PROFESSIONAL BURNOUT AMONG
MIDWIVES: CAUSES AND
CONSEQUENCES
E. BRIE THUMM, CNM, PHD, MBA
Work came to evoke the same response as getting
caught in LA rush hour traffic. Hopelessly helplessly
stuck somewhere I didn’t want to be; there was
seemingly no way for me to get where I wanted to go.
The system in all its complexities felt to be specifically
and particularly bent on impeding my efforts to provide
quality, efficient and effective care.
Anonymous midwife
OBJECTIVES
Objective 1: Define burnout, including causes and symptoms.
Objective 2: Identify conditions of provider distress related to and frequently mistaken for burnout.
Objective: Compare the prevalence of burnout among CNMs/CMs to related groups.
Objective 3: Identify structural characteristics of midwifery practices that are related to high levels of burnout.
Objective 3: Identify modifiable characteristics of the midwifery practice climate that are related to high levels of burnout.
Objective 6: Create strategies to cultivate engagement and prevent burnout.
I was burned out from
exhaustion, buried in the hail
Poisoned in the bushes an’
blown out on the trail
Hunted like a crocodile,
ravaged in the corn
“Come in,” she said, “I’ll give
you shelter from the storm”
Bob Dylan
DEFINE BURNOUT
A psychological condition in which an individual responds to chronic professional stressors with pathologic levels of:
• Emotional exhaustion
• Depersonalization/Cynicism
• A sense of lack of personal accomplishment/efficacy
(Maslach et al., 2001)
The extinction of motivation or incentive, especially
where one’s devotion to a cause or relationship fails to
produce the desired result.
(Freudenberger, 1974)
I felt like a pod person---every activity of every day was just a mindless process of going through the motions---the minimal amount of activity just to get through--- from getting up, to showering, to getting dressed, getting to work and then being at work---just rote motion after rote motion after rote motion. I just felt like my motor completely died---I had zero reserve---and yet I just kept going, kept pushing even though I couldn't really think. I felt dead.
Anonymous midwife
SYMPTOMS OF BURNOUT
Exhaustion
Impaired concentration
Insomnia
Anxiety
Loss of appetite
Feeling hopeless
Increased illness
Loss of enjoyment
Cynicism
Detachment
Isolation
Irritability
DIFFERENTIAL DIAGNOSES
▪ Compassion Fatigue
▪ Moral Distress
▪ Vicarious trauma
▪ Post Traumatic Stress Disorder
COMPASSION FATIGUE
“Progressive and cumulative process that is caused by prolonged,
continuous, and intense contact with patients, the use of self, and
exposure to stress… a state where the compassionate energy that is
expended by [midwives/NPs] has surpassed their restorative
processes, with recovery power being lost.” (Coetzee, & Klopper,
2010)
MORAL DISTRESS
“The person is aware of a moral problem, acknowledges moral
responsibility, and makes a moral judgement about the correct action; yet, as
a result of real or perceived constraints, participates in perceived moral
wrongdoing.” (American Nursing Association, 2015)
VICARIOUS TRAUMA
“The response of those persons who have witnessed, been subject to
explicit knowledge of, or had the responsibility to intervene in a
seriously distressing or tragic event” (Lerias & Byrne, 2003)
• Also known as secondary trauma
POSTTRAUMATIC STRESS DISORDER
Exposure to actual or threatened death, serious injury, or sexual violence in one of
the following ways:
• Directly experiencing the traumatic event.
• Witnessing, in person, the event as it occurred to others.
• Learning that the traumatic event occurred to a close family member or close
friend. In cases of actual or threatened death of a family member or friend, the
event must have been violent or accidental.
• Experiencing repeated or extreme exposure to aversive details of the
traumatic event (e.g. first responders collecting human remains).
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Arlington, VA: American Psychiatric Publishing.
Burnout
Compassion fatigue
Vicarious traumaPTSD
Moral Distress
Stamm, 2010; Mathieu, 2012
Consequences of Burnout
Patient level
Patient satisfaction1
Quality of care2
Failure to rescue3
Longer discharge recovery time4
Hospital acquired infections5
Provider level
Physical health
• Hypothalmic pituitary axis6
• Alcohol dependence7
• Depression8
Organization levelJob satisfaction9
Absenteeism10
Intention to leave one’s job11
Profession levelLeaving the profession
• UK12
• Sweden13
1,2Aiken et al., 2012, 3 Aiken et al., 2002,4Halbesleben & Rathert, 2008; 5 Cimiotti, Aiken, Sloane & Wu, 2012, 6 Pruessner, Hellhammer & Kirschbaum, 1999, 7Sinokki et al., 2009,8 Govardhan, Pinelli & Schnatz,
2012, 9Govardhan, Pinelli & Schnatz, 2012, 10 Hanebuth, Meinel, & Fischer, 2006, 11 Leiter, M. P., & Maslach, 2009,11 Leiter & Maslach, 2009, Gregory et al., 2009, 12 Curtis, Ball & Kirkham, 2006, 13 Hildingsson,
Westlund & Wiklund, 2013
WorkEngagement
ProfessionalBurnout
WorkforceOutcomes
Job Demands-Resources Model
-
-
-
+Patient
Outcomes
Adapted from “The Job Demands-Resources Model: State of the art,” by A.B. Bakker & E. Demerouti, 2007, Journal of Managerial Psychology, 22(3), p. 309-328.
Perceiveddemands & resources in the practice environment
+
+
-
n=330 x 2 subsamples (n=660) of 330 respondents who completed MPCS in its
entirety randomly selected for EFA and CFA
n= 2685 completed all or part of the scales(202 did not complete any scale items)
n=2887 met inclusion criteria(555 did not meet inclusion criteria)
n=3442 CNMs/CMs responded to survey (30.8%)
n=1673 remaining sample for model testing
352 cases removed for missing >20% of any of the 5 scales
Remaining 2025 respondents assessed for missing data
Burnout Survey(n=2,333)
ACNM 2012(n=1,970)
AMCB 2013
(n=1,323)
Age 47.23 (11.8) 51.4 (11.6) 45.5 (15.2)
Years as a midwife 13.86 (10.3) 15.9 (10.8) 19.3 (8.0)
Gender
Female
Male
Transgender
Missing/Unknown
2273 (99.0)
20 (0.9)
2 (0.1)
38 (1.6)
1925 (97.7)
19 (1.0)
NA
26 (1.3)
348 (26.3)
4 (0.3)
NA
971 (73.4)
Race
American Indian/Alaskan Native
Asian
Black/African American
Caucasian/White
2 or more races
Other
Unknown/missing/not reporting
6 (0.3)
17 (0.7)
84 (3.7)
2064 (90.0)
64 (2.8)
13 (0.6)
83 (3.6)
5 (0.3)
9 (0.5)
58 (2.9)
1804 (91.6)
NA
43 (2.2)
48 (2.4)
6 (0.4)
13 (1.0)
38 (2.9)
724 (54.7)
1 (0.1)
4 (0.3)
519 (39.2)
Employment status
Full-time
Part-time
Per diem
Unknown/missing
1849 (79.3)
387 (16.6)
95 (4.1)
2 (0.1)
1392 (70.7)
379 (19.2)
NA
4 (0.2)
529 (40.0)
202 (15.3)
NA
369 (27.9)Fullerton, J., Sipe, T. A., Hastings-Tolsma, M., McFarlin, B. L., Schuiling, K., Bright, C. D., . . . Krulewitch, C. J. (2015). The Midwifery Workforce: ACNM 2012 and AMCB 2013 Core Data. J Midwifery Womens Health, 60(6), 751-761. doi:10.1111/jmwh.12405
Burnout Survey(n=2,333)
ACNM 2012(n=1,970)
AMCB 2013
(n=1,323)
Public hospital/university-affiliated
hospital
596 (25.6) 543 (27.6) 363 (27.4)
Private hospital/medical center 441 (18.9)
Educational Institution NA 238 (12.1) 115 (8.7)
Private physician-owned group practice 513 (22.0) 414 (21.0) 197 (14.9)
Private midwifery-owned group practice 86 (3.7) 157 (8.0) 91 (6.9)
Private solo CNM/CM practice 60 (2.6) NA NA
Private birthing center 88 (3.5) NA NA
HMO 114 (4.9) NA NA
Community health center 222 (9.5) 148 (7.5) 81 (6.1)
Family planning clinic 41 (1.8) NA NA
Nonprofit Health Agency NA 83 (4.2) 71 (5.4)
Military hospital or sites 61 (2.6) 25 (1.3) 17 (1.3)
Federal Government NA 35 (1.8) 19 (1.4)
Correctional facility/detention center 2 (0.1) NA NA
Other 108 (4.6) 119 (6.0) 0 (0.0)
Unknown/missing 1 (0.0) 208 (10.6) 369 (27.9)Fullerton, J., Sipe, T. A., Hastings-Tolsma, M., McFarlin, B. L., Schuiling, K., Bright, C. D., . . . Krulewitch, C. J. (2015). The Midwifery Workforce: ACNM 2012 and AMCB 2013 Core Data. J Midwifery Womens Health, 60(6), 751-761. doi:10.1111/jmwh.12405
Instruments
Midwifery Practice Climate Scale (10 items)2 subscales (Support for the Midwifery Model of Care and Practice Leadership and Participation)
Cronbach’s alpha coefficient 0.87-0.90 (Thumm, 2017)
Maslach Burnout Inventory (22 items)Gold standard in burnout instruments (Maslach & Jackson, 1981)
3 subscales (emotional exhaustion; depersonalization; lack of efficacy)
Cronbach’s alpha in U.K. midwife sample 0.69-0.80 (Sandall et al., 1998)
Utrecht Work Engagement Survey (9 items)3 subscales (vigor, dedication, absorption)
Cronbach’s alpha in 2 Irish midwife samples 0.88 and 0.90 (Freeney & Fellenz, 2013a, 2013b)
Job outcomes scale (4 items)3 items with low Cronbach’s alpha (0.32) (Van Bogaert, Kowalski, Weeks, & Clarke, 2013)
Inter-item correlation “fair to moderate” (0.15-0.21)
Personal communication with author of scale reported the “scale” performed well in modeling
Midwife-perceived quality of care scale (2 items)Items validated to correlate with standard care indicators (Aiken et al., 2012)
Cronbach’s alpha in Irish midwife sample 0.75 (Freeney & Fellenz, 2013a)
BURNED
OUT
40.6%59.4%
PREVALENCE OF BURNOUT AMONG CNMS/CMS
n=2,333
2017 40.6%
23.9
(12.61)
5.47
(5.38)
40.98
(5.66)
0
10
20
30
40
50
EMOTIONAL EXHAUSTION DEPERSONALIZATION LACK OF SENSE OF PERSONAL
EFFICACY
THE 3 ELEMENTS OF BURNOUT
Subscales MBI test
norms
(n=11,041;
Maslach &
Jackson,
1981)
England
(n=128;
Yoshida &
Sandall,
2013)
Poland
(n=59;
Kalicinska,,
Chylinska,
& Wilczek-
Rozyczka,
2012)
Australia
(n=56;
Mollart,
Skinner,
Newing &
Foureur,
2013)
CNMs
/CMs in
the U.S. in
2017
(n=2,333)
Emotional
Exhaustion22
(5.53)
32.9
(9.70)
23.6
(11.03)
20.23
(11.20)
23.9
(12.61)
Depersona
lization7
(5.22)
9.1
(4.35)
7.10
(5.74)
4.98
(4.83)
5.5
(5.34)
Lack of
Personal
Efficacy
43.7
(7.34)
45.8
(5.97)
21.2
(11.10)
34.5
(7.53)
41.0
(5.66)
CONSEQUENCES OF BURNOUT
BURNOUTWORKFORCE
STABILITY
r2= .238, p<.001
n=1673
= .488, p<.001
I saw no alternative but to get out; but now I’ve
lost far more than my income. I’ve lost my
community. I’ve lost purpose and meaning, an
identity that I had had for most of my adult life.
Anonymous midwife
BURNOUTQUALITY OF
CARE
r2=.115, p<.001
n=1673
-.340= . p<001
I felt so mad at both of them [patient and family
member]. I felt myself blaming them in an ugly, of
course, unwarranted, way, mad at myself, of course,
just mad---and exhausted.
Anonymous midwife
CAUSES OF BURNOUT
STRUCTURAL CHARACTERISTICS
PRACTICE CLIMATE
Do I feel
supported by
my practice?
STRUCTURAL CHARACTERISTICS
Upstate University Hospital, accessed 2018
NO
YES
NO
NO
YES
YES
YES
Patient acuity
Patient SES
Attend births
Practice location
Training of
decision-makers
Patient insurer
Daily patient loadAll findings p<.05, n=2333
Number of Birth
Locations
Birth Location
All findings p<.05, n=2333
Size of practice
Shift versus call
Birth volume
Shifts Worked
YES
NO
NO
YES
YES
YES
PRACTICE LOCATION
2.61
(1.41)
2.68
(1.40)2.58
(1.37)
2.82
(1.41)
0
1
2
3
4
5
6
Urban (n=936) Rural (n=353) Suburban (n=550) Mixed (n=459)
F(3,2294)=2.93,
p=.032; n=2298
DELIVERY LOCATION
2.65
(1.38)
2.65
(1.27)1.70
(1.44)
2.70
(1.34) 2.14
(1.30)
2.83
(1.40)2.64
(1.12)
0
1
2
3
4
5
6
Hospital
(n=1625)
Birth center
(n=49)
Home
(n=27)
Hospital &
birth center
(n=118)
Hospital &
home (n=14)
Birth center
& home
(n=28)
Hospital,
birth center
& home
(n=9)
n=1870; p<.05
F(6,1863), p=.018;
n=1868
BIRTH VOLUME (BIRTHS/YEAR)
2.07
(1.42)
2.70
(1.35)
2.75
(1.41)2.60
(1.34)
0
1
2
3
4
5
6
<50 (n=113) 50-199 (n=380) 200-499 (n=630) >500 (n=745)
F(3,1864)=8.35,
p<.001; n=1868
DAILY OUT-PATIENT PATIENT LOAD
2.21
(1.36)
2.50
(1.33)
2.75
(1.37)
2.76
(1.43)
3.17
1.50
2.16
(1.38)
0
1
2
3
4
5
6
<10 pts/day
(n=178)
10-15 pts/day
(n=530)
16-20 pts/day
(n=868)
21-25 pts/day
(n=437)
>25 pts/day
(n=181)
I don't work in an
out-patient
setting (n=104)
F(5,2292)=14.00,
p<.001; n=2298
2.41
(1.38)
2.66
(1.37)
3.00
(1.49)
0
1
2
3
4
5
6
Low risk (569) Moderate risk (n=1350) High risk (n=379)
F(2,2295)=20.21,
p<.001; n=2298
PATIENT ACUITY
TRAINING OF PRIMARY DECISION-MAKER
2.42
(1.31)
2.95
(1.45)
0
1
2
3
4
5
6
CNM/CM Non-CNM/CM
t(2122.45)=-9.05,
p<.001; n=2,294
SHIFTS WORKED
1.97
(1.23)
2.63
(1.44)
2.67
(1.38)
0
1
2
3
4
5
6
Nights (n=51) Day (n=654) Mixed days/nights (n=1589)
F(2,2291)=6.66,
p<.001; n=2,294
EMPLOYMENT STATUS
2.72
(1.40) 2.43
(1.35)2.24
(1.52)
0
1
2
3
4
5
6
Full-time (n=1823) Part-time (n=383) Per diem (n=91)
F(3,2295)=7.58,
p<.001; n=2,299
PRACTICE CLIMATE
Nicole Monet, 2017
BURNOUT RISK FACTORS: THEORY OF WORKLIFE
MISMATCH
Leiter & Maslach, 1999
Reward
Control
Community
Fairness
Values
MIDWIFERY PRACTICE CLIMATE SCALE
Practice Leadership and Participation
Support for the Midwifery Model of Care
Thumm, 2017
Practice Leadership and Participation
I feel valued in my practice environment.
Practice leadership is open to midwife ideas to improve patient care.
Midwives are represented on important committees in my practice and/or
hospital.
Practice leadership takes midwife concerns seriously.
Practice leadership makes efforts to improve working conditions for midwives.
I regularly get feedback about my performance from my practice leadership.
There is effective communication between midwives and practice leadership.
Support for the Midwifery Model of Care
My practice environment understands the Midwifery Model of Care.
My practice environment values the Midwifery Model of Care.
Midwifery care is based on a Midwifery Model of Care, rather than a medical
model.
PRACTICE
LEADERSHIP AND
PARTICIPATION
r2= .256, p<0.001
n=1673
= -.506 p<.001
r2= .156, p<0.001
n=1673
SUPPORT
MIDWIFERY MODEL
OF CARE
= -0.40, p<.001
THE INTERSECTION OF STRUCTURE AND CLIMATE
Nicole Monet, 2017
Training of
decision-
makers 3.6%
Practice
Climate21.4%
BURNOUT
25.0%
*NOTE: ANALYSIS CONDULTED USING HIERARCHTICAL REGESSION ANALYSIS, % REFERS TO VARIANCE IN
BURNOUT SCORE EXPLAINED; ALL SIGNIFICANT AT p,.001
Daily
patient
load 1.7%
Practice
Climate 23.4%
BURNOUT
25.3%
Patient
Acuity 1.5%
Practice
Climate 23.5%BURNOUT
25.0%
Training of
Decision-
maker
3.6%Practice
Climate
21.4%
????
75%
WHAT CAN WE TO PREVENT AND TREAT BURNOUT?
•Practice/Management Level
•Individual Level
•The Midwife Level
MANAGEMENT LEVEL
• Increase participation of midwives on meaningful committees
• Improve leadership
•Allow for employment status flexibility
• Foster support for the midwifery model of care
• Start the conversation with your organization about midwife well-being
I HAVE COME TO BELIEVE THAT CARING FOR MYSELF IS NOT SELF INDULGENT. CARING FOR MYSELF IS AN ACT OF SURVIVAL.
AUDRE LORDE
Nicole Monet, 2017
THE MIDWIFE LEVEL
1. Create HR toolkit
2. Participate in inter-disciplinary trainings
3. Clinical teaching/shadowing
4. Talk with colleagues about midwifery
5. Become involved
6. Give positive feedback
7. Allow colleagues to have boundaries
8. Integrate a 3-5 minute mindfulness mediation into staff meetings/handoffs
9. Random acts of kindness for each other
10. Graciously allow for flexibility of practice members
11. Monitor your practice for burnout
12. Avoid stigmatization and judgement around burnout
14th Dalai Lama
If you want others to be happy, practice
compassion. If you want to be happy,
practice compassion.
WHAT ABOUT THE MIDWIVES WHO DIDN’T RESPOND?
WHAT CAUSES THE OTHER 75%?
DEVELOPING AND TESTING INTERVENTIONS BASED ON THESE
FINDINGS?
HOW SHOULD WE DISSEMINATE THESE FINDINGS TO CHANGE
PRACTICE?
FUTURE RESEARCH
New Statesman; accessed 2018
WHERE TO NEXT MIDWIVES?
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