scheme (CBI) was obtained from the National Research Centre for the Working Environment. The applicability of the CBI questionnaire was discussed in a small project group including the first author and three volunteer midwives. Questions asking about ‘‘work-form” and ‘‘years since graduation” were added to the CBI to be able to assess the association between these variables and burnout. To ensure anonymity among the midwives, who knew each other well, the answers according to ‘‘years since graduation” were recorded in four groups. In this way, no individual midwife was recognisable. An information letter to the midwives was mailed to their home address but was also distributed via workplace ‘pigeon-holes’ to ensure a high response rate. The questionnaires were distributed using the midwives’ ‘pigeon-holes’ and the midwives returned the questionnaires in a post-box. To measure the response rate, the questionnaires were numbered but randomly distributed. A reminder was sent out a week after distribution.
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Participants and study setting This study focused on the level of burnout among midwives working in a tertiary unit with approximately 3200 births a year. In this unit, the midwives work in one of four models of midwifery practice: (1) Caseload midwifery, (2) Standard care, (3) Rotating between different departments of the maternity unit and (4) Only working at the labour ward. (1) Caseload midwifery is the only model focusing on continuity of care where an individual midwife (and/or her midwife partner) follows an individual woman throughout the duration of her care. In this unit full-time caseloading midwives most often work in pairs succeeding each other with one week on call, one day in the ante-natal clinic and six days of leisure time. Some work in a threesome which means working part-time (equivalent to 30 h a week), being on call for 3.5–4.5 days including a day in the antenatal clinic and followed by six days of leisure time. The midwives conduct consultations in small, local antenatal clinics and attend the women during childbirth, mainly in hospitals. Each full time midwife attends 60 all-risk pregnant women a year but here it should be noted that they have only one contact with the couple after birth because health care nurses provide postnatal care. Further elaboration of this model of care is available in a previous study [31]. (2) In standard maternity care, midwives are rostered to work 37 h a week per full time midwife. Besides working in the labour ward, the midwives undertake antenatal visits one day a week, but they do not follow individual women through the duration of care. Women can ask for a meeting with the delivery midwife after birth. (3) Midwives who rotate between the department for hospitalised pregnant women, the postnatal maternity ward for uncomplicated birth and the labour ward. They work in the labour ward for about 40–50% of their working hours. (4) Only working in labour ward means that the midwives are rostered to solely work in the labour ward attending any women giving birth. All midwives employed in these models of care received the questionnaire (n = 61). If they completed and returned the questionnaire this was regarded as implied consent to participate.
Ethical considerations Approval for the study was granted by the chief-midwife at the hospital. The Committee on health research ethics in the North Denmark Region saw ‘‘no obstructing ethical issues in this study” and the study was reported to the Danish Data Protection Agency (j.nr. 2014-41-2928) who rated the study to not include sensitive data.
The Copenhagen Burnout Inventory (CBI) In CBI, the three domains of burnout: personal, work-related, and client-related burnout are described by nineteen subquestions (Table 1). Personal burnout consists of 6 sub-questions, work-related burnout of 7 sub-questions, and client-related burnout of 6 sub-questions. Each sub-question is assessed on a Likert scale with five levels ranging from ‘‘Never” = 0 to ‘‘Always” = 100 points. [32]. The average score for each of the three domains was used in the analysis.
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The normal distribution of data was checked by using histograms, Shapiro-Wilk test for normality and normality-plots. Proportional difference was used to compare the dichotomized burnout score. Unpaired T-tests were used to compare mean scores of burnout across the four work-forms: ‘‘Caseload midwifery”, ‘‘Standard care”, ‘‘Working in different departments of the maternity unit” or ‘‘Only working at the labour ward”. A two-sided probability of P-value <0.05 was considered statistically significant, and 95% confidence intervals were provided when relevant. Stata 13 was used for all statistical analyses.
Table 1 The three domains of burnout and the nineteen sub-questions [32]. Personal burnout
Work-related burnout
How often do you feel tired? How often are you physically exhausted? How often are you emotionally exhausted? How often do you think: ‘‘I can’t take it any more”? How often do you feel worn out? How often do you feel weak and susceptible to illness?
Do you feel worn out at the end of the working day? Are you exhausted in the morning at the thought of another day at work? Do you feel that every working hour is tiring for you? Do you have enough energy for family and friends during leisure time? Is your work emotionally exhausting? Does your work frustrate you? Do you feel burnt out because of your work?
Client-related burnout Do you find it hard to work with clients? Does it drain your energy to work with clients? Do you find it frustrating to work with clients? Do you feel that you give more than you get back when you work with clients? Are you tired of working with clients? Do you sometimes wonder how long you will be able to continue working with clients?
Results
Analysis Two midwives had not answered one of the sub-questions. As specified in the English version of the inventory [32] we calculated the average domain score from the remaining responses. The midwives were categorized according to the four different work-forms and grouped in years since graduation (Table 2). The level of burnout among the midwives in the present study was compared to the level of burnout among midwives in PUMA and to the general score from all participants in PUMA (Table 3). As caseload midwifery was our main focus, we wanted to compare ‘‘high burnout score” between caseloading and not caseloading midwives. The burnout scores were divided into high or low scores by using a cut-point of 50 points. According to the CBI, a score higher or equal to 50 means that a respondent has burnout symptoms that one ‘‘should react to” or ‘‘immediately seek help for” A score below this cut-point means: ‘‘no signs of burnout” or ‘‘be aware of some signs of burnout” [33].
Out of 61 midwives, 50 (82.0%) completed the CBI questionnaire. Six of the midwives were working in caseload midwifery, twenty in standard care, twelve midwives worked in different departments, and twelve in the labour ward only (Table 2). The caseloading midwives’ level of education varied but none of the caseloading midwives had more than 15 years since graduation. Standard care midwives were almost evenly distributed among the grouped years of education although only two midwives had more than 16 years since graduation. Among midwives rotating between different departments, nine out of twelve had from 0 to 5 years since graduation. Of the twelve midwives working only at the labour ward, six midwives had16 or more years since graduation. Burnout in the present study compared to PUMA The level of burnout among all midwives was calculated and compared to the results from the PUMA survey in 2005 (Table 3). For all three domains, the mean score for midwives in the present study was lower than the mean for the 41 midwives participating in PUMA, but similar to the average mean for all participants in PUMA. Proportion of high burnout among midwives The proportions of high burnout scores (a score P50) among all participating midwives were 22% (95% CI: 12–36%) in personal burnout, 20% (95% CI: 11–34%) had high scores in work-related
Table 2 Midwives (n = 50) according to work-form and years since graduation. Work-form
Years since graduation
Caseload midwives (n = 6) Standard care midwives (n = 20) Different departments midwives (n = 12) Only labour ward midwives (n = 12)
Number of midwives (n)
0–5
6–10
5–15
16P
2 5 9 2
2 7 2 1
2 6 0 3
0 2 1 6
6 20 12 12
18
12
11
9
50
Table 3 Mean burnout score in each domain according to midwives in the present study, midwives participating in PUMA and all participants in PUMA.
* ** ***
Domains of burnout
All midwives in the present study (n = 50) Mean (SD)
Personal burnout Work-related burnout Client-related burnout
37.6 (16.2) 35.0 (15.7) 26.5 (16.4)
Ref. [24]. Ref. [13]. Standard deviations not reported.
95% CI
Midwives PUMA 2005* (n = 41) Mean***
All participants results from PUMA 2005** (n = 1914) Mean (SD)
95% CI
(32.6–41.8) (30.5–39.5) (21.8–31.2)
44.7 43.5 38.4
35.9 (16.5) 33.0 (17.7) 30.9 (17.6)
(35.2–36.6) (32.2–33.8) (30.1–31.7)
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I. Jepsen et al. / Sexual & Reproductive Healthcare 11 (2017) 102–106 Table 4 Caseload midwifery compared to other work-forms in the three domains of burnout.
Personal burnout Work-related burnout Client-related burnout
Caseload midwifery (n = 6) Mean (SD)
Not caseloading midwives (n = 44) Mean (SD)
All midwives (n = 50) Mean (SD)
P value
25.7 (12.0) 19.2 (9.8) 10.3 (6.0)
39.3 (16.1) 37.2 (15.1) 28.8 (16.2)
37.6 (16.2) 35.0 (15.6) 26.5 (16.4)
0.04 0.004 <0.001
burnout, and 10% (95% CI: 4–22%) had high scores in client-related burnout. Among caseloading midwives, we found that none had high scores of burnout in any of the measured domains. Among the remaining ‘‘not caseloading” midwives, 25% (95% CI: 14–40%) had high burnout scores in personal burnout, 23% (95% CI: 12– 38%) had high scores in work-related burnout, and 11% (95% CI 5–25%) had high scores in client-related burnout. Burnout and work-form When comparing average burnout scores across work-forms, caseloading midwives had lower burnout scores for all three domains compared to midwives in other models of care (Table 4). When comparing each of the four work-forms to the remaining work-forms combined, we only observed one statistically significant difference (p-value = 0.03) as midwives working in standard care had a higher level of personal related burnout (mean 43.5) compared to the rest of the midwives (mean 33.7).
Discussion We used the CBI questionnaire to investigate whether the organization of care may influence the level of burnout among midwives. For all three domains: personal, work-related and clientrelated burnout, we found that midwives working in caseloading practice had a significantly lower level of burnout than midwives working in other models of care. These results are in accordance with the findings of Newton et al. [22], who also used the CBI for measuring burnout among Australian midwives. Newton and colleagues found that two years after establishing caseload midwifery, the midwives had a significantly lower burnout score compared to standard care midwives. Comparison of the burnout scores from our Danish study to the Australian study suggest that Danish caseloading midwives felt less burnout than the Australian caseloading midwives on each domain: personal burnout (25.7 (DK) vs 35.7 (AUS)), workrelated burnout (19.2 (DK) vs 27.3 (AUS)), and client-related burnout (10.3 (DK) vs 11.3 (AUS)). On the other hand, ‘‘not caseloading midwives” in Denmark resembled the Australian scores for standard care midwives. The observed lower level of burnout among caseloading midwives confirmed the findings from a qualitative study in the same geographical area where caseloading midwives experienced less burnout when they compared their present work in caseloads to their former job in standard care [31]. In fact, standard care midwives in the present study had a significantly higher level of personal burnout than all other midwives combined. To get an overall assessment of burnout in this maternity unit, we initiated our analysis by investigating the level of burnout among all midwives (caseloading and not-caseloading combined). Compared to the midwives participating in PUMA in 2005, all midwives (caseloading and not-caseloading combined) in our study had lower scores of burnout for all three domains; a score that resembled the scores for all health professionals in PUMA. The midwives participating in PUMA were all working in maternity units in Frederiksborg’s county in Denmark. The organizations par-
ticipating in PUMA were self-selected [33] and we do not know why the maternity unit in Frederiksborg chose to participate. Because of these unknown circumstances and the different time points for the surveys, we cannot put too much emphasis on this comparison. The scores on burnout range from 0 to 100 and a high burnout score was in CBI defined as a score equal to or more than fifty. The proportion of all midwives with a high burnout score (caseloading and not-caseloading combined) in the present study was compared to a Swedish [19] and an Australian study [21] that also used the CBIs definitions of high burnout score and included all registered midwives in the respective study settings. The comparison indicated than fewer Danish midwives had high scores in personal burnout (22% (DK) 40% (SWE) 57% (AUS)). Work-related burnout was slightly lower in Sweden but very much higher in Australia (20% (DK) 16% (SWE) 57% (AUS)), whereas the proportion of high scores in client-related burnout was low in all three countries compared to personal and work-related burnout (10% (DK) 15% (SWE) 9% (AUS)). These findings suggest that the level of high burnout among all midwives in this study was moderate but the widths of our confidence intervals reveal a lack of information. Still, it is problematic that every fifth midwife in our maternity unit reported high levels of personal or work-related burnout since these midwives might leave the midwifery profession as reported in other studies [14,15,17]. The Swedish and the Australian study also provided mean scores. These were higher than the scores for caseloading midwives in the present study, but tended to resemble the mean scores for all midwives combined: Personal burnout (37.6 (DK). 43.0 (SWE) 52.1 (AUS)), work-related burnout (35.0 (DK) 33.85 (SWE) 50.9 (AUS)), and client-related burnout (26.5 (DK) vs. 30.42 (SWE) 23.9 (AUS)). Still, the Danish results are equal to or better than the results from Sweden and Australia suggesting that the level of burnout among all midwives in this maternity unit is not high when compared to other countries. Study limitations To the authors’ knowledge, no studies on caseloading midwifery or burnout have studied midwives randomly selected to work in different models of care and therefore the causal relation is difficult to assess. Midwives who choose caseloading midwifery may be different to other midwives, and in the present study, the significantly lower score on personal burnout among the self-selected caseloading midwives compared to other midwives might illustrate this. Newton and colleagues found that midwives choosing to work in caseload midwifery were very supportive and passionate about this model of care [22]. They note that the midwives might have had a vested interest in seeing this work-form succeed which might have introduced an information bias because of their positively skewed responses. This might also be the case in the present study. It is notable that midwives working in standard care in the present study had a significantly higher level of personal burnout than midwives working in ‘‘caseloading”, ‘‘only labour ward”, or ‘‘different departments”, combined, but the absolute difference was
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small. Based on information from a previous qualitative study in the same region [31] the caseloading midwives were on average 39 years old and had been working in caseloads for 4 years, which in itself might lead to a lower level of burnout. Therefore the clinical relevance is doubtful. The high response rate indicates that for this maternity unit, the results are valid. However the number of participants in the study was small and only one maternity unit was examined which may limit the generalisability. When comparing the level of burnout among midwives in the same setting, we believe that the observed difference reflects comparable experiences of burnout as the midwives share workingculture, language, and education, and live in the same society. When comparing the scores of burnout across countries, you may question whether the CBI reflects the level of burnout with the same high reliability. We note that the same questions are used world-wide but we do not know how midwives apprehend the questions and how different societies and different values might influence the working- as well as the private-life of health carers. Conclusion Caseload midwifery in a Danish setting was associated with lower burnout scores compared to the scores of midwives working in other models of care. The findings are in accordance with results from other countries and support the conclusion that caseloading midwifery is a healthy work-form for midwives who choose to and actually work in caseloads. When all midwives were analysed together and the proportion of high scores of burnout was compared to findings from Sweden and Australia, the midwives in our setting reported lower levels of burnout suggesting that the level of burnout in Denmark is not high. Still, every fifth midwife reported high burnout level in person and work-related burnout and this needs considerations. Implications for practice This study should be repeated among all midwives in Denmark taking into account the type of maternity unit and the years since graduation age of the midwives. Health care planners within midwifery should focus on how burnout among midwives could be reduced and examine whether the expanding of continuity of care models influences the well-being of midwives. Acknowledgement The authors wish to acknowledge the chief-midwife at this hospital for facilitating this study. We gratefully thank the midwives who participated in the project group and the midwives who returned the questionnaire. References [1] Homer C, Leap N, Brodie P. Midwifery continuity of care: a practical guide. Chatswood, N.S.W. Churchill Livingstone Elsevier (NSW, Sydney): Elsevier Health Sciences; 2008. [2] Beake S, Acosta L, Cooke P, McCourt C. Caseload midwifery in a multi-ethnic community: the women’s experiences. Midwifery 2013;29:996–1002. [3] Jenkins MG, Ford JB, Morris JM, Roberts CL. Women’s expectations and experiences of maternity care in NSW–what women highlight as most important. Women Birth 2014;27:214–9.
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