Liesbeth Kool

Liesbeth Kool Liesbeth Kool Untangling the elements of midwives’ occupational wellbeing

Untangling the elements of midwives’ occupational wellbeing A study among newly qualified and experienced midwives Liesbeth Kool

COLOFON This thesis was financed and prepared within the department section of Midwifery Science, Department of Primary- and Longterm Care, University of Groningen, University Medical Center Groningen, Department of Primary- and Longterm Care, Amsterdam UMC, location VUmc, Midwifery Academy Amsterdam Groningen, Amsterdam Public Health, Quality of Care. This thesis is published within the Research Institute SHARE (Science in Healthy Ageing and healthcaRE) of the University Medical Center Groningen / University of Groningen. This work is part of the research programme Doctoral Grant for Teachers with project number 023.012.012, financed by the Netherlands Organization for Scientific Research (NWO). Cover: designed by Arniek Doornbos and lay-out by Jurrian Doornbos Printing: Ridderprint | ISBN: 978-94-6483-241-9 ©Liesbeth Kool, 2023

Untangling the elements of midwives’ occupational wellbeing A study among newly qualified and experienced midwives Proefschrift ter verkrijging van de graad van doctor aan de Rijksuniversiteit Groningen op gezag van de rector magnificus prof. dr. C. Wijmenga en volgens besluit van het College voor Promoties. De openbare verdediging zal plaatsvinden op maandag 13 november 2023 om 14.30 uur door Elizabeth Kool geboren op 21 september 1963 te Gouda

Promotores Prof. dr. A.D.C. Jaarsma Prof. dr. F.G. Schellevis Copromotor Dr. E.I. Feijen-de Jong Beoordelingscommissie Prof. dr. M. Nieuwenhuijze Prof. dr. P.L.P. Brand Prof. dr. J.J.H.M. Erwich

"Science is the art of differentiation. Discovering in every man that which distinguishes him from others is to know him." - Hermann Hesse, 1930

TABLE OF CONTENTS Chapter 1 General introduction 9 Chapter 2 Perceived job demands and resources of newly qualified 25 midwives working in primary care settings in the Netherlands Chapter 3 The initiation of Dutch newly qualified hospital-based 45 midwives in practice, a qualitative study Chapter 4 Midwives’ occupational wellbeing and its determinants 67 a cross-sectional study among newly qualified and experienced Dutch midwives Chapter 5 Intentions to leave and actual turnover of community 93 Midwives in the Netherlands Chapter 6 Midwives’ perceptions of performance- and transition 121 Into practice of newly qualified midwives, a focus group study Chapter 7 How to improve newly qualified midwives’ wellbeing 147 In practice, a Delphi study Chapter 8 General discussion 181 Chapter 9 Summary 201 Chapter 10 Samenvatting 209 Appendices 217 Curriculum Vitae 218 Other publications 219 Acknowledgments 220 SHARE publications 222

CHAPTER 1 General introduction

10 | Chapter 1 This thesis deals with the occupational wellbeing of midwives in the Netherlands with a focus on newly qualified midwives (NQMs) and their transition into practice. In this introductory chapter, the concept of occupational wellbeing is explained, including the current situation of the art of occupational wellbeing of midwives. Furthermore, the work environment of midwives in the Netherlands is described, particularly of NQMs. This chapter concludes with the overarching problem statement for this thesis, related research questions, and an outline of the thesis. Midwives’ occupational wellbeing Wellbeing is defined as: ‘When individuals have the psychological, social, and physical resources they need to meet a particular psychological, social, and/or physical challenge. ‘1 Occupational wellbeing is defined as a broad construct that includes individual and organizational factors that interact and lead to the well-being of employees.2 Occupational wellbeing results in a spectrum ranging from positive feelings of autonomy, satisfaction, competence at one end, and negative aspects of work resulting in anxiety and low well-being at the other end.2,3 Occupational wellbeing in healthcare research is often characterized one-sidedly by the prevalence of burnout,4 stress, depression, and anxiety.5 Other measured variables of midwives’ well-being are job strain and intentions to leave the profession.6-8 Occupational wellbeing consists of two different independent processes, a motivational process and a health impairment process, both with different outcomes.9 On the one hand, the health impairment process leads to burnout and negative performance, and on the other hand, the motivational process leads to work engagement and positive performance.9 The literature mainly reports two different constructs of positive wellbeing: job satisfaction and work engagement.9,10 Although job satisfaction and engagement are both positive states of mind, engaged professionals are proactive and more driven in their work than satisfied professionals.11 Work engagement is also more related to work performance than job satisfaction.11 Work engagement is defined as: ‘a positive, fulfilling, work-related state of mind that is characterized by vigour, dedication to the work, and by absorption’.10 Although research on positive wellbeing within the midwifery profession is scarce, outcomes have been reported on job satisfaction or intentions to stay in the profession.12-15 These studies among midwives show that high levels of job satisfaction are associated with less turnover and absenteeism. Satisfied midwives enjoyed the type of work and did not want to leave their job.16 Contributing factors to midwives’ job satisfaction are positive collaborations with colleagues, having meaningful work content, autonomy at work, and a manageable workload.12,17 A few small studies on midwives’

General introduction | 11 wellbeing reported on work engagement.18,19 Midwives showed high levels of work engagement, and determinants of work engagement were working with pregnant individuals and their families, which is perceived as meaningful work. Studies on other professions and occupations show that working with clients, autonomy, and social support are associated with high work engagement.20 As well as occupational determinants, personality traits such as self-esteem, self-efficacy, optimism, and proactive behaviour are associated with high work engagement.21,22 Negative wellbeing among midwives is often operationalized in burnout symptoms.5 International research shows that work-related burnout among midwives ranges between 20 and 60 per cent.5,23 Determinants of burnout include a low maturity level, being young, not much work experience, and being single.5 Furthermore, a lack of staff, low salary, poor professional recognition and organization, and a negative work environment contribute to burnout symptoms among midwives.5 On the other hand, findings in midwifery research show factors in the work which protect against burnout symptoms.5 These factors include working with pregnant individuals, supportive relationships with colleagues, and working with like-minded fellow midwives.6 Furthermore, personal resources, which were referred to in the previous paragraph as contributing to high work engagement, also protect against burnout symptoms. These factors are self-esteem, self-efficacy, optimism, and proactive behaviour. 21,22 Transition-into-practice Occupational wellbeing of newly qualified midwives (NQMs) is related to their transitioninto- practice experiences.24 Transition-into-practice for newly qualified health professionals is viewed as ‘a foundational period of time, at the start of a career, whereby a newly qualified practitioner can build competence and confidence as an autonomously working professional’.25 For midwives, this marked period from graduation as a midwife towards working as a registered midwife is regulated and legislated.25 In countries such as the United Kingdom and Australia, NQMs are required to complete a period of supervised working in practice before being permitted to work autonomously with pregnant women.25 In other countries such as New Zealand, Canada, and The Netherlands, NQMs are registered immediately after graduation and able to work in practice autonomously: providing care across the entire scope of midwifery practice.24 In contrast to other countries,24-26 transition-into-practice experiences of NQMs in the Netherlands have not yet been studied. Transition- into-practice in midwifery research seemed to depend on the work environment NQMs choose to work in.24 In hospital settings, NQMs learn to evaluate and assess risks, and they are socialized to work as an efficient and effective team member within an institution rather than working ‘with the

12 | Chapter 1 women’. In a community setting, however, NQMs face a sense of responsibility which induces anxiety around the decisions they make in practice. On the other hand, working in the community while working in continuity of care also provides NQMs with the benefits of building relationships with the pregnant individuals, of being ‘with the women’ as a midwife.24 Transition support Research suggests that the importance of transition support for NQMs is beneficial for NQMs.24 Transition support in the hospital setting helps NQMs navigate between the expectations of the profession and the realities of working in a medicalized model of care within a hospital. 24,27In the community, transition support helps NQMs to feel a sense of belonging in a small team with fellow midwives and enables them to work in continuity of care.24,28 Furthermore, national transition-into-practice programmes for NQMs were implemented to guarantee safe midwifery care.25 Transition support addresses issues regarding NQMs’ feelings of lacking competence and confidence while working in practice, and strengthens their experience with uncomplicated pregnancies and births.29 Hospital-based transition-into-practice programmes prepare NQMs to work with pregnant individuals who face complications and higher risks in their pregnancy.24 From a broader perspective, supporting the transition of newly qualified healthcare professionals (NQPs) seems effective. Transition support increases NQP’s level of confidence and competence in practice, increases job satisfaction, reduces stress, and increases retention rates.30-32 Research shows that effective transition support consists of different components, a combination of classroom instruction, observational experience, coaching, and computer-based learning alongside well-prepared and supported mentors.30-34 For an effective transition-into-midwifery practice, fellow midwives seem to be pivotal. They can offer a supportive work environment and also offer mentorship.35 The work environment of midwives in the Netherlands Midwives working in the Netherlands can choose between two different work environments: in a community or in a hospital setting. Most of the NQMs (72%) start their career as a locum midwife in the community (see textboxes: The organization of midwifery care in the Netherlands and Midwifery education in the Netherlands).36 A minority of NQMs work as an employed hospital-based midwife (7%).36 A registered midwife working in the community setting is responsible for the continuity of care for pregnant women and their partners, and for risk assessment. When problems arise, she will refer women to secondary care. In the hospital setting, a midwife works partially autonomously, in decision-making and in providing low-risk midwifery care, and partially

General introduction | 13 under supervision of an obstetrician. In medium and high risk-situations, the midwife decides whether and when to involve the obstetrician. As an illustration of NQMs, we created two different personas in the text below: Mirthe, a community-based NQM and Annabel, a hospital-based NQM. Mirthe is a 25-year-old NQM raised in a suburban region in the Northern part of the Netherlands. She recently graduated as a midwife and used to live in the city of Groningen. She now lives with her partner in the region where she was born and raised. Before graduation, she expected to work as a member of a community practice close to her friends and family. In reality, she is working as a locum midwife for three different practices, one of which is near her own home. When she is on-call she cannot always sleep in her own bed. While working, she enjoys the work with pregnant women, and meeting her fellow midwives. She finds it hard not to think about her work during her time off. She is constantly rethinking her decisions. Because of the different practices she works for, she finds it difficult to make connections with colleagues in the area and with the hospital’s collaborators. She also finds it difficult to work in different regions: each region has its own protocols. She also has no guarantees about the number of shifts she will be hired for in the upcoming months. Currently, she feels a bit disappointed about the conditions in which she has to work as a locum midwife. Annabel is currently working as a hospital-based midwife in a teaching hospital in the Randstad, the most densely populated area in the Netherlands. She works in a team with 15 fellow midwives. She chose to work in the hospital for the challenges in the work: complexity of midwifery care, working in a multidisciplinary team and working according to a timetable. Working 8 or 12-hour shifts is a work condition that she prefers. Annabel is 29 years old, recently graduated as a midwife, and previously obtained a Master’s degree in English literature. Before graduation, Annabel expected to work alongside fellow midwives. She was expecting to learn and develop herself as a midwife by sharing experiences. Her team members value her for her openness to learning and developing as a midwife and for her social skills. They describe Annabel as a nice person who can ‘talk to anyone’. Currently, she is a little disappointed with her work. Colleague midwives are usually not available to discuss cases. She also finds it difficult to work in the different roles that are expected of her in the hospital. She likes working in a team, but it is difficult to feel she belongs because she always has her temporary employment contract in the back of her mind.

14 | Chapter 1 Problem statement NQMs’ wellbeing and performance in practice in the Netherlands is unknown, due to a lack of existing research about this topic.24 International research on NQMs is hard to generalize for the Dutch work environment, because these studies mainly focus on hospital-based midwifery.24 Assumptions are made in previous research that NQMs in the Netherlands tend to avoid risks and that the care they provide might be substandard.37 International research indicates that midwives who prefer to be ‘on the safe side’ might initiate more premature interventions (‘too much too soon’).38 Moreover, overuse of interventions leads to unnecessary risks for pregnant women and higher healthcare costs.38 Healthcare workers’ wellbeing is important because their wellbeing is an important indicator of the quality of care provision and the healthcare system in general.39 Burnout, psychological distress, and poor social resources are associated with suboptimal patient care, unprofessional conduct, and leaving the profession.39 The importance of work engagement and its contribution to performance in practice and professionals’ wellbeing is shown for various occupational groups but data about midwives is lacking.20 Previous research on NQMs suggest that they lack self-confidence and doubt their own competence, which has implications for their wellbeing and performance in practice.24,40 NQMs meet different challenges in their chosen work environment.25 For instance, NQMs have to become a trustworthy member of the monodisciplinary and multidisciplinary team and have to work as a member of the profession.27 Furthermore, NQMs experience a theory-practice gap, and have to work according to job expectations. When these expectations do not meet their own values, NQMs experience anxiety, stress, and attrition from the job.27,41-43 Research on NQPs who work in independent practices indicates that this environment creates barriers to asking for help from colleagues, which affects their performance in practice.44 Furthermore, the importance of a supportive team and positive support from fellow midwives in the transition-into-practice is highlighted in previous research. 24,26,29 Knowledge gaps Research on midwives’ occupational wellbeing in the Netherlands is outdated. Data on burnout levels date back to 1996.45 Internationally, research on occupational wellbeing of midwives primarily focuses on negative wellbeing: burnout symptoms.5 There is a lack of knowledge on the positive wellbeing of midwives and its determinants in the hospital and in the community settings.18 How the specific work environment of NQMs in the

General introduction | 15 Netherlands (with greater accountability and working alone) contributes to their wellbeing has not yet been studied. There is also no previous research about NQMs’ transition-into-practice in the Netherlands and how they perceive their work from the point of graduation as a registered and accountable midwife in practice. Due to the independent and autonomous work of NQMs in the Netherlands, often without the resources of nearby fellow midwives, it is not known how they perceive their transition-into-practice.24,44 Furthermore, it has not been previously studied how stakeholders in midwifery care in the Netherlands perceive the importance of supporting NQMs and what they perceive as applicable in the current organization of midwifery care. Aim of this thesis and research questions Therefore, this thesis aims to provide knowledge about 1) the occupational wellbeing of NQMs in practice, 2) the transition-into-practice experiences of NQMs, and 3) how to support this transition period in practice. As research shows that NQMs in practice need supportive fellow midwives for self-confidence and feelings of competence in practice,24,26 we also studied experienced midwives’ wellbeing, their perceptions on supporting NQMs, and whether they have intentions of leaving the profession. Research questions within this thesis are: 1. How do NQMs perceive their transition-into-midwifery practice, and how is this transition supported in practice? 2. What are the levels of wellbeing of NQMs and of experienced midwives in the Netherlands, and which determinants are associated with wellbeing and intentions to leave the practice? 3. What are the desired and the feasible components of support of the NQMs’ transition-into-practice? With these studies, we aim to contribute to the knowledge of midwives’ occupational wellbeing and the importance of adding positive wellbeing to the knowledge of midwives’ wellbeing internationally. With this knowledge, the midwifery profession can identify the work-related factors associated with positive wellbeing and make changes in the organization of midwifery care according to these factors. Furthermore, this thesis contributes to knowledge about the transition-into-practice experiences of communitybased NQM midwives and their wellbeing. With this new knowledge, we aim to contribute to the professional wellbeing of NQMs and, ultimately, to their performance in practice and overall contribution to the required quality of midwifery care. Without this knowledge, it is impossible to gain a thorough picture of the wellbeing and performance of NQMs in community-based practice in particular.

16 | Chapter 1 Theoretical model For this thesis, the Job demands and Resources (JD-R) theory is used as a theoretical framework for multiple reasons. First, this model is based on a comprehensive approach to employee wellbeing, with integrated intrinsic and extrinsic factors and their impact on outcomes.46 Second, the JD-R model is a heuristic model that helps identify the specific demands and available resources in a specific occupation.22 Third, the JD-R model is based on the premise that employee wellbeing is the result of the balance between workload and resource availability at work.47 Knowledge of midwives’ occupational wellbeing and its determinants can be developed through the research on the influence of specific job characteristics and personal characteristics, as identified in the specific work environments.9,47 Occupational wellbeing in the JD-R model (figure 1) is based on two different constructs: burnout and work engagement.10 High work engagement, a result of a motivational process, is associated with better mental and physical health, better work ability, and is beneficial for work performance and workplace safety.20 Burnout is a health impairment process in which professionals deplete their energy resources, leading to reduced involvement with the work, and with the clients.47 Job demands (JD) are aspects of the job requiring effort and are associated with mental or physical costs.47 Job resources (JR) help professionals to achieve job goals or to reduce job demands.47 Personal resources (PR) are positive self-evaluations that are linked to resilience and refer to an individual’s sense of being in control and the ability to impact their environments successfully.48 Personal resources contribute positively to wellbeing, and they can also initiate an upward spiral of resources that reinforce each other, resulting in higher work engagement.48 Furthermore, personal resources are mediators for the health impairment process, reducing the development of burnout symptoms.22,48 Figure 1. Adapted JD-R model22

General introduction | 17 Outline of this thesis The overview of the studies in this thesis is presented in Figure 2, based on the JD-R model. In chapter two and three, we answer the first research question. We identify job demands, job resources, and personal resources, which affect occupational wellbeing and performance of NQMs in community-based midwifery (Chapter 2) and among hospital-based NQMs (Chapter 3). In chapter four, we report on a quantitative study on the occupational wellbeing of midwives in the Netherlands and the determinants associated with wellbeing. We answer the third research question by measuring work engagement (WE) and burnout symptoms (BO) among midwives in the Netherlands. Furthermore, we identify the work characteristics and personal characteristics associated with wellbeing (WE and BO) among midwives: NQMs and experienced midwives. In chapter five, we explore midwives’ intentions to leave and reasons to leave the profession as a midwife. Furthermore, reasons leading to leaving the profession were qualitatively explored. In chapter six, we identify the perceptions of experienced midwives regarding NQMs in the workplace. We explore the views of midwives on supporting NQMs in practice. Chapter seven includes a study on feasible components of support for NQMs’ transitioninto-practice by exploring maternity care stakeholders’ commitment to important and applicable components of support for NQMs. Figure 2. JD-R model in chapters and research questions in this thesis

18 | Chapter 1 The organization of midwifery care in the Netherlands Historically, the scope of midwifery in the Netherlands is related to the law of 1865.49 This law legislated midwives only to attend deliveries that were the work of nature and forbade midwives to attend ‘abnormal’ deliveries.50 This tradition was common practice until the 1960s.50 From the 1970s, women began to prefer choosing where to deliver their children: in a hospital or at home. Therefore, outpatient births were introduced, where women give birth in a hospital accompanied by their primary care midwife and are discharged within 24 hours after birth. Furthermore, hospitals also employed midwives in a hospital setting to enhance physiology in medically indicated births.50 Midwives in the Netherlands are trained to work autonomously in maternity care.51 The majority of Dutch midwives work in the community (72%).52 They are also responsible for risk-level selection: whether women should be referred to an obstetrician based on the Obstetric Indications List (VIL). Community-based midwives mainly work selfemployed in a (group) practice in the community. They work as equal partners and hire locum midwives to cover for holidays, maternity, or sick leave. A minority of midwives (713%) work in secondary care in a hospital setting. They are responsible for women with medium and high-risk pregnancies.52 In the hospital setting, the tasks and responsibilities between obstetricians and clinical midwives are divided, with midwives being autonomously responsible for some tasks according to strict protocols and working under supervision of an obstetrician for others.53 Hospital-based midwives are in charge of the delivery rooms most of the time and delegate some tasks to obstetric nurses. They bridge the gap between primary-care midwives and obstetricians.53 In the Netherlands, a trend over the last decades is that NQMs work as a locum midwife (72%) and a minority work as a partner in a community practice (4%).36 Until 2005, these percentages were different: 0-5% of the NQMs worked as a locum, and 20-45% worked as a partner in a midwifery practice or hospital-based (10-25%) or were not working as a midwife (2060%)36Job-seeking midwives largely wanted to work in a partnership in a communitybased midwifery practice (58%).36 Midwifery education in the Netherlands Students are educated in a four-year direct-entry midwifery programme at a university of applied sciences. Three different universities offer a Bachelor of Science midwifery programme, and 220 students start the programme annually. The inflow of student midwives is regulated by the government through a numerus fixus (a restriction of the number of places on offer on popular and costly degree programmes).51 The professional

General introduction | 19 education of midwives in the Netherlands prepares students for a full qualification. They are allowed to register themselves as a midwife after graduation.54 The regulation of the educational programme at a national level is laid down in an Order of Council Midwifery.55 Due to the inflow of midwifery students in the Netherlands being limited by the government, there is also an influx of NQMs who are educated in other countries. Midwives with a bachelor’s degree in midwifery obtained in another European Union Member State can practice as a midwife in the Netherlands. Twenty per cent of all practicing midwives in the Netherlands were educated abroad.36 Most of them were educated in Belgium. Belgian midwifery students are also trained to be independent professionals in the care of women with uncomplicated pregnancies.56 However, they are mainly trained in a hospital setting. Therefore, Belgian midwifery students do not acquire all the professional competencies and autonomy they need to work in the community.56 For a Master of Science degree, midwives are dependent on generic Master of Science programmes in research or health sciences. In 2023 a Master midwifery programme started at national level, provided by a collaboration between all universities with a bachelor of midwifery programme. PhD tracks have been developed at the midwifery academies in cooperation with other universities.

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General introduction | 21 16. Nedvědová D, Dušová B, Jarošová D. Job satisfaction of midwives: A literature review. Central European Journal of Nursing and Midwifery. 2017;8(2):650-656. 17. Wangler S, Streffing J, Simon A, Meyer G, Ayerle GM. Measuring job satisfaction of midwives: A scoping review. Plos one. 2022;17(10):e0275327. 18. Yuriko K, Hitomi K. Work engagement among midwives working at advanced perinatal care facilities in Japan. International Journal of Nursing and Midwifery. 2020;12(1):1-6. 19. Elliott R, Fry M. Psychological capital, well‐being, and patient safety attitudes of nurses and midwives: A cross‐sectional survey. Nurs Health Sci. 2021;23(1):237-244. 20. Hakanen JJ, Ropponen A, Schaufeli WB, De Witte H. Who is engaged at work?: A large-scale study in 30 European countries. Journal of occupational and environmental medicine. 2019;61(5):373-381. 21. Mastenbroek N, Jaarsma A, Scherpbier A, van Beukelen P, Demerouti E. The role of personal resources in explaining well-being and performance: A study among young veterinary professionals. European Journal of Work and Organizational Psychology. 2014;23(2):190-202. 22. Schaufeli WB, Taris TW. A critical review of the job demands-resources model: Implications for improving work and health. In: Bridging occupational, organizational and public health. Springer; 2014:43-68.\23. Hunter B, Fenwick J, Sidebotham M, Henley J. Midwives in the United Kingdom: Levels of burnout, depression, anxiety and stress and associated predictors. Midwifery. 2019;79:102526. 24. Gray M, Malott A, Davis BM, Sandor C. A scoping review of how new midwifery practitioners transition to practice in Australia, New Zealand, Canada, United Kingdom and the Netherlands. Midwifery. 2016;42:74-79. 25. Gray M, Kitson-Reynolds E, Cummins A. Starting life as a midwife. An International Review of Transition from Student to Practitioner, Springer, Cham, Switzerland. 2019. 26. Hopkinson MD, Kearney L, Gray M, George K. New graduate midwives’ transition to practice: A scoping review. Midwifery. 2022:103337. 27. Clements V, Fenwick J, Davis D. Core elements of transition support programs: The experiences of newly qualified Australian midwives. Sexual & reproductive healthcare : official journal of the Swedish Association of Midwives. 2012;3(4):155-162. 28. Kitson-Reynolds E, Ferns P, Trenerry A. Transition to midwifery: Collaborative working between university and maternity services. British Journal of Midwifery. 2015;23(7):510515. 29. Fenwick J, Hammond A, Raymond J, et al. Surviving, not thriving: A qualitative study of newly qualified midwives’ experience of their transition to practice. J Clin Nurs. 2012;21(13‐14):2054-2063.

22 | Chapter 1 30. Edwards D, Hawker C, Carrier J, Rees C. A systematic review of the effectiveness of strategies and interventions to improve the transition from student to newly qualified nurse. Int J Nurs Stud. 2015;52(7):1254-1268. 31. Zhang Y, Qian Y, Wu J, Wen F, Zhang Y. The effectiveness and implementation of mentoring program for newly graduated nurses: A systematic review. Nurse Educ Today. 2016;37:136-144. 32. Tyndall DE, Firnhaber GC, Scott ES. The impact of new graduate nurse transition programs on competency development and patient safety: An integrative review. ANS Adv Nurs Sci. 2018;41(4):E26-E52. 33. Brook J, Aitken L, Webb R, MacLaren J, Salmon D. Characteristics of successful interventions to reduce turnover and increase retention of early career nurses: A systematic review. Int J Nurs Stud. 2019;91:47-59. 34. Whitehead B, Owen P, Holmes D, et al. Supporting newly qualified nurses in the UK: A systematic literature review. Nurse Educ Today. 2013;33(4):370-377. 35. Kensington M, Campbell N, Gray E, et al. New Zealand’s midwifery profession: Embracing graduate midwives’ transition to practice. New Zealand College of Midwives Journal. 2016(52):20-25. 36. Kenens RJ, Batenburg R, Kasteleijn A. Cijfers uit de registratie van verloskundigen: Peiling 2016. . 2017. 37. Offerhaus PM, Korfker D, de Jonge A, van der Pal KM, Scheepers B, Lagro-Janssen TL. Midwives and variation in referral decisions during labour. Patterns In Primary Midwifeled Care In The Netherlands. 2015:103. 38. Miller S, Abalos E, Chamillard M, et al. Beyond too little, too late and too much, too soon: A pathway towards evidence-based, respectful maternity care worldwide. The Lancet. 2016;388(10056):2176-2192. 39. Ray-Sannerud BN, Leyshon S, Vallevik VB. Introducing routine measurement of healthcare worker’s well-being as a leading indicator for proactive safety management systems based on resilience engineering. Procedia Manufacturing. 2015;3:319-326. 40. Reynolds EK, Cluett E, Le-May A. Fairy tale midwifery—fact or fiction: The lived experiences of newly qualified midwives. British Journal of Midwifery. 2014;22(9):660-668. 41. van der Putten D. The lived experience of newly qualified midwives: A qualitative study. British Journal of Midwifery. 2008;16(6). 42. Avis M, Mallik M, Fraser DM. ‘Practising under your own pin’– a description of the transition experiences of newly qualified midwives. J Nurs Manag. 2013;21(8):1061-1071. 43. Hughes AJ, Fraser DM. ‘SINK or SWIM’: The experience of newly qualified midwives in England. Midwifery. 2011;27(3):382-386.

General introduction | 23 44. Griffin A, Abouharb T, Etherington C, Bandura I. Transition to independent practice: A national enquiry into the educational support for newly qualified GPs. Education for Primary Care. 2010;21(5):299-307. 45. Bakker RH, Groenewegen PP, Jabaaij L, Meijer W, Sixma H, de Veer A. ‘Burnout’among Dutch midwives. Midwifery. 1996;12(4):174-181. 46. Pagán-Castaño E, Maseda-Moreno A, Santos-Rojo C. Wellbeing in work environments. Journal of Business Research. 2020;115:469-474. 47. Bakker AB, Demerouti E. The job demands-resources model: State of the art. J Manage Psychol. 2007;22(3):309-328. 48. Xanthopoulou D, Bakker AB, Demerouti E, Schaufeli WB. The role of personal resources in the job demands-resources model. International journal of stress management. 2007;14(2):121. 49. Feijen-de Jong E, Kool L. Transtion to practice for newly qualified midwives in the Netherlands. In: Starting life as a midwife. Springer; 2019:167-179. 50. van Lieburg MJ, Marland H. Midwife regulation, education, and practice in the Netherlands during the nineteenth century1. Med Hist. 1989;33(3):296-317. 51. Gottfreðsdóttir H, Nieuwenhuijze MJ. Midwifery education: Challenges for the future in a dynamic environment. Midwifery. 2018;59:78-80. 52. Kenens, Van der Velden, Vis, Batenburg. Cijfers uit de registratie van verloskundigen, peiling 2018. . 2020. 53. Cronie D, Rijnders M, Buitendijk S. Diversity in the scope and practice of hospital‐ based midwives in the Netherlands. Journal of Midwifery & Women’s Health. 2012;57(5):469-475. 54. CIBG: Ministry of Health, Welfare and Sport. Big register. The BIG-register gives clarity about the care provider’s qualifications and entitlement to practise. Accessed: 9 February 2023. 55. NZA (Nederlandse Zorgautoriteit). Beleidsregel verloskunde (Policy rule midwifery) - BR/REG-23128b. Accessed: 9 February 2023. 56. Vermeulen J, Luyben A, Buyl R, et al. The state of professionalisation of midwifery in Belgium: A discussion paper. Women and Birth. 2021;34(1):7-13.

CHAPTER 2 Perceived job demands and resources of newly qualified midwives working in primary care settings in the Netherlands Kool L, Feijen-de Jong EI, Schellevis FG, Jaarsma ADC Midwifery 2019;69:52–58

26 | Chapter 2 ABSTRACT Objective: The objective of this study is to identify perceived job demands and job resources of newly qualified midwives (NQMs), working in primary midwifery care during their first years in practice. Design/Setting: A qualitative study, with semi-structured group interviews was conducted. Midwives working less than three years in primary midwifery care in the Netherlands were invited to join a focus group interview. Measurements and findings: Five focus group interviews were conducted with 31 participants. Interviews were transcribed and analyzed. Data were analyzed thematically by using the different characteristics of the Job Demands Resources model. Working as a locum midwife is demanding for Dutch NQMs, due to a large number of working hours in different practices and a lack of job security. Decision-making and adapting to local guidelines and collaborations demand a high cognitive load. These aspects of the work context negatively impact NQMs’ work and private life. Working with clients and working autonomously motivates the newly graduates. Support from colleagues and peers are important job resources, although colleagues are also experienced as a job demand, due to their role as employer. Strictness in boundaries, flexibility and sense of perspective are NQMs’ personal resources. On the other hand, NQMs perceived perfectionism and the urge to prove oneself as personal demands. Key conclusions and implications for practice: Dutch NQMs’ first years in primary midwifery care are perceived as highly demanding. In primary care, NQMs usually work as locum midwives, self-employed and in different practices. Working in different practices requires not only working with different client populations and autonomous decision-making, but also requires adaptation to different local working arrangements. Building adequate support systems might help NQMs finding a balance between work and private life by having experienced midwives available as mentors. Furthermore, training and coaching of NQMs help them to become aware of their personal resources and demands and to help them strengthen their personal resources. Improving NQMs’ working position through secure employments require changes in the organization of maternity care in the Netherlands.

Perceived job demands and resources of newly qualified midwives working in primary care settings in the Netherlands | 27 INTRODUCTION Performing as a newly qualified midwife (NQM) in midwifery practice is challenging and demanding.1 Newly qualified midwives are fully responsible and accountable for providing care to their clients from the moment of graduation (or registration).2 International research shows that the weight of responsibilities in the first year of practice can negatively influence NQMs’ professional confidence as well as the overall quality of the provided care.3,4 Further to the outcomes of international research studies, NQMs in the Netherlands are likely to face a number of additional challenges due to the specific Dutch context. First, in Dutch primary midwifery care, midwives work independently in providing pre- and postnatal care, and during labor and birth. The primary care midwife is the professional in charge for low–risk pregnant women.5 Second, NQMs in other countries are supported in their transition from student to registered midwife.1,6,7 In the Netherlands, formal support programs for NQMs do not exist. Third, in the Netherlands 72 percent of NQMs work as a locum midwife (explained in textbox 1) in primary care during their first years in practice,8 as opposed to most other developed countries, where NQMs are usually employed by a hospital and work in a hospital setting.1,6,9 Within the Dutch midwifery care system, primary care midwives refer pregnant women to obstetricians when complications arise. Over the past decade, referral rates have been increasing which could partly be attributed to midwives’ attitudes due to feelings of insecurity and anxiety.10 These increasing referral rates could threaten in the long term the unique choice for women in the Netherlands to give birth at home. Primary care midwifery practices hire a locum midwife to cover for holiday, maternity or sick leave. Locum midwives are self-employed. In order to be recognized as selfemployed (“autonomous professional without personnel”) by the Dutch tax agency, locum midwives are required to work for a number of different midwifery practices, to demonstrate their in- dependence.11 International studies on NQMs show that factors such as reality shock,12 applying a different midwifery philosophy of care,13,14 and delay in securing employment and work allocations make the first years a very demanding period for NQMs.15 Studies on work resources for NQMs show that positive support and mentorship from colleagues,1,15 working in continuity of care models,16,17 and postgraduate preceptorship programs are associated with increasing confidence and competence.1,14

28 | Chapter 2 International research shows a gap in knowledge about the specific work and personal characteristics of NQMs.1 Also, as stated earlier, Dutch primary NQMs’ working circumstances differ from NQMs in other countries. Therefore, the aim of this study is to identify perceived job demands, job resources and personal resources by NQMs working in primary midwifery care during their first years in practice. METHOD A qualitative descriptive design was used for this study. Data were collected through focus group interviews with NQMs. For reporting this study, we used the COREQ checklist.18 The Job Demands-Resources (JD-R) model19 was used as a theoretical framework (figure 1) to identify the specific work-related demands and resources in primary midwifery care. The JD-R model was developed in the early nineties of the twentieth century,19 and has been widely used for different (healthcare) professions, which allowed us to compare our results with other professions and occupations.20 The JD-R model describes the relationships between job and personal characteristics as two intertwined processes: 1) the motivational process, leading to work-engagement and 2) the stress process, leading to exhaustion and burnout. The JD-R model is based on the assumption that, although work characteristics differ for various occupations and professions, they can be modelled in two categories: job demands and job resources. Contrary to other models, the JD-R model permits the incorporation of many possible working conditions, depending on the specific working context.20 In addition to work characteristics (job demands and job resources), personal resources were integrated in this model.21,22 In this study we only used elements of the JD-R model, to identify job demands, job resources and personal resources that are relevant for NQMs. We did not use the other components of the JDR model (exhaustion and work engagement) in this study. Job demands are aspects of the job requiring effort and are associated with mental or physical costs, for example work overload, heavy lifting or job insecurity. Job resources help the professional achieve job goals or reduce job demands, such as feedback, job control or social support. Personal resources help employees in achieving goals, such as resilience, optimism, flexibility and self-confidence.20 Participants were NQMs, less than three years after graduation and working in primary midwifery care in the Netherlands. Participants were recruited from course participant lists from continuous professional development (CPD) courses, organized by all four midwifery academies in the Netherlands and from alumni of cohort 2016 of the midwifery academy Groningen. From the participant lists, which included year of

Perceived job demands and resources of newly qualified midwives working in primary care settings in the Netherlands | 29 graduation, we invited eligible midwives by email. All selected NQMs were willing to participate in a focus group interview. The ones that were able to join a scheduled focus group interview, participated in the study. Figure 1. Theoretical model the Job Demands-Resources model.19 We conducted five focus group interviews, with four to ten NQMs each. Focus group interviews were conducted until data saturation was reached. The interview questions were based on a topic guide (see appendix A) which was derived from previous literature on NQMs and the JD-R model.19,20,22 Four focus group interviews (A-D) took place after a CPD course, where the participants were recruited. One focus group interview (E) was held as a stand-alone event at the midwifery academy in Groningen. The interviews were facilitated by trained moderators and observed by a researcher or research student. The observer took the audio recordings and notes. All participants were first asked to sign a consent form, and then answer four questions on paper about their first period in practice (see appendix B). The moderator started the group discussion by inviting participants to share their notes with the group members. The moderator asked questions for further explanation and invited all participants to join the discussions. In the fourth and fifth focus group interviews, categories and themes from the first analysis were added as input at the end of the interview session. Participants were asked if they recognized themselves in the specific categories and themes. As interviews four and five did not yield any new information from participants, data saturation was assumed to have been reached. The interview records were transcribed.

30 | Chapter 2 MAXQDA (11.0) was used to analyze data. The transcribed interview content was analyzed thematically. After three focus group interviews, two researchers (LK, EF) conducted a first analysis. They individually coded the data, underlined text fragments, and both created interpretive codes. Categories were identified for similar codes. The researchers then compared and discussed the categories until they fully agreed. Subsequently, categories were labeled, using the aspects of the JD-R model: job demands, job resources and personal resources. For example, the code: ‘working with other health care providers costs energy’, was labelled as ‘colleagues’ and identified as a Job Demand. Additional themes were added when labels did not match the themes. For example, ‘personal demands’ was added as a new theme. After focus group interviews four and five, the researchers coded, categorized and labelled data from the fourth and the fifth interview transcripts as previous interviews. In line with legal requirements in the Netherlands ( medical ethical approval was not necessary. However, we asked all participants for written informed consent. Confidentiality was guaranteed with anonymous reporting of the data by numbering the interviews and participants. Raw data were saved securely at the University of Groningen. Written consent forms as well as the transcribed interviews are stored and available upon request. RESULTS The duration of the five focus group interviews ranged between 45 and 75 minutes. Fiftyone NQMs agreed to take part with 32 finally being able to participate in focus group interviews. One participant did not meet the inclusion criterion of being less than three years graduated. The data of this participant in the focus group interview were deleted from the transcripts before the analyses. In total, data of 31 female midwives were analysed, with a mean age of 26 years (range 23 – 44). All participants worked in primary midwifery care in the Netherlands. Five (16%) graduated from universities in Belgium and the remainder from academies in the Netherlands (84%, n=26). The majority of the participants worked as a locum midwife (71%, n=22) in different practices, eight midwives worked as an employed midwife (26%, n=8), and one participant was selfemployed as partner in a midwifery practice. Nearly half of the participants worked in an urban area (45%, n=14); the other half of the participants worked in a rural environment (39%, n=12) or in both an urban and a rural area (13%, n=4).

Perceived job demands and resources of newly qualified midwives working in primary care settings in the Netherlands | 31 Table 1. Background characteristics of participants (N=31) Characteristics N (%) Midwifery Academy Amsterdam Groningen Maastricht Rotterdam Belgium 7 (23) 9 (29) 4 (13) 6 (19) 5 (16) Year of graduation 2013 2014 2015 2016 2 (6) 10 (32) 12 (39) 7 (23) Employment Locum Employed Partnership 22 (71) 8 (26) 1 (3) Work context Urban Rural Rural/Urban Other 14 (45) 12 (39) 4 (13) 1 (3) The results are presented in figure 2, using the themes of the JD-R model: job demands, job resources, personal resources and an additional theme: personal demands. In the analysis we used examples of categories within the themes, according to the job demands and resources from Schaufeli and Taris,20 for example work overload, job insecurity, and time pressure as job demands; and positive client contacts, task variety and autonomy as job resources.

32 | Chapter 2 Figure 2. Job demands, job resources and personal resources experienced by Dutch primary care midwives (N=31) Job demands Important job demands (figure 2) are working as a locum midwife, balancing work and private life, adjusting to local practice and protocols, dealing with emotions from clients, and administrative and organizational tasks. Working as a locum midwife was experienced as highly demanding. NQMs faced unexpected challenges, such as the number of shifts they have to work on a fulltime basis and working shifts in different practices. On the one hand, employers expected flexibility from NQMs, as they needed the locum midwife to fill a gap in the work schedule. NQMs wanted to work as much as they could, so they took all the work they could get. The reasons for this were twofold: for themselves, to gain experience and, secondly, to appear employable to their employers. Participants stated that they have to learn to manage their work hours and to have sufficient time off. Yes, you know …you have no job-security, so you take all the work you can get everywhere. And, yes, I can recall, the insecurity that belongs to locum midwifery … that increases pressure”. (A1) You want to work everywhere and therefore you will cross personal boundaries. (D5) As a locum midwife, NQMs had to learn to get the right amount of work as well as balancing work and private life. Combining work with their private life was also mentioned as physically and mentally demanding. During on-call shifts, they had to sleep within the practice area, which affected their private life, especially for NQMs with partners and children. The irregularity in working hours also influenced leisure time activities. When I was working, everything went all right, but when I was at home, I collapsed so to speak. Then, emotions came up, so to speak. (B1) Colleagues were mentioned as both a demand and a resource. Support from colleagues was mentioned as a resource for NQMs, but as a locum midwife, colleagues were also their employers. NQMs worry that consulting a colleague may imply incompetency. Participants mentioned that they are aware of their colleagues’ different roles. I can deal very well with my colleagues, but sometimes when I am in doubt about a small issue, I think: yes, I can call my colleague, but then they could think: why is this employee working for us? (D7)