Midwives can experience both organisational and occupational sources of work-related psychological distress, which can continue to affect them throughout their professional journey (Leinweber and Rowe, 2010; Rice and Warland, 2013; Leinweber et al, 2016; Sheen et al, 2016). In England, the recent National Maternity Review (2016) has highlighted that midwives are more likely to report feeling pressured at work than other NHS staff. This is significant because poor staff health and the disaffection and disengagement from work is intrinsically linked with poorer patient outcomes, increased infection rates, higher mortality rates and an increase in medical errors (Laschinger and Leiter, 2006; Boorman, 2009; West and Dawson, 2012; Francis, 2013; Royal College of Physicians, 2015).
As the midwifery profession strives to support excellence in maternity care, it will be important to meet the work-related psychological distress of midwives with the provision of effective support. This paper summarises a doctoral research project, which outlines the case for the development of an online intervention designed to support midwives in work-related psychological distress.
Background
In response to the emotional labour of caring in midwifery practice, there has been a long-standing maladaptive coping strategy of distancing oneself emotionally from both women and colleagues (Hunter, 2016). Some midwives can become self-judgemental about the high standards they aspire to, are left to their own devices when dealing with the emotional labour of caring for women, or are left to cope with their distress by ‘swallowing’ their emotions in cultures of service and sacrifice (Davies and Coldridge, 2015; Beaumont et al, 2016; Schrøder et al, 2016). Should midwives continue to use persistence and avoidance as coping strategies for dealing with distress, they may not be able to recognise ill health in either themselves or their colleagues.
Some midwives have been known to experience a lack of peer support, shame, fear in disclosure, and punitive and apathetic responses to psychological distress in the workplace (Hood et al, 2010; Mollart et al, 2013; Young et al, 2015; Crowther et al, 2016). Some maternity workplace cultures may also have seen the development of hierarchical, uncivil and toxic working environments, where it can be challenging to find or invest in trusting relationships (Begley, 2002; Hutchinson, 2014; Davies and Coldridge, 2015). This may not enable midwives to engage with positive help-seeking behaviours in the workplace.
Those in work-related psychological distress can experience some of the behavioural symptoms of mental ill health, such as excess drinking, substance abuse disorders and a display of uncaring behaviour (Begley, 2002; Happell et al, 2013; Horgan et al, 2016). In fear of shame and a punitive response, these midwives may further shy away from open disclosure and help-seeking behaviours. Face-to-face support such as the Schwartz rounds and restorative supervision already support some midwives in work-related psychological distress (Wallbank, 2010; Barker et al, 2016). Yet for midwives seeking more private, confidential and anonymous support, the development of a targeted online intervention may be required.
In 2014, a situational analysis has highlighted a lack of targeted support interventions available for midwives in work-related psychological distress (Strobl et al, 2014). Other populations have reported a preference for internet-based mental health support interventions, citing that these are better able to assure anonymity, are easier and more flexible to access and less embarrassing and shameful to use (Wallin et al, 2016). They also report that they feel more able to express feelings, self-disclose and be honest within an online intervention. As such, the provision of online support may also be the preferred option of support for midwives in distress.
Some nurses already use online social net work ing sites to ameliorate work-related psychololgical distress (Happell et al, 2013). Many more health professionals are creating impromptu self-help groups online. Although this may indicate that the health professions are keen to engage with online support, archetypal social networking sites may not be appropriate for vulnerable users to engage in sensitive dialogue. Therefore, along with being a cost-effective option for health care employers, a more tailored and evidence-based online intervention produced in collaboration with its end users may complement existing face-to-face support.
The psychological distress that some midwives endure can impair their cognitive function, decision-making skills and ability to provide compassionate, safe and high-quality care (Knezevic et al, 2011; Beaumont et al, 2016; Creedy and Gamble, 2016). The mental wellbeing of midwives can also be directly correlated with high staff turnovers, high staff sickness rates and low productivity rates (Kenworthy and Kirkham, 2011; Brunetto et al, 2013; Jarosova et al, 2016). This becomes important as the world tries to recruit and retain a high-quality midwifery workforce in the face of global shortages (McInnes and McIntosh, 2012).
The lack of support currently available to midwives in work-related psychological distress is not conducive to excellence in maternity care. This research project is the first step towards the development of an online intervention designed to effectively support midwives in work-related psychological distress.
Methodology
Firstly, a literature review was conducted to identify the scale and scope of the problem. The review aimed to find the origins and nature of work-related psychological distress in midwifery populations across the world, by looking at any published and peer-reviewed literature generated from the year 2000 to 2016.
To explore whether or not it may be ethical to provide anonymity and confidentiality in an online intervention, a realist synthesis review was also conducted. This review explored what may work for whom, in what circumstances, and why. Online interventions that promote the principles of both anonymity and confidentiality also permit their corollary, amnesty. As such, it was important to explore whether or not it would be ethical to afford midwives the provision of amnesty for the purpose of seeking psychological support, where they may not otherwise have done so.
This review followed the Realist And MEta-narrative Evidence Syntheses: Evolving Standards publication standards (RAMESES) (Wong et al, 2013). Following an iterative literature search, the retrieved papers were examined for ideas relating to the ethical dimensions of online interventions to support midwives in work-related psychological distress. The review uses a narrative approach and aims to generate debate on whether an intervention designed to support midwives should offer the provision of anonymity and confidentiality online.
Once the ethical argument for the development of an online intervention had been realised, a systematic literature review was conducted. The purpose of this systematic review was to identify the nature and existence of interventions designed to support midwives in work-related psychological distress, and their effectiveness at improving the psychological wellbeing of midwives. This was done in order to discover whether or not an online intervention designed to support midwives in work-related psychological distress had already been made available or tested, and to identify any effective components of support, which may be included in any final design.
Finally, a Delphi study was conducted in partnership with a panel of experts to determine what should be prioritised in the development and design of an online intervention to support midwives in work-related psychological distress. A total of 185 experts were invited to participate in a two-round Delphi study questionnaire, where they were asked to rate 39 questions on a 7-point rating scale. This scale was anchored at ‘not a priority’ and ‘essential priority’. Participants were also invited to contribute open text responses to further express themselves and their contributions. Findings were then analysed via statis tical and thematic analysis. The full methodological protocol for this research has been published elsewhere (Pezaro and Clyne, 2015).
Recruitment
Midwives and other subject experts were recruited to participate in this project via a research blog (https://healthystaff4healthypatients.wordpress.com). This blog was shared via the author's Twitter account (@SallyPezaro) and various other social media channels.
Participants were also identified via academic literature, where the authors of relevant papers were invited to participate and extend this invite to relevant professional networks. Key stakeholders within the health care community were also invited to participate in this way.
Findings
The first narrative review identified 30 papers outlining the sources, nature and prevalence of work-related psychological distress in global midwifery populations. Findings highlighted that midwives from Nigeria, the USA, Ireland, the UK, Australia, France, Poland, Croatia, Israel, Italy, Japan, Uganda, Turkey and New Zealand can experience both organisational and occupational sources of distress.
Causes of psychological distress can include hostile behaviour towards staff, either from other staff or patients, workplace bullying, toxic organisational cultures, medical errors, traumatic ‘never events’, critical incidents, occupational stress, workplace suspension, whistleblowing, investigations via professional regulatory bodies and employers, and/or pre-existing mental health conditions. The consequences of psychological distress in midwifery populations can result in death by suicide, anxiety, depression, burnout, depersonalisation, compassion fatigue, shame, guilt, substance abuse disorders, and symptomatic displays of self-destructive and unethical behaviour.
The published research (Pezaro et al, 2015) called for the development of effective interventions to support midwives, the promotion of psychologically safe working cultures and the development of non-punitive responses towards adverse behavioural symptoms, medical errors and whistleblowing. This research has been published elsewhere (Pezaro et al, 2015).
The realist synthesis review identified nine papers, which addressed the topic of providing midwives in distress with confidential and anonymous online support. Following a thematic analysis, findings suggested that the principles of confidentiality, anonymity and amnesty should be upheld. A full outline of this ethical debate has been published elsewhere, and invites those within the health care community to engage in further dialogue (Pezaro et al, 2016). Early results from the ongoing systematic literature review within this project suggest that there may be no other evidence-based interventions of this type currently available.
Following a structured consultation with 66 midwives and other experts participating in the Delphi study, findings revealed that the future development of an online intervention designed to support midwives in work-related psychological distress should prioritise confidentiality and anonymity, along with 24-hour mobile access.
Although participants expressed enthusiasm for the development of this online intervention, they also stressed that there would be a need for effective moderation within an online discussion forum. Contributors also decided that additional legal, educational, and therapeutic components should be available within an online intervention designed to support midwives. As the users of such an online intervention may be distressed, the participants indicated that midwives should also be offered a simple user assessment to identify those deemed to be at risk of either causing harm to others or experiencing harm themselves, so that those in need of appropriate support may be directed to it. The full results of this Delphi study have been published elsewhere (Pezaro and Clyne, 2016).
‘ While face-to-face interventions may be effective for some midwifery populations, they may not fully support those midwives who feel shame, fear and guilt about their own ill health, mistakes or behaviours’
Discussion
This doctoral research has taken a logical approach in making the case for the development of an online intervention designed to support midwives in work-related psychological distress. It is clear that midwives from around the world experience work-related psychological distress and tend to suffer in silence. While face-to-face interventions may be effective for some midwifery populations, they may not fully support those midwives who feel shame, fear and guilt about their own ill health, mistakes or behaviours. The perseverance that some midwives employ as a coping mechanism for their distress may only be resolved once these midwives are enabled to disclose and recognise ill health in themselves.
Some midwives may experience a punitive response from their employer and their colleagues once an episode of psychological distress becomes apparent (Stone et al, 2011; Robertson and Thomson, 2015; Young et al, 2015). In this scenario, the midwife can be subject to the psychological distress of both disciplinary and regulatory proceedings. For some midwives who raise concerns, face-to-face discussions can have a punitive feel (Currie and Richens, 2009). These experiences can prevent some midwives from disclosing their need for help and must be met with appropriate support.
Whether an online intervention providing support with total anonymity for midwives in psychological distress can be endorsed remains open for discussion. The argument to permit the provision of anonymity for midwives is fortified by the findings of the Delphi study, referred to in this paper, which reported the need for anonymity to enable open and honest disclosure. However, although this project has put forward the argument for ensuring the greatest benefit for the greatest number of people, society may still prefer cultures in which immediate accountabilities are enforced.
Our Delphi study revealed how midwives and other experts would value the provision of total anonymity, with some proclaiming that they would only disclose the true magnitude of their distress if they were afforded this online. In line with the pathways to disclosure model, positive help-seeking behaviours may be encouraged in mid wives who feel stigmatised by their psychological distress, behaviours, mistakes or lifestyle choices online. Within this model, previously used for gambling and alcohol addictions, it is the safety of absolute anonymity and confidentiality online that remain key to sustainability in recovery, as users progress from a status of ‘lurking’ online to full disclosure in the real-world setting (Cooper, 2004). The use of this model could also satisfy some of the ethical concerns assoc iated with offering midwives anonymity online.
Should the provision of anonymous support remain unavailable to midwives in work-related psychological distress, unhealthy coping behaviours, increased psychological morbidity and episodes of professional dissatisfaction may persist. Both onlookers and midwives themselves observe episodes of psychological distress in midwifery populations (Smith et al, 2009). However, midwives may avoid occupational health services owing to the negative consequences they fear may occur (Wallbank, 2010). Midwives who are unwell and do not seek help may be more likely to make errors and become less safe practitioners. This situation may also see women and babies receive suboptimal maternity care. Nevertheless, some experts remain reluctant to approve a platform where midwives may anonymously disclose episodes of ill health, incompetence, medical errors and misconduct without immediate consequence and accountability. Satisfying these concerns will be key to the ongoing development of this project.
It is clear that midwives value support which is non-judgemental and confidential, as some feel unable to express themselves, stigmatised, and ‘required’ to cope. They may feel that they have a responsibility not to burden their colleagues with their own psychological distress. In these cases, face-to-face help-seeking behaviours may be absent, and the damaging effects of work-related psychological distress may persist. Therefore, a confidential online intervention designed to support midwives in work-related psychological distress may be worthy of exploration, especially as some midwives report that their preferred method of supportive correspondence is via email (Banks et al, 2012).
Future implications
Parts of this research have already informed guidance published by the Royal College of Midwives in relation to workplace stress. These findings could also be used to inform the development of an online intervention designed to support midwives in work-related psychological distress. The intention is to co-produce this with midwives from around the UK. It will be important to organise both feasibility testing and adequately powered randomised controlled trials to secure the evidence base in any other ongoing plans. The author invites all midwives to support and follow ongoing research in this area via The Academic Midwife page on Facebook.
Should this online intervention prove to be efficacious for both midwifery populations and maternity services, it could be adopted for use within larger midwifery populations and alternate professional groups, in a variety of geographical locations. This research would require a large number of midwives to initially test and co-produce an online intervention. The ongoing vision for this research is to pursue the development of effective and evidence-based online support for midwives in work-related psychological distress and promote excellence in maternity services.
Conclusion
This article has presented a doctoral research project, which makes the case for the development of an online intervention designed to support midwives in work-related psychological distress. Via literature reviews, a realist synthesis review and a two-round Delphi study, it has demonstrated how midwives experience work-related psychological distress and how this distress can negatively affect the individual midwife and the quality of maternity care. This research has also highlighted midwives' enthusiasm for the development of an online intervention designed to support them, and what should be prioritised in its design. The ethical issues concerning the development of this online intervention have also been explored with a view to widening the debate about how the wellbeing of midwives may be balanced with the requirement to protect the public and the professional reputation of midwifery.
The overarching purpose of this research project has been to identify and unite original evidence to make the case for turning the vision of online support for midwives into practice. The relevance of this research will be pertinent to health care providers, service users and policy makers as they look to improve recruitment rates, retention rates and the staff experience in line with the quality of maternity care. Unless the support needs of midwives are met, key strategies for positive change may never be realised. As such, health care leaders must champion evidence-based solutions which support midwives to enjoy a psychologically safe professional journey and deliver optimal maternity care.
Midwives are entitled to be psychologically safe, and both women and their babies deserve excellence in maternity care. As this care can only be delivered by a flourishing workforce, it behoves all of society to support the needs of midwives in the workplace. This paper unites new evidence in favour of the development of an online intervention designed to support midwives in work-related psychological distress, and aims to galvanise the support and participation of midwives in its future development and testing.
‘Midwives value support that is non-judgemental and confidential, as some feel unable to express themselves, stigmatised, and “required” to cope. They may feel they have a responsibility not to burden colleagues with their own psychological distress’