In their study of physician stress, Hannan et al (2018) note that in 1974, the American psychologist Herbert Freudenberger first coined the term ‘burnout’, defining it as ‘a state of mental and physical exhaustion related to caregiving’ and describing its three key symptoms as ‘emotional exhaustion, depersonalisation (or feeling distanced and detached from work), and a sense of low personal accomplishment leading to decreased effectiveness at work’.
In a recently published survey of almost 2 000 UK midwives, Hunter et al (2019) found that many ‘are experiencing high levels of stress, burnout, anxiety and depression, which should be of serious concern to the profession and its leaders. NHS-employed clinical midwives are at much greater risk of emotional distress than others surveyed…’, with 83% experiencing moderate to high personal burnout, and 67% experiencing moderate to high work-related burnout.
Many years ago, I worked in a busy NHS hospital virus diagnostic laboratory, where changing work practices contributed to high-stress levels. Back then, succumbing to stress was considered a sign of weakness, with increased ‘phoning in sick’ and absenteeism typical responses. So, it was interesting to read an editorial by Garelick (2012) who draws attention to ‘presenteeism’ among those who seldom take sick leave but opt to continue to work, out of a sense of loyalty to their colleagues. But as the title of Garelick's editorial implies, both professional discomfort and a sense of stigma remain attached to those who experience stress and burnout.
What can be done? At a general level, NHS Employers (2018) acknowledge that a problem exists, recommending that an organisation's culture should not stigmatise those with mental health issues, but ‘actively encourages people to maintain good mental health and feel able to talk about it.
Line managers have training and support to assist staff who disclose a mental health issue’. NHS Employers (2018) also cite the example of resilience training undertaken by Northumbria Healthcare NHS Foundation Trust's psychology and counselling team, describing an acceptance and commitment therapy (ACT) intervention to improve wellbeing and resilience. Approximately 1 850 staff at all levels received the intervention, and a sample of nurses found that ‘the training elicited a significant, and clinically meaningful, improvement in nurses' mental health over a three-month assessment period’ (NHS Employers, 2018).
The outcome of a more targeted intervention, specifically aimed at midwives, was recently reported by O'Riordan et al (2019) from Ireland's Cork University Maternity Hospital. Eighteen doctors in training (DITs) and 22 midwives completed pre-intervention questionnaires to assess burnout, compassion fatigue and perceived stress, and completed questionnaires six months after support interventions consisting of posters promoting self-care, team bonding sessions, and end of shift meetings.
They found that nearly 45% of midwives and obstetrics and gynaecology DITs experienced high levels of emotional exhaustion, but there was a telling response to the interventions. For example, ‘recognise and reflect’ end-of-shift meetings, led by a specialist registrar and senior midwives, aimed to provide an opportunity to reflect on the completed shift, discuss positive aspects and identify emerging issues in a non-judgmental way. However, these were abandoned after five weeks due to a 50% attendance rate, with one midwife commenting, ‘I personally found at the end of a 12-hour shift, most people are impatient to return home/exhausted/drained’ (O'Riordan et al, 2019).
On the other hand, despite their impaired wellbeing, many participants ‘also felt a high sense of personal accomplishment and compassion satisfaction. Previous research has found that midwife-mother relationships where midwives feel appreciated were personally and professionally sustaining’ (O'Riordan et al, 2019). This is an important observation, especially when we consider the concept of ‘moral distress’, coined in 1984 in relation to the professional role of nurses who ‘were unable to act in a way that was consistent with their moral values and beliefs because of institutional obstacles’ (McCarthy and Monteverde, 2018). An ongoing problem for midwives, but how can it be best addressed? Addressing midwife burnout demands prompt but thoughtful consideration.