Professional Documents
Culture Documents
Thesis
Sunniva Engelbrecht
Roskilde University
Faculty of Psychology, Philosophy and Science Studies
Ph.D. Thesis
Sunniva Engelbrecht
Acknowledgements.............................................................................................. 7
Abstract ................................................................................................................ 9
Resum ............................................................................................................... 13
Chapter 1: Introduction.................................................................................... 17
1.1 Research interest, research field and research question...................... 17
1.2 Research approach .................................................................................. 19
1.3 Relevance .................................................................................................. 21
1.4 Structure of the monograph ................................................................... 22
Chapter 2: Theory ............................................................................................. 25
2.1 Introduction and organisation of the chapter....................................... 25
2.2 Burnout research throughout the last 30 years .................................... 25
2.2.1 Historical development from phenomenon to syndrome .................... 26
2.2.2 Burnout: symptoms, definitions, and measurement............................ 28
2.3 Selected motivation concepts .................................................................. 46
2.3.1 Implicit and explicit motivation .......................................................... 47
2.3.2 Commitment ........................................................................................ 49
2.3.3 Flow..................................................................................................... 52
2.3.4 Motivational concepts developed from within burnout research........ 53
2.3.5 Relationship and overlap between motivational concepts introduced
above .................................................................................................... 56
2.3.6 The relationship between motivation and burnout.............................. 56
2.3.7 The existential model of burnout ........................................................ 57
2.4 Selected empirical studies on the relationship between motivation and
burnout..................................................................................................... 59
2.5 Work Family Conflict (WFC)................................................................. 65
2.6 Emotions at work ..................................................................................... 68
2.6.1 Concepts of emotion work .................................................................. 68
2.7 Summary and conclusion ........................................................................ 73
Chapter 3: Epistemological reference frame and method ............................ 75
3.1 Introduction.............................................................................................. 75
3.2 Phenomenology as research paradigm .................................................. 77
3.2.1 The phenomenological method ........................................................... 79
3.2.2 Context dependency ............................................................................ 84
3.2.3 The use of theory throughout the monograph ..................................... 85
3
Acknowledgements
The present Ph.D. thesis was written at the National Institute of Occupational
Health (NIOH) in Copenhagen, Denmark which in cooperation with the Danish
Research Agency provided me with the financial resources to carry out this
research. The NIOH has been my physical workplace for the time living in
Copenhagen and many of my colleagues at the NIOH have supported me in the
course of this Ph.D. project. I want to thank: Vilhelm Borg for encouraging me
to apply for the Ph.D. scholarship; The colleagues at the former psycho-social
department of NIOH Copenhagen for welcoming me as non-Danish research
colleague, holding space at times when my Danish was far from perfect and not
at least for inspiring me professionally in many ways; Elizabeth Bengtsen, Rikke
Nilsson, Birgitte Helm Nr, Elisabeth Frederiksen from the institute library, for
their knowledgeable and friendly support in searching and ordering literature for
me; the technical support staff at NIOH for help with connecting me virtually;
Sofie LaCour Mosegaard who transcribed the interviews; Ingrid B. Lauritsen for
support with the design and drawing of figures; Anna Garleff, Pia Gotterup,
Bodil Holst for helping me with the problem of handling three languages by
translating and correcting in a thorough and clear way. Palle rbk, Kim
Winding and Elsa Bach for having trust in me and going unconventional ways in
regard to physical presence at work after our move back to Germany in April
2003. A special thanks to Marianne Borritz for being an exceptional friend and
colleague.
Those midwives who gave insight into their experience of motivation and
burnout at work I want to thank. I honour their extracurricular interest and
engagement by supporting me with invaluable insight in their field of work. This
may be the place to explain about the picture on the cover of this Ph.D. thesis. It
was painted of my 4-year old daughter Muriel on one of the busy days during
the fall of this year. She gave it to me as a present and I put it up on the wall of
my office at home. While I was finishing this thesis it caught my eye often and
7
sometimes I had the feeling it was talking to me about the midwives I was
writing about. The expressive eyes, wide open, looking at the recipient of her
service. The mouth is smiling a big smile but in the next moment is freezing into
a stressed face. Large hands and fingers reaching out to help giving birth and yet
seeming to be separated from the core of her body. It is a perfect picture to
express what I have learned about motivation and burnout in midwifery which is
content of the present Ph.D. thesis.
Grateful thanks I owe Birgit Aust for taking responsibility of being the project
supervisor at NIOH at a critical point of the project. The constructive feedback
and structural help on the Ph.D. thesis has been an invaluable support.
Furthermore, I want to thank Peter Olsn for taking the responsibility to be my
main supervisor and helping me through the administrative jungle of a Ph.D.
process. In Hamburg I want to thank Maren Masberg for opening the door to the
qualitative research group at the University of Hamburg and for being a sparring
partner in a short but exciting period of the project. A warm remembrance goes
to Uschi Brucks an outstanding model of an impeccable researcher who died too
early and whose knowledge and firm scepticism I immensely missed in the last
phase of the project
A Ph.D. thesis cannot be written without the support in private life. A special
thanks to Anne Sluhan, my dear American friend, who opened her house for me
whenever I needed to be in Copenhagen for work, and who supported me
emotionally through periods of having enough. My AuPair girl Anna
Baghdasaryan from Armenia deserves a big thank you for helping with all the
practical things in the house. A loving thank you goes to my emotional buddy,
spiritual source, and dear husband Frank for being just as he is. I dedicate this
work to Muriel and Tali, my too little girls, who cheered me up at points of
burnout and showed me that life goes far beyond writing a Ph.D. thesis.
Sunniva Engelbrecht
8
Abstract
This Ph.D thesis summarizes the findings from a qualitative case investigation
on the relationship between motivation and burnout carried out in the field of
midwifery in Denmark. Major interest of the study was to understand the high
burnout score amongst midwives in an ongoing six-year prospective
intervention study in the human services sector (PUMA, Kristensen et al.,
2005a). At baseline (1999-2000), and also in the three-year follow up (20022003), midwives were at the top of 15 job groups from the human services
regarding burnout score measured with the Copenhagen Burnout Inventory
(CBI, Kristensen et al., 2005a). Combined with the interest to understand the
high score of burnout stood the interest to understand the relationship between
motivation (engagement) and burnout in a job group which otherwise has one of
the most meaningful primary tasks defined as helping to give birth. Midwives
are known as a job group highly engaged in fulfilling their primary task.
Therefore, it was both surprising and expected that midwives showed such a
high level of burnout on each of the three scales of the CBI (personal, workrelated, and client-related burnout) at baseline and consistently over time in the
three year follow up investigation of PUMA. It was a surprise as those who were
investigated in PUMA are still at work but nevertheless showed a high level of
burnout. The high burnout score in PUMA can also be interpreted as expectable
in the sense that a strong initial motivation is thought to be necessary in order to
develop burnout (Freudenberger & Richelson, 1980; Pines, 1993; Burisch, 1989;
Bssing, 1992; Schaufeli & Enzmann, 1998; Maslach et al. 2001).
Following from this the aim of this case investigation was:
1. To reach an understanding of the high score of burnout amongst midwives
in the PUMA study.
2. To gain insights into the relationship between motivation and burnout in
midwifery in Denmark.
This project consists of two parts: the methodological summary and the
empirical study. In the first part, the project describes the authors theoretical
fore-understanding (Gadamer, 1960/1990) and delineates the methodological
approach. This is done in some depth to clarify the frame of reference and to
exemplify the explicit explorative approach into an established research field
such as burnout research. In the empirical part, the author investigates the
relationship between motivation and burnout using participative observation,
single interviews, and a group interview following a case study approach. Fully
transcribed interviews were analysed using the phenomenological method
(Giorgi, 1985; Malterud, 1996). By using a qualitative in-depth approach
grounded on a subject theoretical perspective (Dreier, 1993 & 1994 in Pedersen,
2002), the author sheds light on how the relationship between motivation and
burnout in the field of midwifery can be understood.
The case study approach yielded the following findings: Firstly, midwifery was
described by the case study participants as highly-demanding with regards to
work time, work pace, responsibility, low decision latitude, client demands, and
emotional demands. A high level of engagement in the job was described as
necessary precondition and is expressed as exceptionally professional self, good
work spirit and high care for others, frequently leading to over-dedication and
high commitment as well as an exaggerated feeling of responsibility as typical
characteristics of a midwife.
Some person-related and work-related factors of burnout were described by the
participating midwives. Biological age and generation membership (understood
as membership to a group being educated at the same time, having the same job
age) were described as playing a role in the development of burnout. Younger
generation midwives were described as having a different occupational identity
from older generation midwives in regard to the acceptance of high demands
and low resources at work. As work-related issues, working time was discussed.
Shift work was viewed to be a critical and in principal unchangeable condition
10
12
Resum
Afhandlingen sammenfatter resultaterne fra en kvalitativ case-undersgelse, som
omhandler forholdet mellem motivation og udbrndthed blandt jordemdre i
Danmark. I afhandlingen er der lagt stor vgt p at forst den hje hyppighed af
udbrndthed blandt jordemdre i et igangvrende 6-rigt prospektivt
interventionsstudie i socialsektoren (PUMA, Kristensen et al., 2005a). Iflge
CBI (Copenhagen Burnout Inventory, Kristensen et al., 2005a) viste
baselineundersgelsen (1999-2000) og den efterflgende 3-rs follow-up
undersgelse (2002-2003), at jordemdre l i toppen af 15 udvalgte jobgrupper i
den sociale sektor, hvor udbrndthed var mest markant. Foruden at fokusere p
at f belyst den hje hyppighed af udbrndthed fokuseres der ogs p at f
belyst forholdet mellem motivation (engagement) og udbrndthed indenfor en
faggruppe, som normalt er karakteriseret som at have en af de mest
meningsfyldte og vigtigste opgaver defineret som fdselshjlper. Jordemdre
hrer til en faggruppe, hvor et stort engagement er pkrvet for at opfylde deres
vigtigste opgave. Det var derfor meget overraskende og uventet, at jordemdre
udviste en hj hyppighed af udbrndthed p hver af de tre CBI-skalaer
(personligt, arbejdsrelateret og patientrelateret udbrndthed) ved baseline og
konsekvent over tid. Det var overraskende, at de personer som deltog i PUMAundersgelsen stadig er i arbejde men ikke desto mindre udviste en hj
hyppighed af udbrndthed. Den hje hyppighed i udbrndthed i PUMA kan
ogs tolkes som forventet, dvs. forstet sledes, at en strk motivation i
begyndelsen er ndvendig fr man kan komme til at fle sig udbrndt
(Freudenberger & Richelsen, 1980; Pines, 1993; Burisch, 1989; Bssing, 1992;
Schaufeli & Enzmann, 1998; Maslach et al. 2001).
P baggrund af dette er formlene med denne undersgelse flgende:
1. At forst hvad der ligger bag den hje hyppighed af udbrndthed blandt
jordemdre i PUMA-undersgelsen, og
13
16
Chapter 1: Introduction
18
19
In the literature, different expressions for the German Vorverstndnis (Gadamer, 1990) are
used: fore-meanings, fore-conception, fore-structure of understanding, or fore-understanding.
For the sake of consistencey fore-understanding is used in the present monograph.
20
1.3 Relevance
Gathering more knowledge about the relation between motivation and burnout is
relevant in regard to three different aspects. First, the relation between
motivation and burnout which would explain the onset, development, and indeed
the whole process of burnout, has not been investigated sufficiently in
occupational health research. Especially complex and dynamic, ecological
models to explain these phenomena in context are missing. Context specific
knowledge (local understanding and theory) is meant to be an invaluable
resource in order to understand the onset and development of burnout. The
present project aims to establish a dialogue between different research traditions,
theoretical assumptions and findings from the field in order to answer the
research question. Second, relevance of the research question is found in the
present organization and structure of work. The shift from mainly industrial
work settings to human service work and knowledge based work has not
attained enough recognition in work psychology models, concepts, and theory
(Skovstad, Einarsen, 1996; Brucks, 1998). The late recognition of emotion work
in work psychological theorizing (Ashkanasy, Hrtel & Zerbe, 2000) is one
example of the need to reflect on the appropriateness of traditional work
psychology approaches (e.g. action theory) in modern work life. Third,
midwives in Denmark (and also in other countries) face a change of working
conditions as result of societal, organisational, and structural changes (e.g.,
health care sector as profit oriented business organization). These changes have
impact on the recipients of service as well as on the service providers. Along
with these actual changes go unchangeable conditions of the midwifes job
which can be regarded as stressful from the start. As the PUMA study has
shown have these conditions negative impact on health and well-being of the
investigated job group. Accordingly, the case investigation is not only relevant
out of theoretical interest but also in a practical sense of providing practical
knowledge for those who work in this field of human service work.
21
and burnout in human service work. In Chapter 8, the core statements and
findings from Chapters 4 to 7 are summarized and reflected and related back to
existing theoretical accounts in the field and explained along the primary task in
midwifery. Challenges for further research are discussed and the practical
implications of the findings for the field of midwifery are outlined.
23
24
Chapter 2: Theory
25
28
Personal
Affective
Cognitive
Physical
Behavioural
Motivational
Depressed
mood,
tearfulness,
emotional
exhaustion,
changing
moods,
decreased
emotional
control,
undefined fears,
increased
tension, anxiety
Helplessness, loss
of meaning and
hope, fear of
going crazy,
feelings of
powerlessness and
impotence,
feelings of being
trapped, sense of
failure, feelings of
insufficiency,
poor self-esteem,
self
preoccupation,
guilt, suicidal
ideas, inability to
concentrate,
forgetfulness,
difficulty with
complex tasks,
Rigidity and
schematic
thinking,
difficulties in
decision making,
daydreaming and
fantasising,
intellectualisation,
loneliness,
diminished
frustration
tolerance
Headaches,
nausea, dizziness,
restlessness,
nervous tics,
muscle pains,
sexual problems,
sleep disturbances
(insomnia,
nightmares,
excessive
sleeping), sudden
loss or gains of
weight, loss of
appetite,
shortness of
breath, increased
pre-menstrual
tension, missed
menstrual cycles,
chronic fatigue,
physical
exhaustion,
hyperventilation,
bodily weakness,
ulcers, gastricintestinal
disorders,
coronary disease,
frequent
prolonged colds,
flare-ups of preexisting disorders
(asthma,
diabetes), injuries
from risk-taking
behaviour,
increased heart
rate, high blood
Hyperactivity,
impulsivity,
procrastination,
increased
consumption of:
caffeine, tobacco,
alcohol,
tranquillisers, illicit
drugs, over- and
undereating, high
risk-taking
behaviours (e.g.
sky-diving),
increased accidents,
abandonment of
recreational
activities,
compulsive
complaining
Loss of zeal,
loss of idealism,
disillusionment,
resignation,
disappointment,
boredom,
demoralisation
29
pressure,
increased electrodermal response,
high level of
serum cholesterol
Personal
(continued)
Interpersonal
Irritability,
being
oversensitive,
cool and
unemotional,
lessened
emotional
empathy with
recipients,
increased anger
Cynical and
dehumanising
perception of
recipients,
negativism with
respect to
recipients,
lessened cognitive
empathy with
recipients,
stereotyping of
recipients,
labelling
recipients in
derogatory ways,
blaming the
victim, air of
grandiosity, air of
righteousness,
martyrdom,
hostility,
suspicion,
projection,
paranoia
Violent outbursts,
propensity for
violent and
aggressive
behaviour,
aggressiveness
towards recipients,
interpersonal,
marital and family
conflicts, social
isolation and
withdrawal,
detachment with
respect to
recipients,
responding to
recipients in a
mechanical manner,
isolation or
overbonding from
other staff, sick
humour aimed at
recipients,
expression of
hopelessness,
helplessness and
meaninglessness
towards recipients,
using distancing
devices, jealousy,
compartmentalisation
Loss of interest,
discouragement,
indifference
with respect to
recipients, using
recipients to
meet personal
and social
needs,
overinvolvement
Organizational
Job
dissatisfaction
Cynicism about
work role,
feelings of not
being appreciated,
distrust in
management,
peers and
supervisors
Reduced
effectiveness, poor
work performance,
declined
productivity,
tardiness, turnover,
increased sickleave, absenteeism,
theft, resistance to
change, being overdependent on
supervisors,
frequent clock
watching, going by
the book, increased
accidents, inability
to organize, poor
time management
Loss of work
motivation,
resistance to go
to work,
dampening of
work initiative,
low morale
30
Lists of symptoms are impressive for illustrating the broad character of the
recent description of burnout, but they are also confusing, as they do not lead to
differential insight and are not useful as basis for research. Schaufeli &
Enzmann (1998, p. 30) summarize the following problems in regard to laundrylists of symptoms:
1. Most symptoms result from uncontrolled observations rather than from
empirical studies. Validity might be low.
2. Symptoms listed are rather indefinite.
3. Throughout the process of development of burnout symptoms may change
from one symptom into the opposite, e.g. over- or under-involvement
4. Different patterns of burnout are assumed, showing different groups of
symptoms.
5. Symptoms, precursors, and consequences of burnout are confused.
Schaufeli and Tarris (2005) point out that the strategy to include as many
burnout characteristics as possible should be discouraged. Instead, they
recommend looking for the smallest number of core symptoms that bear
theoretical meaning and that are sufficient to characterize burnout.
31
Freudenberger &
Richelson
1980
1986
1988
1989
Burisch (1993,in
Rsing, 2003, p.
63/65)
1997
32
Burnout definition
to fail, wear out, or become exhausted by making
excessive demands on energy, strengths or
resources. (in Sderfeldt, 1997, p. 17)
a state of fatigue or frustration, brought about by
devotion to a cause, way of life or relationship that
failed to produce the expected reward. (in
Sderfeldt, 1997, p. 19)
The first stage involves an imbalance between
resources and demands (stress). The second stage is
the immediate, short-term emotional tension, fatigue,
and exhaustion (strain). The third stage consists of a
number of changes in attitude and behaviour, such as
a tendency to treat clients in a detached and
mechanical fashion, or a cynical preoccupation with
gratification of ones own needs (defensive coping).
Burnout is a syndrome of emotional exhaustion,
depersonalisation, and reduced personal
accomplishment that can occur among individuals
who do people work of some kind.
a state of physical, emotional, and mental
exhaustion caused by long term involvement in
situations that are emotionally demanding.
Burnout has a certain gestalt quality, including
configurations of symptoms, lifestyles, modes of
thinking, job situation, and so on.
Burnout embraces one, several, often all of the
following signs: over or underactivity; feelings of
helplessness, depression and exhaustion;, inner
restlessness; reduced feeling of self-confidence and
demoralization; declining social contacts; active
effort to change the condition (translated by the
author, sen).
(Burnout)represents an erosion in values, dignity,
spirit, and will an erosion of the human soul. It is a
malady that spreads gradually and continuously over
time, putting people into a downward spiral from
which its hard to recover.
2001
Schaufeli &
Greenglass, 2001, p.
501 (in Kristensen et
al., 2005a)
Kristensen
2005
33
burnout from Maslach & Jackson (1986). Burnout is, in most publications,
defined as restricted to the sphere of work but spill-over effects to private life
are discussed (Burke & Greenglass, 2001).
35
36
38
Even though many aspects in Burischs conclusion might be right, the baby
should not be thrown out with the bathwater. At the end of the chapter, relevant
findings concerning to the relation between motivation and burnout are
introduced and discussed. In the following table strengths and weaknesses of the
contemporary burnout research are summarized.
Table 2.3 Strength and weaknesses of contemporary burnout research
Strengths
Weaknesses
39
The listings in Table 2.3 make clear that strengths and weaknesses of
contemporary burnout research are two sides of the same coin. The
measurement of burnout is regarded as a serious problem at present. The
extensive and mostly uncritical usage of the MBI in 90% of the published
studies on burnout must be viewed critically. Newly developed instruments,
such as the CBI, challenge the established concept of burnout and spark the
needed discussion to further develop the burnout concept. However, also the
CBI stays within the established paradigm of burnout research (Kristensen et al,
2005a).
The predominance of cross-sectional, quantitative studies using self-ratings
(mainly the MBI) to measure burnout must also be viewed critically. More indepths studies, using other approaches to gather knowledge than focussing on
the correlation between two pre-defined concepts are necessary to overcome the
one-dimensional research approach. A different path has been started with the
planning and realization of longitudinal studies on burnout. Throughout the last
years, more prospective studies have been conducted, which leads to the
assumption that we soon will learn more about the causes and consequences of
40
using categories as diagnosis for a single person or a job group without looking
at the specific constellation of context. By doing this the category burnout
becomes a label and a self-perpetuating process. This is also referred to by
Kristensen et al. (2005a) pointing to the fact that burnout can be seen as a selfperpetuating process: at the moment that results about investigations of burnout
are communicated to recipients, burnout is regarded as an unavoidable
consequence of their specific work setting. A subject theoretical proposal to
overcome some of the problems named by Pedersen (2002, p. 74) is to
investigate burnout as a development of manifold and different subjective
interpretations of action strategies in regard to different historical and local
aspects of the development and organisation of work.
Even though many burnout researchers (e.g., Schaufeli & Enzmann, 1998;
Kristensen & Borritz, 1998; Sderfeldt, 1997; Burisch, 2002; Rsing, 2003)
think that a qualitative approach to investigating the phenomenon could be
helpful to understanding some of the open questions in the field, not much has
happened (Rsing, 2003). It is a striking fact that qualitative, in depth studies
which take the subjective, the individual and the specific into account are hardly
known. Although burnout research originates in the description of subjective
states (Freudenberger, 1974; Maslach, 1976), the scientific development of the
phenomenon has forgotten about the quality of the qualitative. This is mainly
due to the rules of the main scientific community emphasizing big, statistically
sophisticated, and objective study of the phenomenon (Rsing, 2003). So far,
burnout research has undergone a metamorphosis from being a promising new
field of psychological research to developing into an image of its own
conditions. The distance between researcher and person participating in a
research study is huge and has parallels to the state of burnout described as
depersonalised (Rsing, 2003).
Kirkcaldy, Athanasou & Trimpop (2000) introduced a new and promising
qualitative approach in the field of stress research. The focus of the approach is
the subjective understanding of the work context and the idiosyncratic
42
44
certain setting can bring about a meaningful strategy to prevent and cure
burnout. This PhD study, with its in-depth qualitative approach is one example
of such an investigation which is needed to understand the specific
circumstances for burnout in a particular job group.
2.2.2.6 Summary
Burnout is regarded as a complex phenomenon in context, with emotional
exhaustion as core property. Further, it is regarded as a process, developing (and
re-developing) in stages with differential properties. In this sense, burnout is
understood as reversible. Personality is thought to have an influence on the onset
(proneness), development, and the coping with burnout. Taking the context into
account, new and important aspects for burnout research come into focus, e.g.
the cure for burnout and the prevention of it. Burnout can develop in very
different contexts, not only in human service work. One might want to
differentiate the sources of burnout. From the individuals point of view,
burnout causes can originate in personal as well as social problems. Last but not
least, burnout causes tremendous suffering, which needs some form of serious
recognition beyond the recommendation of Go, take a break! Beyond that, is
burnout understood as a slowly developing process throughout which a person
and his/her social field need to be attentive to early changes of a persons
attitude, behaviour, and decline in emotional well-being. This is to a certain
point paradoxical because burnout processes are slowly developing, most of the
times first recognized when serious limitations have occurred. By any means
this is a huge challenge for most modern work places where resources are cutdown to a minimum.
Burnout research has a poor theoretical foundation. This is due to the
complexity of the phenomenon and the in some parts existing overlap to other
concepts. An approach taking the subjective into account will open up new
perspectives in the field. The recommendation to investigate single cases in
order to understand the subjective causes and consequences of burnout better
45
(Schaufeli, 1998; Burisch, 2002; Rsing, 2003) is put into practice with the
present case study of motivation and burnout in midwifery.
2.3 Selected motivation concepts
Motivation is an umbrella term for a wide array of very different concepts in
psychology, ranging from attitude, belief, idealism, involvement, commitment,
goals, expectancies, intentions, aspirations and meaning, to emotions. The
interest in motivational concepts in work and organizational psychology lies in
their ability to explain why people put effort and energy into the things they are
engaged in. Motivation in the work setting is best described by referring to what
a person does (direction), how hard a person works (intensity), and how long a
person works (persistence) (Kanfer, 1990). In order to organize motivational
constructs, Kanfer (1990) groups them in three related paradigms: (a) needmotive-value, (b) cognitive choice, and (c) self-regulation-metacognition.
Theories in the need-motive-value paradigm look at the role of personality,
stable dispositions, and values as a basis for behavioural variability. Theories in
the cognitive choice paradigm focus on cognitive processes involved in
decision-making and choice. The description of motivation in the third
paradigm focuses on self-governing cognitive mechanisms that determine the
transformation of motivational force into behaviour and performance. Further,
motivation theories can be posed on a continuum of proximal and distal
constructs. The impact of distal constructs on behaviour and performance is
often indirect. At this end, needs, personality and interests might be found.
Proximal constructs, on the other hand, focus on motivational constructs at the
level of purposive action, e.g. goal setting theory (Locke & Latham, 1984).
Distal and proximal theories of motivation generate complementary knowledge
about the motivational system.
In this following section, three relevant concepts of motivation in relation to
work life are introduced, representing different motivational approaches on the
continuum from proximal to distal and the three paradigms described above.
46
47
dimensions has recently found more and more scientific recognition and proves
to be a valuable motivational approach - also in applied research (Niitamo,
1999). The PSI theory provides an integrative framework by combining
knowledge about personality traits with approaches to motivation, volition, and
emotion. The concept of implicit and explicit motivation is valued as important
perspective in the work context, as implicit motivational processes are thought
to have important influence and consequences for well-being (Brunstein,
Schultheiss, Grssmann, 1998). Moreover, the implicit component of motivation
is a neglected side, especially in work motivational research. This is interesting
as in research on knowledge transfer and transactional memory systems in
organizations concepts of implicit knowledge are of exceptional importance for
the understanding of information processing and knowledge development in
modern organizations (Masberg, 2004). Furthermore, has implicit knowledge
proved to have an influence on the emotional exchange of a person with his/her
environment (Herbig, 2001).
2.3.2 Commitment
Organizational commitment can most concisely be described as a
psychological state linking employees to their organization (Meyer & Allen,
1997, p. 23). There is some consensus among commitment researchers to
understanding commitment as a multidimensional construct, but less consensus
about what kind of dimensions there are to be described. The most prominent
model of commitment at the workplace at the moment is the three dimensional
model (ibid). According to this model, commitment can be described by (a) the
employees relationship to the organization (affective commitment), (b) the
awareness about the costs of leaving the organization or the need to remain there
(continuance commitment), and (c) the felt obligation to continue employment
in the organization (normative commitment). Commitment is commonly
regarded as a win-win-situation for employer and employee: for the individual
commitment is thought to lead to a feeling of social identity; for the
49
develop serious health problems, such as burnout, because he/she does not take
the time to care for herself. Tan & Akhtar (1998) stress the point that
organizational commitment has culturally-bound connotations. The influence of
culture on the globally used construct of commitment might be a strong
predictor when investigating the relation of commitment and health related
outcome factors, such as burnout.
Dlugos & Friedlander (2001) formulate a working definition of passionate
commitment based on the concepts of optimal experience (Flow,
Csikszentmihalyi, 1990), burnout and burnout prevention (Cherniss, 1995;
Grosch & Olsen, 1994) and commitment (Marks, 1976 in Dlugos & Friedlander,
2001). Passionate commitment is defined as (a) a sense of being energized and
invigorated by ones work, (b) the ability to continue to love and thrive on ones
work; (c) be in balance in other life areas; and (d) a sense of energizing and
invigorating those with whom one works. On this conceptual background,
twelve peer-nominated psychotherapists were interviewed to provide an
understanding of their high levels of work-commitment by identifying
behavioural, existential, interpersonal, and personality factors that they might
have in common. For the purpose of testimonial validity (Stiles, 1994; in Dlugos
& Friedlander, 2001), self-ratings were conducted as well. Interesting in the
context of the present project is the result that all persons interviewed showed a
high level of personal accomplishment, suggesting that participants viewed
themselves as competent and successful in their work. The results for emotional
exhaustion and depersonalisation reach from low to moderate (two scoring high
on depersonalization) but remain uncommented on by the authors.
In summary, the concept of commitment introduced above is thought to supply
an interesting perspective when investigating the research question of how to
understand the relationship between motivation and burnout throughout the
following chapters. The inclusion of the commitment concept as one possible
addition to understanding work motivation addresses explicitly the relationship
51
between the organization and its different levels and the person working in a
particular setting. In reference to the three paradigms described by Kanfer
(1990), commitment is regarded as a cognitive choice approach to motivation.
2.3.3 Flow
Mihaly Csikszentmihalyi first introduced the concept of flow 30 years ago
(Csikszentmihalyi, 1990). Flow describes a state of optimal experience; an
optimal balance between opportunity and ability, according to its own
requirements, without interruptions. This kind of experience is called autotelic,
referring to the Greek words autos=self and telios=goal; self-rewarding. The
state of optimal experience is described by the following characteristics: (1)
Merging of action and awareness; distortion of time perspective; (2) undivided
intentionality because of clear goals; knowledge about means to reach these
goals; and last but not least clear feedback; (3) a loss of self-consciousness in a
positive way; attention is focussed on the demands of the activity and not the
self as an object of awareness.
Csikszentmihalyi calls this state emergent motivation, a motivation which comes
from within the person and is triggered by specific experiences which provide
unique rewards never before encountered (ibid, p. 99). Flow experiences can
occur in almost any situation in life, but work has shown to be the activity which
is most often associated with flow experiences (Csikszentmihalyi & LeFevre,
1989). Intense concentration, involvement, and loss of self-consciousness occurs
most frequently when working and not at leisure (Csikszentmihalyi, 1985, p.
105). The capacity to experience flow can be regarded as an important personal
skill. At the same time, conditions that further the experience of flow will
affect the ease with which people may find optimal experiences
(Csikszentmihalyi, 1985, p. 107).
Flow is defined as the optimal balance between challenge and skill. In situations
where skill is greater than challenge, boredom is present. On the other side,
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when challenge is greater than skill, anxiety is present. Flow is defined as the
diagonal between challenge and skill. At the lower end of the diagonal, anxiety
and boredom are most likely to occur. At the higher end, flow is more likely to
occur. A necessary precondition for the continued experience of flow in a
certain situation is the range of increasing challenges. If challenges are limited,
flow will occur up to the point where routine is reached. Routine at work for
example is often experienced as positive state because of the control and
security reached. At the same time, routine might lead to boredom when
challenges are no longer present. To describe it in Csikszentmihalyis words:
Higher up the diagonal, behaviour is more complex because more
differentiated responses are required to meet the demands of the situation.
Therefore, the experience might be described as being more deep, since the
cognitive and affective skills involved require more psychic energy to acquire,
and the attention is more concentrated (Csikszentmihalyi, 1985, p. 109). This
process leads to personal growth.
energy, involvement, and efficacy; the direct opposites of the three burnout
dimensions. In the process of burning out, energy turns into exhaustion,
involvement turns into cynicism, and efficacy turns into ineffectiveness
(Maslach et al. 2001, p. 416). According to the authors of the concept,
engagement can be differentiated from other established constructs in
organizational psychology, such as job satisfaction, organizational commitment,
or job involvement. Engagement focuses on the relation to the work itself,
unlike organizational commitment, where the employees allegiance to the
organization is centre of attention. Job satisfaction is defined as the source of
need fulfilment and contentment. Job involvement is similar to one component,
involvement, but does not include energy and effectiveness. Engagement seems
to be the broader concept, providing a complex and thorough perspective on an
individuals relationship with work.
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useful, and important in the larger scheme. Pines assumptions are based on the
thought that modern human no longer shares the strong religious belief of Gods
will. Instead, work is meant to fulfil meaning in life. Burnout is viewed as the
result of a process which implies an initial state of high motivation and high
involvement. People who are devoted to the work they do and are emotionally
involved, and who expect to derive a sense of existential significance, live in a
higher risk of becoming a candidate for burnout.
motivation and burnout, whereas different motivational concepts are used. The
selection of the first five studies was done on the basis of a comprehensive
search in two databases (PsychInfo and medline) in the year 2000 for the
purpose of writing a review on the relation between motivation and burnout. A
number of 470 references were found in the two databases, searching in the
timeframe between 1980 and 2000. All abstracts were printed out and read. The
table below shows the search category and number of articles found in each
category as well as the number of articles ordered home in parentheses.
Table 2.4 Number of references found in PychInfo and medline
Search category
#Work motivation and burnout#
Number of references
found in PsychInfo
20 (7)
Number of references
found in medline
74 (4)
57 (11)
191 (13)
84 (26)
44 (9)
All articles ordered home were read and evaluated in regard to the nature and
quality of the reference. Even though the review was never written as it was
intended originally, the database was used to find the five references shortly
described below. The search was updated in the year 2003 after the authors first
maternity leave. Selection criteria at this point were relevance in regard to the
research question of the present project.
Above those studies derived from the larger database search the work of Bakker
et al. (1996) and Sandall (1997) should be named in the context of investigating
burnout in midwifery in particular. The first study relates to a more positivist
paradigm whereas Sandalls work makes use of an exploratory multiple case
study.
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that burnout and engagement are to a certain extent antipodes, sharing onequarter to one-third of their variance.
(6) Burnout among Dutch midwives (Bakker et al., 1996)
In a cross-sectional investigation of 200 community midwives in independent
practice Bakker et al. (1996) tried to determine whether burnout amongst Dutch
community midwives can be explained in terms of work load and work capacity.
As indication of workload the average hours a midwife works per week,
percentage of supervised home births, and level of urbanisation is used. Work
capacity is operationalized as work experience (number of years a person has
been working), practice type (number of midwives working in a practice), social
support received (perceived support from significant others), and coping style
(active and passive coping). Burnout is measured with the Dutch translation of
the MBI. Response rate was with 74% fairly high. Some of the findings were
contradictive, e.g. the more hours a midwife worked per week the higher was the
sense of personal accomplishment (PA); a higher rate of home births leads to
less emotional exhaustion (EE) and less depersonalisation (D). Accordingly
number of hours worked was found to be a poor predictor of burnout and high
percentage of home births is thought to reduce the risk of burnout. All three
work capacity variables were significantly related to burnout: more social
support leads to lower levels of EE and D and higher levels of PA. More passive
coping style was related with higher levels of EE and D, no significant
relationship with PA. The following three interaction terms showed significant
correlates with burnout: More passive coping style showed in a significant
correlation between percentage of home births and D. Combination of
percentage of home births and practice type is significantly related to PA. The
third interaction term found was the degree of urbanisation and practice type as
being significantly related to D. Compared to a group of general practitioners
the midwives showed same levels of EE, lower levels of D and higher levels of
PA.
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One conclusion drawn by the authors (ibid) is of particular interest in the context
of the present thesis: for Dutch community midwives supervising births at
the clients home instead of in a hospital maternity ward reduced their risk of
burnout (ibid, p. 180).
(7) Midwives burnout and continuity of care (Sandall, 1997)
Sandall (1997) investigated in a multiple site case study of community based
maternity care the impact of continuity of care on midwives burnout. The data
were gathered at three different sites being located on a continuum of complete
one-to-one continuity of care to continuity within a team. From the interviews
with 48 midwives and key informants three themes emerged from the data
relating to sustainable practice, the avoidance of burnout, and the provision of
flexible women-centred care: (1) occupational autonomy, (2) social support and
(3) developing meaningful relationships with women.
Control over own work organization, social support at work and at home, and
being able to develop meaningful relationships with the women were associated
with reduced burnout. Sandall concludes that models of care that recognize these
factors are more likely to lead to sustainable work practice of the single midwife
as well as to more personalized women-centred care.
in males (Burke & Greenglass, 2001), even though women shoulder a greater
responsibility for family issues than men (Hochschild, 1997).
Midwifery is still a mainly women dominated work sphere. Frankenhaeuser
(1991) could show that stress levels in men and women differ greatly after they
returned home from work (declining for men and accelerating for women),
showing the inability of women to unwind and relax after a demanding work
day, whereas men are able to relax and recover directly after returning home
from work. Therefore, it is reasonable that for women, the demand of one role
interferes with participation and performance of the other role, causing WFC
and consequently leading to health impairments. Jansen et al. (2003)
investigated risk factors for the onset of work family conflict and could show
that these differ for men and women. For women, physical demands, overtime
work, commuting time, and having dependent children at home were found
responsible for being risk factors for the onset of work family conflict.
Burke & Greenglass (2001) could show that work-family concerns accounted
for significant increments in explained variance on all three psychological
burnout components (measured with the MBI). In a comprehensive review,
Allen et al. (2000) report a number of studies focussing on the relation between
WFC and job burnout. There is a significant mean correlation across studies
(.42) for job burnout. Overall, the review stresses the importance of recognizing
the serious consequences associated with WFC.
Geurts et al. (1999) report a clear mediating role of work-home-interference
between work characteristics (worktime schedule, quantitative workload, and
dependency on supervisor) and home characteristics (overtime partners) and
health outcomes (psychosomatic health complaints, sleep deprivation and
burnout). Jansen et al. (2004) examined the effects of different worktime
arrangements on work-home interference, controlling for other work-related
factors, private situation, and health-status. They could show that worktime
arrangements are clearly related to work-home interference. The outcomes are
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of particular interest in the context of the present case study: (1) compared to
daywork, baseline shiftwork was associated with higher work-home interference
overtime. (2) baseline-overtime work and commuting time were especially
critical for part-time workers. (3) Work-home interference at baseline was a
good predictor for changing workhours over time. Altogether, they conclude that
worktime arrangements are a good tool for reducing work-home interference.
In a comprehensive review of existing theory and research in the field of work
family conflict, Barnett (1998) proposes a systemic view onto the subject. A
wide array of the literature on WFC is one-dimensional, focussing only on one
single relationship. However, as Barnett (2000, p. 154) puts it: Clearly people
have multiple roles; they do not have multiple separate selves. Barnett proposes
a model taking an offset in the idea of the family adaptive strategy (Moen &
Wethington, 1992 in Barnett, 1998). The idea is that workers adopt a certain
work/social strategy to meet their various needs. The strategy takes proximal
conditions (personal needs, values, and aspirations, the social system
represented by family, friends, community as a whole and personal
characteristics such as gender, age, race, health status, ability, education, marital
and parental status) and distal conditions (macro economic, social-structural,
and attitudinal factors, workplace policies and practices, as well as job
conditions) into account. Fit describes the extent to which a worker is able to
meet the various components of his/her work/family adaptive strategy. The
complex model suggests a list of different outcomes, ranging from individual
mental and physical health, to spouses needs, child/parent issues, friends,
community, and finally, the workplace. Without going into depth into the
interrelation of work and social spheres, it is safe to conclude that using a
work/social system adaptive strategy will lead to a win-win situation. There is
no doubt that there is considerable influence of one sphere onto the other:
changes at the workplace will have impact on the social world of the employee
as changes in the private social realm will lead to influences at work.
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deep acting, individuals alter how they feel in order to get closer to what is
expected from them to feel, e.g. a midwife is putting herself into an emotional
state of feeling empathy in order to be able to be empathetic in a birthing
situation.
To express positive feelings is not per se bad. It is the estrangement or alienation
from one aspect of self, which has damaging effect on the individual. Kruml &
Geddes (2000) differentiated emotional dissonance from emotional effort and
investigated different acting types in relation to the experience of burnout. They
found, among other outcomes, that the more dissonance between ones own
feelings and the demanded feelings that the workers experience, the more likely
they will be emotionally exhausted. The findings also indicate that people who
are more likely to express their true feelings are less likely to experience
emotional exhaustion. Brotheridge and Grandey (2002, p. 33) could show that
deep acting in service professions contributed to a greater sense of personal
efficacy at work.
In an earlier concept on emotions at work, Strauss et al. (1980, in Brucks, 1998)
differentiate between sentimental work and emotional work. Sentimental work
describes work which takes the wishes, comments and demands of the recipient
into account and is understood always to relate to the primary task. Emotional
work refers to the process of regulating ones own emotions as reactions to the
primary task. On this background, Brucks (1998) discusses a third type of
emotional labour as a specific job demand: the manipulation of feeling of the
other. She describes the relation between a nurse and a patient as being nonreciprocal. In contrast to other human service professions, the object/matter
(health, giving birth) and its quality are not to be seen apart from the other (the
client/patient).
Brucks (1998) points to the shortcoming of many work psychological constructs
focussing on autonomous planned behaviour only to explain human work
behaviour. As one example from burnout theory, she names Burischs integrated
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burnout model (1984, ibid). However, work roles, especially in human service
work, cannot be understood by looking at the side of autonomous planned
behaviour only. Work routine, in the context of the present case investigation, is
understood as the part of work which can be planned ahead and valued after the
criteria of autonomous planned behaviour (Hacker, 1986). Other parts of the
midwifes daily job are not accessible through this approach. Technical mastery
and control are necessary but not sufficient. A birth is a process that goes
beyond technical mastery and control. This other part touches the intimacy of
the other. By doing this, social tensions and emotional entanglement are ready to
occur. The action and reaction of the other is not calculable. In all human service
professions, the recipient plays a particular role. In midwifery, the recipient of
the midwifes service is in an acute state. Even if the person is known
beforehand, her behaviour and the behaviour of the husband and family are not
foreseeable. This is part of the thrill but can also be a challenge for the midwife.
The importance of the service provider-client relationship is further described in
the following section when referring to the work of Zapf et al. (1999, 2001).
Zapf et al. (1999, 2001) combine concepts from the literature on emotion work
(=emotional labour) with action-theory based approaches in stress research. In
action theory, the psychological component of work is defined as a psychic
regulation of work actions. Regulation requirements (hierarchic-sequential
organization of action), regulation possibilities (control) and regulation
problems (stressors) are thought to be differentially related to health and wellbeing. Accordingly, emotion work understood in the framework of action theory
is part of intentional and goal-directed behaviour. In the realm of regulation
requirements, Zapf et al. differentiated between frequency and variety/intensity
of emotion work. Further sensitivity requirements are described as the
necessity to be sensitive and consider the emotions of clients. Emotion work
control is operationalized as a specific form of job control. Emotion work
control describes the extent to which an employee can decide whether and to
what point to show a certain emotion. Emotional dissonance is considered to be
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Figure 2.2 Emotion psychological triangle (in reference to Brucks, 1998, p. 169).
own feelings. A client might evoke certain feelings (e.g., compassion) which go
beyond the personal capacity to control this feeling. In burnout research, it
became obvious that the hope of gratitude from the client, or the motivation
through feeling compassion are not regarded as professional (and in second line
healthy) ways of taking action (Brucks, ibid). Another aspect which seems to be
important in regard to emotional labour in midwifery is the cooperation between
the human service worker and the recipient of service. The extent to which the
human service worker and the recipient (here: client and midwife) can find ways
to cooperate, the better to lower the feeling of non-reciprocity.
Bruckss conclusion reaches so far that emotional labour stands in second line to
the primary task in human service work. At points, emotional labour is even
more important than the primary task. Openness and transcendence of personal
borders are important in order to be open for the feelings of the other. Yet, the
fulfilment of the primary task still needs to be possible. If emotions are
experienced as too overwhelming by the individual, performance of the primary
task is impossible (Brucks, 1998).
2.7 Summary and conclusion
In the previous chapter, the most prominent theories in burnout research were
introduced; some selected approaches to motivation were outlined and an
introduction to research to the fields of work family conflict (WFC) and
emotion work was given. Burnout research has shown to be dominated by the
usage of the Maslach Burnout Inventory (MBI, Maslach & Jackson, 1986),
leading to a vast amount of research studies on burnout but not much
knowledge about complex causes and consequences. Research on work
motivation presented here is also diverse but not nearly as comprehensive. On a
broader level of reflection, it can be concluded that most theorizing in work
psychological research lacks a clear commitment to a specific setting under
investigation. In Table 2.3 (p. 39), strengths and weaknesses of contemporary
burnout research are summarized. The remaining question seems to be how
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3.1 Introduction
The epistemological paradigm a researcher refers to is the expression of a basic
belief system regarding the process of how to reach understanding. Thomas
Kuhn (1970) introduced the term paradigm in order to describe the process of
gathering scientific knowledge. A paradigm is a certain belief system or
mindset, which enables the scientist to relate to new knowledge in a certain way.
At the same time, a paradigm is an entrance ticket to a scientific community.
The knowledge about which paradigm one refers to enables the recipient of
scientific insights to understand the outcome on a deeper level of understanding.
Guba & Lincoln (1994, p. 105 in Christians, 2000, p. 149) emphasize the
importance of the research paradigm, stating that questions of method are
secondary to questions of paradigm, because the paradigm is the basic belief
system or worldview that guides the investigator, not only in choices of method
but in ontologically and epistemologically fundamental ways.
From the analysis of existing theory and research approaches in the field of
motivation and burnout (Chapter 2), it became obvious that there is a strong
need for an in-depth research approach to investigate the relationship between
motivation and burnout. The statistically rather sophisticated approaches of
quantitative research leave some important questions unanswered. This is partly
due to the complex nature of the phenomena in context as well as the diversity
of subcultures and lifestyles in modern society, as well as in organizations.
Research approaches and methods need to take the diversification of modern
ways of living with different contexts and perspectives into account (Flick,
2002; Pedersen 2002). Knowledge needs to be understood as local and transient.
The investigation of a phenomenon is bound up in a specific context; the life
world of the person. Qualitative research has the methodology to investigate
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following must be said: Most of all, natural settings are complex systems with a
variety of influencing factors. The understanding about phenomena in a complex
system cannot be more than an approach to reality. Moreover, the reality of
complex systems is defined as being dependent from the observer and the
observed (Ludewig, 1992). The quality and variety of communicative action
between the two sets the ground for a good fit of findings and phenomena in the
natural setting. The communicative nature of qualitative research takes into
account that understanding and misunderstanding happen in the same way as in
everyday communication. The difference is the reflexive nature of
communicative action. The researcher in the qualitative setting is committed to
reflect on his/her understanding critically on her own (e.g. in a log book,
research diary) and together with others (e.g. colleagues, participants) for the
aim of communicative validation. Last but not least, qualitative research implies
the usage of not-standardized methods. Again, this must not lead to arbitrary
procedures in qualitative research projects. Instead, thorough documentation of
the approach, the chosen procedure of data collection and data analysis, and the
way of interpreting meaning are ways of showing how knowledge is
constructed.
The purpose of the following chapter is to document and describe the research
process from first epistemological assumptions to concrete methodological
steps. Phenomenology as an epistemological paradigm is outlined; the frame for
the research project is described as set by outer conditions and as decisions of
the author; research methods are introduced and described on a practical level in
regard to their realization in the present project; and, at the end of the chapter,
quality criteria for the present investigation of the case are introduced and
discussed.
3.2 Phenomenology as research paradigm
Lamnek (2005, p. 48) describes the different levels of theory within social
research as follows: Epistemological assumptions lead to a paradigm, which
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Bracketing is a step in
phenomenological reduction, in
which the focus of the research is
placed in brackets (Moustakas,
1994, p. 97). Bracketing is a form
of contemplation on the essence of
the phenomenon. An object is
considered precisely as it is
intended by an intentionality in the
natural attitude (Sokolowski, 2000,
p. 49). The form of manifestation
an object has for the subject in the
natural attitude is maintained.
78
necessary and invariant for the object of investigation. Fourth, the remaining
objects give a structure; they are the essence of the phenomenon.
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This step of analysis relates strongly to the text. Natural meaning units are a
more systematized classification of themes from the first step of analysis. This
practical procedure is called coding. In the further process, only those themes
are more closely investigated which seem to be interesting for further analysis.
Malterud (1996) describes a variety of practical advice while coding which are
used as guideline throughout the coding process of the present project:
A double or triple coding of the same meaning unit is not regarded as a
problem, but the code should be checked for precision.
Coding is a systematic decontextualization because parts of the material
are taken out of their former context to relate them to other parts (text
elements) with the same meaning. A matrix can be helpful to get an
overview of the different codes and their origin (interviewee). This table
can be used to validate ones findings at the end.
On the way from raw-data to themes to codes, it is recommended to take
a look back at the logbook (also understood as research diary) once in a
while and reflect on hidden rules used to establish codes and the rules
about inclusion and exclusion.
Through the coding work, principles for decontextualisation are
developed. The analysis can be described as work in progress.
Throughout the process of decontextualisation, meaning units across the whole
material are used in comparison to other text elements which concern a similar
issue.
In the present project, coding is done in the logic of emic coding (Seeberg,
2001), which is described as an inductive coding process based on principles of
grounded theory, e.g. focus for coding are not the questions asked but the
answers given.
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Ad 4) Recontextualisation
The fourth step in phenomenological data-analysis is recontextualisation.
Recontextualisation assures that the patterns found throughout the process of
decontextualisation still resemble the original holistic material and account for
the informants reality (Malterud, 2001). Throughout the first three steps of the
phenomenological analysis, the original material is taken apart in smaller bites
and transferred into abstract language. Then these constructed units are
collected and used to shape and to describe new concepts. To describe the
structure of the phenomenon in more abstract terms, little comments (also
called memos) are written. Each subgroup is put down in a section on its own.
To describe these sections, expressions from the natural meaning units are used.
This description of content is done for each coding group. This is a way of
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showing and making public how the interpretation is related back to concrete
raw material. A headline for the content description is to be formulated.
In the present project, the coded material was structured around four themes:
the description of engagement and burnout, the description of work context, the
role of resources, and emotional demands and feelings at work. In all of these
four sections old knowledge was confirmed as well as new understanding to the
existing concepts of motivation and burnout was added.
Reflection of own procedure using the phenomenological method
The decision to use the phenomenological method is based upon the focus of the
present project. Whereas the grounded theory approach (Strauss, 1998) is
directed towards the inductive process of formulating new theory, the
phenomenological method points at the description of the essence of the
phenomenon. Formulation of new theory is regarded as a by-product. In the
present project, the essence of the phenomenon has different aspects. First of all,
context is regarded as important and as not to be neglected. How to deal with
contextuality when focussing on the essence of the phenomenon in the practical
phase of data-analysis was not clear. The problem was solved by recognizing the
importance of always regarding a phenomenon as a phenomenon in context (see
next section). Second, the two phenomena are each described in relation to one
another. This is different from focussing on one phenomenon in its own right.
Even though the relationship between the two phenomena is focus of the present
project, the two phenomena are described individually. The (assumed)
relationship is not explicitly formulated as a question in the interview guide, but
is mentioned in the introduction of the interview to the participant. This was
decided intentionally in order to keep the focus as open as possible. At the same
time, it could be regarded as a weakness of the design of the single interviews.
For practical reasons, transcribed data was analysed using a computer program
based upon the principles of grounded theory. It has to be recognized critically
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that any computerized logic is a reduction of the whole. Therefore, the fourth
step of the phenomenological analysis is regarded as very important, where the
whole material is re-read in order to make sure that nothing important was lost
in the process of reduction.
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85
top-down process refers to the deductive use of theory, taking the path from a
general theory to the explicit case in order to explain an observation. The
bottom-up process refers to the inductive use of theory. Here, the observation of
a single phenomenon leads to the formulation of a more general description of
the phenomenon. Throughout the inductive process, new names for categories
need to be found in order to sort different observations into categories.
Following this logic, there cannot be a top-down use of theory without taking
the inductive step. Qualitative research projects can be both deductive and
inductive. In any case, it is important to recognize the existing research and
theory in the field in order to set ones own work in relation to existing
assumptions and findings in the field.
Two different research models can be compared to each other: a linear and a
circular model (Flick, 2002; Lamnek, 2005). The linear model describes the
deductive use of theory. The circular model describes the research process as a
movement between existing theories, assumptions about the phenomenon, and
investigation of the case.
Figure 3.1 Model of different research strategies (Witt, 2001, in Lamnek, 2005, p. 195).
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Translation from German: Ein qualitativer Dialog ist nicht autoritr-kritizistisch, sondern
egalitr. Eine Antwort erzeugt in der Regel eine neue Frage (und mglicherweise eine neue
Versuchsanordnung), diese wieder eine neue Antwort usw., bis die Struktur des Gegenstandes
aufgeklrt ist (Kleining, 1986, p. 734).
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and again. It is a challenge to keep ones mind and heart open for any new
aspects in the course of a research project. It is a challenge to stay rational at
points where ones heart is engaged in sympathy for the situation of the
informant. Indeed, it can be annoying to be confronted suddenly with an
interviewee who is stepping out of an already established pattern of meaning.
Yet one should be thankful for any new insights gathered during the course of
the investigation. Conflicting information gives a new dimension of insight into
a social system.
3.3 Formal and methodological frame of the Ph.D.-project
In the following section, the formal and the methodological frame of the Ph.D.
project is described. First, the projects development in the process of working
with the subject is outlined. Second, the PUMA investigation (Danish acronym
for Project on Burnout, Motivation, and Job Satisfaction) is described, being the
basis for the choice of field for the investigation. Third, the role of the researcher
in the project is described. Fourth, the case study approach as an approach to
investigating the relationship between motivation and burnout is introduced.
Finally, the process of entering the field of midwifery is described.
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91
Work-related Burnout
Job
Score
1.
Midwives
44.7
2.
Client-related Burnout
Job
Score
Job
Score
1.
Midwives
43.5
1.
Prison wards
41.2
2.
41.8
2.
Midwives
38.4
3.
Hosp. secretaries
39.4
3.
Hospital doctors
39.8
3.
35.9
4.
Social workers
38.8
4.
Hospital secretaries
37.8
4.
34.1
5.
38.7
5.
Assist. Nurses
36.1
5.
Social worker
33.1
6.
District nurses
38.4
6.
Social workers
35.8
6.
Assist. Nurses
31.4
7.
Assist. nurses
37.9
7.
Nurses
35.0
7.
Nurses
29.7
8.
Nurses
36.9
8.
34.6
8.
Supervisors
26.8
9.
Hospital doctors
36.6
9.
Prison wards
32.6
9.
Hospital doctors
26.7
35.0
31.4
26.2
33.0
29.8
26.3
32.6
29.2
25.8
31.3
28.8
25.3
14. Supervisors
30.8
14. Supervisors
27.9
21.4
29.5
26.4
19.7
Average
35.9
Average
33.0
Average
30.9
Midwives have the highest rating for personal and work-related burnout and the
second highest rating for client-related burnout. The table shows 15-20 points
difference from top to bottom which is regarded as substantial. Differences of 5
points or more are significant for the individual (Kristensen et al., 2005).
92
Midwives are also one of the job groups with similar ranks on all three scales
whereas other job groups have high ranks on one scale and middle to low on the
other (e.g. hospital doctors, hospital secretaries). At the three year follow-up
midwives still showed considerably high ratings on all three scales, as clientrelated and work-related burnout even went up some points and personal
burnout was only slightly below the score measured in the first round of PUMA.
minimum. This led to a distanced position of the researcher. With the reintroduction of interpretive methods as main source of gathering knowledge in a
field of interest, the researchers role changes from the neutral observer to a
catalyst in the process of creating meaning. Becker (1998, in Denzin & Lincoln
2000, p.4) describes the qualitative researcher as a bricoleur, using the aesthetic
and material tools of her craft, deploying whatever strategies, methods, or
empirical material are at hand. In the following, three different aspects of the
researchers role in the post-positivist era are outlined: the researcher as catalyst
for the production of knowledge, the researcher as traveller, and the researcher
as observer. These metaphorical descriptions emphasize the research position
chosen throughout the present project and therefore are introduced in the
following.
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of pre-existing knowledge about a phenomenon. Malterud (2001) defines foreunderstanding as previous personal and professional experiences, pre-study
beliefs about how things are and what is to be investigated, motivation and
qualifications for exploration of the field, and perspectives and theoretical
foundations related to education and interests. It is the personal backpack of
experience, knowledge, hypotheses, perspectives, ready to use as reference
frame, mode for interpretation, and basis of reflection. The explication of ones
fore-understanding is important in order to reach a greater degree of freedom for
interpretation of the empirical material. Within phenomenological research, this
step is called Epoche (Moustakas, 1994). It is the process of setting ones
prejudgements aside and opening the research interview with an unbiased,
receptive presence (Moustakas, 1994). Unbiased, receptive presence is
understood as reflected subjectivity not neutrality. In other words: the better a
researcher has explicated her own fore-understanding about the investigated
phenomenon, the better she is able to differentiate between new insights and old
knowledge about a phenomenon. A good example to illustrate this is
therapeutical work. A psychotherapist is not immune against psychological
disorder but in her work she uses conscious techniques to reflect her work with a
client, e.g. in supervision. Later, in the process of writing about the findings of
the empirical project, the formulation of fore-understanding can serve as point of
reference. The degree of surprise stemming from the empirical data is a
measure of how much new knowledge was found.
95
96
reliable data, because the depth and richness of qualitative data depend on the
trust and contact established between the researcher and her participants
(Malterud, 1996; Fog, 1994). Understanding in the qualitative paradigm is like
dancing an unknown dance with somebody just met. To be able to dance in
harmony one has to be grounded as a person in context, trust the partner to
follow or lead, be sensitive to any signal from the other, and be able to listen to
the inner voice of intuition for movement to music.
98
100
only that this might have induced even more fear, it would in any case
have spoiled my observation with the fear and negative anticipation
which accompanied me through this phase. The second conscious
bracketing happened in regard to the two natural and uncomplicated births
I had. Both of the deliveries went well, strengthening my belief that
natural birth is the best choice to make. This is very much in common
with what I have heard from the midwives I interviewed. At some point
my supervisor shared the concern of my being too much in coalition with
the case study participants, seeing the world through their eyes. The need
to bracket my own fore-understanding and experience at births in order to
come to a better understanding of the phenomenon itself helped me to
qualify my conclusion and understanding from the case investigation
beyond my personal experience.
101
At some points during the single interviews, the author decided not to
investigate further into the subject, because the interviewee signalized clearly
that she was not willing to reflect further on the subject. This might to be
explained by the following outcome of the case study: the heroic description of
an engaged midwife given by the interviewees and at the same time the problem
of describing concrete experiences of burnout in the subjective work situation
(see Chapter 4). From the authors perspective, the interviewees made clear that
they dont want to boil the problem of burnout down to a personal problem
and at the same time they exaggerated the positive feature of being engaged in
the job to an unobtainable level. Looking at this observation through the lens of
ethical consideration makes the acceptance of borders set by the interviewees
evident. In work psychological research, the tension between person-related
factors and work-related factors which are made responsible for causing a
certain condition is a constant point of discussion. It is obvious that a person
contributes to a condition in a particular way (by personality trait, habits,
cultural descent, etc.), but the more important question while investigating
health issues at work goes beyond the single condition. The present project is
actually riding on the edge of this tension. By diving into the single condition,
patterns are found to understand the phenomenon on a more general level. The
investigator (interviewer, observer, field attendant) has the responsibility of
holding the space and balance for a positive tension.
Another ethical consideration was the renunciation of using material from the
interviews which focussed on a particular person, e.g. the management of the
maternity ward. The potential gain by using this information in order to gain a
greater understanding in regard to the research question was estimated as being
too low compared to the risk of offending the management which then could be
traced back to a certain person. At the same time, the author believes that if a
person definitively wants to know who delivered a certain statement, this is
possible with the information given in the book even though the interviewees
name is kept secret.
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The methods used within a case study approach refer to the criteria of qualitative
research, as they are communicative, naturalistic, authentic, and open (Lamnek,
2005). A case study is conducted within a naturalistic setting, employing
communicative methods, such as open or narrative interviews, group
discussions, participant observations, and document analysis.
A case is defined by any kind of social unit, a person, a group, an institution, a
culture, an organisation, a specific characteristic, etc.. The scientific approach to
a case differs from an everyday understanding of a case in the sense that the
scientific approach (also within the interpretative paradigm) reconstructs reality
through controlled cross-understanding (German: Fremdverstehen) (Lamnek,
2005, p. 312). The goal is the identification of extreme, ideal or typical action
patterns, not the observation of singular action, as for example is true for case
analysis within the psychoanalytical setting. The research goal is to produce
information that can be shared and applied beyond the study setting
(Malterud, 2001, p. 485). In the qualitative research paradigm, cases are selected
103
after theoretical sampling procedures. The field of investigation and the single
cases are systematically chosen, either representing an extreme or an ideal type.
The investigation of the present case is done in the natural setting of midwifery
in Denmark. Within the research setting of the investigation of motivation and
burnout in human service work, a maternity ward of a hospital on Zealand,
Denmark is defined as case. More precisely, the group of midwives who already
were involved in the PUMA investigation defines the field of research. Out of
pragmatic considerations, it made sense to follow up with the group who already
committed time and effort into a quantitative investigation of burnout and who
were interested in following up with an in-depth approach. Moreover, a case
investigation asks for some suggestive cases in order to be able to come to a
greater understanding about a certain phenomenon. Two things define the
borders of the case: job definition and voluntary participation. Regarding the
former, only midwives were asked to participate even though there are other
people working at the maternity ward, such as medical doctors, nurses, nurse
assistants. This is taking the fact into account that midwifery has some specific
job features, being important for the investigation of the relation between
motivation and burnout. Through the investigation of motivation and burnout in
single persons (midwives), insights into the relation between motivation and
burnout in midwifery (and maybe even broader, in human service work) are
thought to be possible. The aspect of voluntariness was regarded as important
for an in-depth approach. Qualitative research uses proximal methods and
techniques to approach the field and the single participant. Therefore, it is
important to have the full commitment of a participant, letting her decide
whether to take part or not. Critical in this respect might be a selection bias. It is
possible that only those midwives participated who want to get their opinion
about the issue through. Also the healthy worker effect (McMichael, 1976)
should be discussed; meaning, to get commitment only from those who are
healthy and still at the workplace. The triangulation of methods and the
104
investigation of subunits of the case diminish the selection bias. The healthy
worker effect is not easy to control since only those midwives were asked to
participate who are not absent from work. In the present project, this was
deliberately taken into account because the case was defined accordingly. In the
last chapter of this monograph, different options for further investigations are
discussed. For the present work, both aspects of bias were recognized and
reflected upon but not solved.
In order to get an impression of the group and to give them a possibility to get
acquainted with the mode of questioning throughout the project, they were asked
to discuss positive aspects of the work of a midwife. This first session served as
possibility to establish a first relationship (rapport) with the group. This
happened to be successful: When the actual empirical phase of the project
106
began, participants did remember the authors presentation at the ward even
though almost two years had passed due to maternity leave. In the session the
midwives were asked to discuss the question of: What is positive about being a
midwife? in an open forum.
The following answers were documented by the author:
To get insight into the whole range of life
Get close to people, a great moment (almost religious)
The atmosphere during the delivery, to study the parents
The many sides of the job and the different people you meet
The unpredictability
To guide people through a crisis
Responsibility
To be the expert
Independence
Creativity, find new solutions
Do something that makes people remember me (important to ones selfesteem)
To be appreciated
To see people grow during the delivery
When a team works well
That nature is an incredible and uncomprehensable concept
To get well through a difficult delivery
Always good to talk about when you meet other people
Professional pride
A first interesting discussion about getting well through a difficult delivery
started. Two of the midwives said it was OK that not all deliveries are according
to the book, but that it is nice that they have the opportunity to guide the parents
in a situation where the child is stillborn or in a poor condition. This comment
provoked a hot-headed discussion. To the investigative question of which job
107
group they think they can be best compared with, the midwives were at one
about being best comparable with nurses working in an intensive care unit. The
list of positive characteristics of being a midwife contains some interesting
details. Some of the points mentioned as positive are defined as problematic in
other job settings, e.g. unforeseeability. The aspect of spirituality was rather
surprising and is regarded as enlargement of the authors fore-understanding
about the research interest. The first hurdle to entering the field was passed
when the presentation at the center meeting went well and the participating
midwives signalled interest.
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110
111
Job title
Clinic/on duty
Head of centre
Head of department
Head of centre
Midwife leader
Midwife with special tasks
Chief midwife
Vice chief midwife
Deputy chief
Managing (county) midwife
Principal
Midwife, clinical instructions
Midwife, instructions
Teacher, head of department
e.g. consultant, researcher
Substitute
Middle managers
Managers
Teacher, in practice
Teacher, theory
Other work
Substitute
112
The Table describes different positions in midwifery and the corresponding job
title to exemplify the differences between the positions. In correspondence with
category and title stand different functions of the midwife. It is close at hand that
the difference in function makes also a difference in health status. Besides job
type, two other features of the midwives job seem to be important and need to
be discussed: job age - defined as years on the job, and work load - defined as
birth per year. These two aspects are further reflected on in Chapter 4.
113
115
given birth before) who had a negative first birth experience more often request
a caesarean section. It seems to be of great importance to assure a positive first
birth experience not only for economical reasons but also for health reasons. At
the moment there is an ongoing discussion in the media, the health professional
circles and in the Danish parliamentary health committee about how to approach
a growing number of maternally requested caesarean sections. Further research
seems to be necessary to make a final conclusion but one aspect discussed in a
recent report of the Danish Health Committee (Sundhedsstyrelsen, 2005) is the
need for balanced information about the benefits and risks of a caesarean section
for both mother and child.
The percentage of stillborn children in Denmark went down unexpectedly by
0,1% from 0,5% in 2004 to 0,4% in 2005 even though the gestation age of the
foetus went down from 28 weeks to 22 weeks counting a child as being
stillborn.
116
working conditions but some global questions give a rather good impression of
the global appraisal of the psychological working conditions. About half of the
study participants stated that they are subject to psychological strain at work to a
greater or lesser extent. Comparable numbers are reported for physiological
strain at work. The reported strain is higher in larger organizations with a higher
birth rate (births per year). Another interesting outcome of the investigation is
the list of the three most important reasons named to look for a new job: (1) low
pay level, (2) high workload, and (3) dissatisfaction with the possibility of doing
the work in a responsible manner. The present case investigation took place in
one of the counties investigated in the member survey having a rather high rate
of sickness absence among midwives.
Forms of Observation
Nave
Systematic
Standardization
Transparency
Unstructured, not
standardized
Open
Structured,
standardized
Closed
Observer
Participant
Non-Participant
Degree of Participation
Active Participant
Passive Participant
Reality Orientation
Direct
Indirect
Naturalness of the
Situation
Field Observation
Lab Observation
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Forms of observation move between the poles of the seven dimensions. One
main dispute in social research is the differentiation between cognitiveobservation and emotional-participative experiences of reality. The former is
observation in a limited and empirical form, also described as scientificanalytical. The latter is observation in the sense of understanding. Observation
in the sense of understanding sets the precondition of Adoption of an adequate
mindset suiting the social system observed (Lamnek, 2005, p. 551) 5. This form
of observation comes closer to a pragmatic, everyday form of observation. Good
participant observation needs both aspects. Observation is the way to investigate
behaviour in the real setting. The life world (natural setting) of the participant is
the place for observation. Participant observation is a way to understand
behaviour and routines, which might have become natural and self-explanatory
for the observant.
3.4.2.1 Aims of participant observation
Because not much particular information about the specific work routine of
midwives was accessible to the author, it was decided to do participant
observation at the work place. The observation period served two different
purposes: (1) get a profound insight into the field of midwifery in Denmark, the
organizational work flow at the particular labour ward and to get an
understanding of the overall climate at the ward, as well as (2) to observe a
midwife being on duty throughout a whole shift in order to understand the
particularities of the job, the daily organization of work life, and differences in
fulfilling the job. The daily routines and core tasks were observed and
questioned in order to understand the conditions which are an important part of
the picture looking at motivation and burnout amongst midwives. Data from
participant observation are used as supplement and confirmative asset while
describing and interpreting data from the single interviews and the group
interview.
118
119
120
is a risk for selection bias. This risk is regarded as negligible because the focus
of observation is the organization of work and not the behaviour of the particular
person. A second hurdle to be described goes a step further. The leading
midwife, being the gatekeeper in regard to getting access to the field, plays a
particular role at this point. From her side came the permission for the researcher
to step in at any day at any time. This made life very simple for the researcher
because there was no need to plan long ahead. To approach the field in this
rather surprising way had positive and negative effects. At least with two
midwives being present at the two different shifts resistance could be felt when
the researcher (author) arrived at the ward without having been announced
beforehand. It was a little awkward to step in and demand how things would
work best and be present throughout the whole shift without preliminary
announcement. On the other hand, the surprise factor can be seen in a positive
light. In fact, there was no time to build up assumptions about how it would be
to have a researcher at the side to be ones shadow.
interviewer owns the role of being the one to ask questions, whereas the
interviewee has the role of the one being forced to answer. Nevertheless,
communication in the course of the single interviews is understood as a twosided process, as dialogue (Kleining, 1982). Both interviewer and interviewee
are able to direct the flow of the dialogue, even if the interviewer per definition
has the power to interrupt and ask questions, which lead into a different
direction than expected or even intended by the interviewee. In this sense, the
interview can be understood as an interpersonal drama with a developing plot.
Reality is negotiated between the parties of the communication (Holstein &
Gubrium, 1995). In this post-modern understanding of the interview (Kvale,
1994; Fog, 1994), reality and truth are constructed in dialogue between the
122
interviewer as knowledge and information seeker and the respondent as the one
opening themselves up for the questions asked, interpreting and answering them
in a specific and subjective way.
An important aspect while interviewing another person is what is known as
rapport in the therapeutic setting. Here, rapport is understood as the researchers
ability to take the role of the respondents and to attempt to see the situation
from their viewpoint, rather than superimpose his or her world of academia and
preconception upon them (Fontana & Frey, 2000). Rapport is established
through confidence and trust in the person who is conducting the interview. The
more personal the theme of the interview, the more important it is to have
established collaborative, reciprocal, trusting, and friendly relations with those
studied.
3.4.3.2 Participants
Participants of this case study are midwives employed at a hospital on Zealand,
Denmark. A number of wards of this particular hospital participated in the
PUMA investigation (see section 3.3.2). All midwives (N=49) employed at the
gynaecological ward in the month of October 2002 were asked in written form
to participate in the present case study. A letter, a short form with demographic
questions (Appendix B), and a free return envelope to the authors workplace
address was put into the personal post boxes at the ward. Midwife students were
not invited. Out of 49 midwives employed at the ward at this point, 26
volunteered to participate in the single interview. Approximately 30% of the 49
midwives were working part-time. On average, 2,600 children per year are born
at the ward. Altogether, the author got the impression that the interest in
participating in the case study was quite strong. Different reasons were given for
this interest. Some of the midwives felt that the PUMA study disclosed
important shortcomings and challenges in the work life of midwives that need to
be investigated in more depth. Others were rather discontent with the processing
123
moving on to the next. This procedure enables the researcher to take information
from one interview to the next, going into more depth with an issue of interest.
Throughout the process of investigation stages, it became clear that saturation
(Lincoln & Gobi, 1985) was reached after the first nine interviews.
The following Table (3.4) summarizes the age profile of midwives working at
the ward. As can be seen in the age profile of the midwives employed at the
ward, the middle age group (35-50 years old) is the largest group at the ward (31
out of 49 midwives belong to that group). In the group of midwives being
younger than 35 years there were at total only five midwives.
124
Number of midwives
25-30
31-35
36-40
11
41-45
46-50
12
51-55
56-60
61-65
49
The demographic profile of the final sample for the single interviews (N=9) is
documented in the table below. The purposeful selection of participants was
done hierarchically. From a theoretical point of view, age seemed to be an
important discriminator. In practice, age was not useful as criterion for selection
because many of the midwives are about the same age, ranging from 38 to 58
years of age.
Table 3.5. Demographic profile of interview partners in the single interviews
Interview
partner
Age
Years of
working
as a
midwife
13
Years in
the present
job
Job function
Married
living
together
Other
professional
education
PUMA
participation
38
Number
of
children
at home
4
Midwife
(special tasks)
yes
no
Yes
46
20
18
midwife leader
yes
no
Yes
43
midwife
yes
yes
45
20
17
midwife
yes
no
Yes
49
midwife
yes
yes
Yes
58
33
leading
midwife
yes
no
No
48
12
12
midwife
yes
yes
Yes
50
24
24
midwife
yes
no
Yes
44
18
midwife
yes
yes
No
125
Unfortunately, it did not occur that someone from the group of younger
midwives volunteered to take part in the round of single interviews. A second
order factor was job age. Two groups of participating midwives could be
interviewed, the one being in the middle job-age group (5-10 years old) and the
other being part of the high job-age group (10-20 years old). Midwives who
were only a short time on the job (less than five years) did not volunteer to
participate in the interview. As third order factor, a second professional
education was defined as being a discriminating factor. The group of midwives
was split in half: four of them having had a former education before being
educated as a midwife, five of them having started with midwife education right
after high school. Family status was not a discriminating factor, because all of
the midwives were married or living together with a partner. Of the nine
midwives, three midwives worked with special assignments. Two of them were
in a leading position.
126
way of establishing rapport. The remaining questions from the interview guide
were asked in each interview in flexible order depending on the flow of the
interview. The findings from the single interviews are documented in the result
sections (Chapters 4-7).
Table 3.6.Research questions and related interview questions
Research questions
Interview questions
127
128
3.4.4.1. Purpose
The purpose of the group interview is to
check the results back with the members of
the investigated group. Gobi & Lincoln
(1985) refer to this procedure with the
expression member check. The condensed
information is taken back to the field and
is discussed in the course of a group
interview.
129
The themes in the first column of the table are the headlines for outcomes of the
interview regarded as being important. In the second column, the underlying
research questions are formulated which are to be answered throughout the
group interview. In the third column, interview questions are pre-formulated.
The interview guide for the group interview serves the same purpose as the
interview guide for the single interview: being a flexible guideline in the course
of the interview but not in the sense of a predetermined script. Throughout the
group interviews, an interview guide is especially important in order to keep
focus because of the variety of possible themes that arise during the discussion.
Table 3.7 Interview guide for group interview
Themes
Research questions
Interview questions
Engagement
(Motivation)
Is involvement/purpose at
work described
sufficiently?
Resources and
safety
Emotional
demands and
feelings at work
130
The group interview played the part of both giving and seeking information.
Being designed as a way to member check the results from the single interviews,
four pre-selected topics were discussed: definition of burnout, definition of
engagement, the role of resources for the feeling of security on the job, and the
work at the interface between life and death (traumatic birth incidences). The
participants got first hand information about the outcome of the single
interviews and were asked to supply new or supplementary information about
the four topics. On the background of a recent restructuring of the ward other
burning issues came up in the meantime which proved to be related to the role
of resources in regard to felt security doing the job of a midwife.
Besides the author, a research assistant was present for the course of the group
discussion. She was instructed to make notes about the process and help with the
technical aspects of recording. The same assistant transcribed the single
interviews and was also responsible for the transcription of the group interview.
3.4.4.3 Participants
All midwives at the maternity ward who were contacted for the single interview
were contacted again for the group interview. Both the midwives who already
participated in a single interview and those who did not were welcome to
participate in the group interview. A blending of new and old interview partners
was wished for. A written invitation was sent to each of them with the
possibility of choosing between two different days for participation. Selection
criteria were not formulated in advance because it was expected that all who
volunteered to participate would do so. On the answer sheet, the midwives were
asked to give information about their age, job age, job position, and telephone
number and address in order to be able to compose groups after the principle of
most possible heterogeneity.
131
organizational change. The author kept the balance of letting conversation flow
and keeping focus. A second group interview was not scheduled after the first
because of saturation of knowledge.
3.5 Quality criteria used in the present study
Quality standards for qualitative research are discussed in depth and with
different positions (e.g. Malterud, 2001; Guba & Lincoln, 1985, 2000; Kvale,
1989, 1996; Seale, 1999; Steinke, 2000; Flick, 2002; Lamnek, 2005; see also
Appendix E). In reference to quality standards published by Malterud (2001)
and Mayring (2002, in Lamnek 2005), the quality of the present project was
evaluated using the following quality criteria: (1) proximity to the subject
matter, (2) reflexivity and metapositions, (3) triangulation, (4) validity, and (5)
transferability. In the following sections, the five quality criteria are used to
reflect on the research process of the present case study.
133
closing comments after the group interview referred to the trusting atmosphere
established by the researcher, which made it possible to discuss critical aspects
of work at the ward. Beyond that, the phase of participant observation as the first
step within the case study had a very positive effect for the researchers overall
understanding of midwifery in Denmark. This was useful knowledge in the
single interviews and was positively recognized by the participants through
single comments about the authors knowledge of the subject matter (here
midwifery) expressed in language.
3.5.2 Reflexivity
The second criterion focuses on the reflection of the position as a researcher in
the research process. The researcher in qualitative studies plays an important
role. In Section 3.3.3.4, the importance of reflecting on the fore-understanding
before starting a research investigation is discussed. Malterud (2001, p. 484)
refers to this term with the metaphor of the knowers mirror, relating to the
process of reflecting on each step in the research process in regard to the
researchers own position; the preconceptions brought into the project, and the
metapositions established in order to keep a balanced position as observer. This
second aspect is the reflection of knowledge gathered through qualitative
investigation from an archimedical point of view (Brucks, 1998, p. 12).
Malterud (2001) describes this position as metaposition, creating an adequate
distance from the study setting engaged in. The research has to be focussed and
reflective about the course of the dialogue from a distanced perspective, being
observer of the self and other.
In summary, reflexivity refers to the thorough documentation of the whole
research process from the researchers role to the clear documentation of the
research process. This is even more important when procedures are used which
have not been documented before. Steinke (2000) recommends the use of
134
3.5.3 Triangulation
In order to establish credibility of the investigation, methods of triangulation are
recommended (Lincoln & Guba, 1985; Law et al., 1998; Denzin & Lincoln,
2000; Steinke, 2000). Triangulation furthers to the dependability of an
investigation by using different methods, theories, or researchers in one
investigation. Formerly thought of as establishing validity, triangulation now is
regarded as a quality standard in its own right (Flick, 2002), heightening the
depth, breadth, and consequences of the methodological procedure.
In the context of the present case study, triangulation was applied by using
different methods of investigating the phenomenon. The methods were applied
The research circle at the University of Hamburg (PD Ursula Brucks), the research circle at
the National Institute of Occupational Health (NIOH) and the research circle at Technical
University of Denmark (DTU), Copenhagen.
7
With my colleague Marianne Borritz (PUMA) and the members of the Qualitative Network
at the NIOH (Danish: Kvalinetvrk). Further, an unplanned reflection happened through
discussion of the material with the scientific assistant Sofi LaCour Mosegaard who
transcribed the interviews and was present throughout the group interview. Unintended as so
far as it was not planned beforehand but it yielded interesting information, e.g. about the point
of saturation.
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3.5.4 Validity
Communicative validation can be established through prolonged engagement
and persistent observation, triangulation, peer debriefing, negative case analysis,
and member check.
In the present project, communicative validation was realized by designing the
group interview in the form of a member check (Lincoln & Guba, 1985; Steinke,
2000; see Box 3.5). Interpretations made on the basis of single interviews were
taken back to the participants for discussion in the group interview. The
participants of the group interview were invited to make comments about the
interpretation of results from the single interviews. The member check also
served as a proof of authenticity of the findings.
3.5.5 Transferability
Transferability of results is important in regard to external validity. External
validity refers to the question of what contexts the findings can be applied in
(Malterud, 2001). A prominent aim of research is to reach insights which can be
shared beyond the specific setting of the study. To what degree this might be
possible should be reflected on thoroughly. An important aspect related to
transferability is the way sampling is done. In qualitative research, it is common
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4.1 Introduction
The present project aims to investigate the relationship between two single
phenomena: motivation and burnout. In the light of a phenomenological
understanding, the interviewees were asked about their subjective understanding
of each single phenomenon, relating to their personal experience in job
situations. The interpretive nature of the chosen approach aims to understand the
essence of the phenomena. Accordingly, statements about cause and effect
cannot be made on the basis of the narratives from the interviews because
participants do not distinguish between the two.
4.2 Reactions to the results of the PUMA study
At the beginning of each interview, participants were asked about their first
reaction to the high burnout score found in the baseline investigation of the
PUMA study. Overall, a wide range of different explanations were given which
reached from understanding, to doubt, astonishment, and disbelief. Altogether,
participants were eager to find examples and external reasons for the devastating
results.
Interview 2: 46 years old, 20 years work experience as midwife
The PUMA report was made right after the electronic journal system had been
introduced.
.
Yes, and when an entire ward introduces such a new product at the same time, it
is something that is really hard. The preparations were fine, they had provided
good training, but they had not given us enough support during the
implementation of the system. There was money for new computers but there
wasnt any money for computer work stations. And we also have a couple of
employees on long-term sick leave. That has made a great impression on me that
an apparently healthy, young woman among us suddenly got it as bad as she did.
As learned from the preceding quote, some of the explanations given were quite
simple and at the same time astonishing: e.g., the first round of the PUMA
investigation took place at the same time as the electronic journal was
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The conditions described refer to the whole range of dimensions to estimate the
quality of work: job demands, reward and recognition, job conditions, emotional
demands, leadership quality. The three statements above show the variety of
reasons given by the participating midwives. Taking a single condition as cause
of burnout in midwifery is exaggerating the meaning of the single condition
named. Nevertheless, the variety of reasons named is interesting to note. In the
first interview excerpt, high work demands, paired with low financial reward
and at the same time bad working conditions are made responsible for the high
burnout score in the PUMA baseline study. The second statement refers to one
aspect in midwifery which is referred to as a cause of burnout: the demand to
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give something of one self. In the last interview quote, leadership problems are
meant to be the reason for high burnout.
Interview 4: 45 years old, 20 years work experience as midwife
No- I was also alarmed to hear that our field did so badly. This I have to say, I
was very alarmed about it.
Some of the participating midwives stated they were surprised at the results
from the PUMA study. They stated that they were alarmed and startled about the
devastating outcome.
Interview 7: 48 years old, 12 years work experience as midwife
I was a little surprised that it was so extreme, but I can certainly understand why
you burn out. It is partly the nightshift and the irregular shifts, and I understand
that you get very involved in your work. You familiarize yourself with the work
in another way than I did at the time I was working in a kindergarten. You work
with children, it is an important job, of course it is. But I have never, and that is
why I keep my job, I think it is exciting, and it is not a shallow job where you
just go home from work and that was that. You keep working and you think
about if it was right or wrong. It is wonderful, but I can also understand those
who burn out as they are so involved. You cant just go home and say that was
it. I really understand. If you are not good at working with things afterwards and
get through it, become scared, then I can absolutely understand that you burn
out.
Interview 9: 44 years old, 18 years work experience as midwife
Yes, in a way I was surprised, as you always use yourself as reference, and I
could feel that some things became more and more difficult. You can still
handle it, but I didnt think that they were so burned out. No, that surprised me.
Another thing which surprised me was that the night shifts well you can feel
on your own body is so hard on you. But that it is so dangerous .
The midwives who said they were surprised at the outcome try to make sense of
the findings by looking for suitable explanations. Again, the participating
midwives name clearly the different conditions in the job which are meant to
cause burnout. The reaction of surprise and striving to find meaning in the
results of the PUMA investigation can also be interpreted in the light of a
healthy worker effect: only those midwives who are still on the job are asked
about their understanding in regard to the phenomena of motivation and burnout.
It is reasonable that these midwives have not necessarily experienced burnout or
even just a decline in motivation themselves and therefore are surprised about
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the devastating result from PUMA baseline study. There are also other reasons
one can imagine which could be made responsible for this: maybe they are the
most successful suppressing any sign of burnout and the symptoms of it, or they
are those with the most support at home.
Besides the total understanding and the surprise mentioned by the midwives in
regard to the outcome of the PUMA study, one midwife analysed the outcome of
the PUMA study from the perspective of disbelief.
Interview 6: 58 years old, 33 years work experience as midwife
Well, first I was a little surprised, that I must say, but if you scrutinize the
questions given to the midwives and the answers they gave, then there are some
notes and differences which show it may not be that bad if you analyse it. I think
that the things presented and focused on in the newspapers give a very crude
picture but there are differences. There really are. So when I close-read the text
and the questions again Im not surprised at all Im really not surprised.
No, I dont think they are burned out. I dont. Much of it is just talk; we call it
washroom talk right? Oh yes, she is right etc, etc. We have tried to do
something about it. We have thought, we listen and focus on it and when you
start a debate it is not that bad.
Given up. You will not find that here. The midwives are willing to fight for
things, e.g. a minor procedural thing. No, hell no, we shall not, we should work
for things to become as we want them to be because that is what we think is the
best. Maybe were not always right and then we must surrender at some point
but we will fight. So in that way we are not burned out, we do not give up and
mess about. We really fight. And again, I think we have had some successes in
our lives which make us prepared to fight. So what has been written is not true, I
think, that we are not burned out.
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One interview participant referred to the public discussion of the PUMA results.
Interview 1: 38 years old, 14 years work experience as midwife
You said something about how I thought the results from the PUMA report had
led to some changes or how it had been received..on the other hand, I think
that the report has been poorly recognised by society. Not from the researchers
side but by the general population and the press. Midwives always complain and
they are not willing to make an effort in relation to the woman in labour.
Midwives only want the women to suffer and be in pain so why is it that you
have to feel sorry for the midwives. That is why I think the report has been
received negatively in public.
The results of the PUMA study were not directly addressed by these
interviewees. Frustration was given voice concerning the intervention process
after the results of the PUMA baseline study had been published. Even though
there had been some effort put into investigating the psycho-social work
environment, according to these midwives, no change had happened.
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First, the work conditions are accused of causing burnout. The job of the
midwife is described as fantastic in regard to the primary task but at the same
time, the conditions under which the job has to be accomplished are described as
problematic. Hence, there is a felt imbalance between the pleasure connected to
carrying out the primary task and the problems faced while fulfilling the primary
task. The primary task is regarded as the energizing factor, but the conditions are
experienced as being draining. Especially work-family balance and working
conditions in regard to time (shift work and work at night) are named as critical
factors. These aspects are further referred to in Chapter 5.
Another work-related aspect of burnout is seen in missing recognition (being
heard) from the leadership.
Interview 1: 38 years old, 14 years work experience as midwife
Not being heard when you complain to the management. Not being heard, not
being taken seriously, nobody takes care of you. Showing care for the
employees - if it is not part of ones everyday then you burn out.
.
And then there is the work conditions and also the wage. It is sad to say, but it is
of some kind of importance (laughing).
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them is regarded as important for staying motivated while doing the demanding
job of a midwife.
Lost strength of mind in using yourself in the way you use yourself during a
delivery. You really dont feel like doing it. Maybe you think there have been
too few wonderful experiences and you just feel more and more used.
The interviewees referred to the loss of spirit, interest, and pleasure in carrying
out the primary task of a midwife. This state of feeling demotivated finds
expression on a behavioural level in low energy to get started. It is explained by
the fact that midwives give a lot and are used by their clients continuously and
in different ways. The state of having lost the readiness to give something of
ones self is associated with burnout because this readiness to give is seen as
part of the primary task (job inherent demand) in midwifery.
The second sign for emotional burnout is described as the loss of volitional
control over emotions.
Interview 2: 46 years old, 20 years work experience as midwife
And then .. I have felt that way, and I know of others who have worked here
and felt the same way that you are instable. Cry easily, become distressed and
cant handle the fast shifts which we usually handle quite well. It is like you
finish a delivery and then there are two more so what do we do now. Normally,
we would all be able to say that the paper work should wait but you become
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very pertinacious and say that you must finish the paper work before you can
take on a new assignment, you cant have it all in your head.
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The emotions and emotional reactions described in the foregoing section are
interpreted by the interviewees as signs of burnout. They are described as
reactions to work conditions and unchangeable conditions (such as the possible
exposure to traumatic incidences) in midwifery, which are experienced as
demanding. Emotional demands in midwifery appeared to be a main theme in
the single interviews, which was also confirmed in the group interview.
Therefore, emotional demands in midwifery are discussed in depth in Chapter 7.
you distance yourself from everything and you dont care to participate.
but we have some who are a little slow to rise from their seat (laughing), as we
say. It could also be a different style of working. It could be all kinds of things,
that is difficult to know.
Low client service finds its expression in different aspects described by the
participating midwives: tiredness, losing the sense of responsibility, serving at a
minimum level. The behavioural metaphor used to describe this state is the
promptness of getting off the chair when a client asks for help or a new client
needs to be greeted.
Interview 4: 45 years old, 20 years work experience as midwife
When a person who is burned out comes through the door its like ahhhhh. Sits
down, looks at the whiteboard and says God there is so much to do today, Im
tired, Im exhausted, cant I get something easy to do?.
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A burned out person is described as someone for whom any demand seems to be
too much. Easy tasks are chosen and a distanced position to ones work and the
clients is taken. There is no sign of community and team spirit left. A burned out
midwife cares for herself, not for others. This last aspect is also described in the
following section:
Interview 5: 49 years old, 8 years work experience as midwife
But a person who is burned out can behave in many different ways, but an
example could be when we report to each other and you can see there is an easy
delivery then there is another delivery which you can see can take all evening
and it is pathologic and so many other things then the colleague will always
choose the easy one. Or she starts with saying she is so tired and doesnt have
the strength to do it. That must be being burned out. And it can actually pass on
to the colleagues as you may be a bit irritated if a colleague always avoids the
difficult tasks and takes the easy way. It is okay for a while, but if it lasts for a
long period then it affects the colleagues, I think. Personally I get irritated, it
also affects others.
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The person meant to be prone to burn out is the one who feels responsible not
only for things she has done herself but also for the actions of others. The
rumination about what could have been done to make a difference can lead to a
breakdown because some of the aspects are beyond ones own control.
Group interview
IP2: I think it affects the basic burnout if you resign totally if you put on
blinkers and only concentrate on your own little square and withdraw from
everything. Maybe the burnout isnt so obvious for the others, but you mind
your own things and go home as soon as possible. I think this frustration makes
you less committed. The thing that is lacking is so massive that you just give up.
That is how I see it on the outside
IP4: No, it should be a right, as we talked about before, to be the one who is
burned out. To be she who withdraws and says she will only have the normal
situations afterwards. And Im a little afraid that we are exposed to such
situations at the moment, and then you know that you will be very busy on the
next days shift, you must be there, and be busy for 8 or 12 hours depending on
your shift. It is unfair and impossible.
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The findings from the group interview support the results from the single
interviews. In the group discussion, burnout was associated with resignation and
seclusion on the one side. Beyond this negative behavioural aspect and
supplementary to what was found in the single interviews, burnout is further
described as an adaptive behaviour, understood as a coping mechanism when
demands go too far.
Group interview
IP 3: That is the reason why they frown on a midwife who always cries off and
the other midwives can see that the patient is not cared for properly. In general,
that is not accepted in the group. This lack of acceptance comes out in many
ways, it is deeply rooted in us that we cant accept that.
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carries out. In other words: the midwives described a person being engaged as
one who knows what to do and likes to share her knowledge with others.
Interview 3: 43 years old, 6 years work experience as midwife
One you can look up to and use as a confidante. You can say you feel you can
go to her if you have something to ask about. It shouldnt be that you think: oh
no I cant ask her either because she probably doesnt know and some people
are more insecure than others, or because you think she thinks badly about you
if there is something you dont know.
A person who is engaged at work was described as one who has a lot of
professional knowledge and a high professional work ethic. It is one who can be
asked in cases of insecurity and questions. She can be trusted since she signals
openness and is ready to hand her knowledge on to others. In this sense, she is
described as one you can have confidence in. She is active in the acquisition of
knowledge and shares this knowledge eagerly. It is a person of respect, one you
can look up to.
Interview 1: 38 years old, 13 years work experience as midwife
And at the same time she is full of initiative in relation to that therethat way
there is development all the time, so you dont stagnate.
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A person who is engaged is described as one who has a positive work spirit
expressed through being the pacemaker for others, especially in situations where
work morale is low and frustration spreads. She radiates energy and keeps the
spirit up at the ward. She is ready to do whatever needs to be done. She is not a
complainer as described in Section 4.3.3. She expresses negative critique, but at
the same time also constructive critique. In this respect, she is regarded as
critical but positive, handing energy on to others by giving feedback in a polite
and helpful way.
Interview 7: 48 years old, 12 years work experience as midwife
But she is that type who wants to do it all when you come with the report in the
morning. What shall I do and Ill do it now. Sometimes she leaves the meeting
before it is finished just to go and relieve one of the other midwives. She is also
involved in many other activities at the maternity ward. She is what I call really
involved; positive in her work. Always speaks positively about her work and
colleagues. She lives for her work.
She is seen as a source of inspiration for herself and others. She has a positive
attitude towards her work and is happy for the things she is doing. The love of
the job she is doing is expressed through the passion with which she fulfils her
daily tasks. In addition to the normal tasks of a midwife, she is also engaged in
other job-related but voluntary activities at the ward.
Interview 2: 46 years old, 20 years work experience as midwife
When you are involved . then you radiate joy of being in a work
situation. You take on the tasks that appear, you dont refuse any of them. Such
persons are happy and have energy when they leave their work. They . When
it has been a busy shift and there seem to be more clients than we can handle
then such girls smile and say we must make the best of it. Other colleagues sit
down and ask what to do. It can be an unorganised as well as a much organised
person. It has nothing to do with that. They are good at involving the others.
They spot when their colleagues are having a bad day and help them. They
immediately stand up to receive and say hello to a new client, whereas the others
remain sitting when they say hello. It is important to me that you stand up and
say hello when they arrive at the ward.
A midwife who is engaged in her job is described as being the motor for
colleagues, triggering good spirit and active engagement. She is cheerful even
when the work piles up and looks for good solutions with restricted resources
instead of complaining and mourning about it. Any task is good enough to be
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done. The pleasure of doing the work stands in the centre of the description
above: pleasure to serve, pleasure to give, pleasure to make the impossible
possible. It puts some emphasis on the fact that this kind of behaviour is
independent of being a neat or a disorderly person.
Interview 6: 58 years old, 33 years work experience as midwife
An engaged midwife is one who has the spirit to lead the pregnant women
through a long process. The short process is nothing. But in the morning she
knows that this special delivery will be tough. But she does it with an open
mind, and she says Ill do it, Ill go into that woman and Ill handle it. She
will also deal with all the other things to follow up upon. At the same time there
are offers to participate in various obstetric groups, shift planning etc. and she
signs up for what she finds interesting. She has the energy to do that. She has
four kids at home and a husband who travels etc.. That is what I call being
involved and enthusiastic. That is a midwife who enjoys it, and she has the
ability to accomplish it. There are many of such midwives, especially here.
Spirit and pleasure are also at the centre of the last citation. Pleasure in fulfilling
the job no matter how demanding or challenging a birthing situation might be is
named as a sign of engagement. Further, an engaged midwife is described as a
superwoman, being able to handle the primary task, extracurricular engagement
in work groups, family and home. Moreover, enthusiasm about the work one is
doing is named as sign for engagement.
A person who is engaged is described as one taking care of others. This is not
only true for clients but also for colleagues. She has an eye on everybody being
on the shift that needs to be taken care of. Even if things are running fast, a
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person who is engaged finds the resources to take care of the group spirit. She
promotes a sense of community in order to get over hard periods during a
workday.
Interview 2: 46 years old, 20 years work experience as midwife
It is those who answer telephone calls very calmly. Take the time to listen to
what the caller says. She finishes the call in a proper manner. The engaged
colleagues also see to it that their tasks are accomplished; nothing is left in a
mess.
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the contact is out of balance, the midwife finds herself in a situation of giving
without getting something in return.
A feeling of being responsible for always taking the hard chores is also named
as a cause of losing engagement and developing burnout. A person who feels
responsible for tackling the difficult tasks is regarded as being prone to slide into
negative experiences by being overcommitted. The balance between
responsibility and commitment on the one hand and the concern for ones own
well-being and pleasure in doing the work on the other hand is named as being
important in a demanding field such as midwifery.
Interesting to note at this point, is the description of midwifery as being to a high
degree nurtured by the positive birth experiences and drained by negative
experiences. The absence of positive birth experiences is like cutting out the
heart of the job, leaving behind an empty shell. This aspect needs some
discussion in regard to work organisation in midwifery and the structure of
modern maternity wards with increasing division of labour.
Interview 3: 43 years old, 6 years job experience as midwife
Professionally at work, it could be the managerial problems which are the
reasons why you dont feel they listen to you. Maybe you feel a need for .I
dont know not having so many night shifts or weekend shifts or time off
for a period and then you feel they dont listen. I have seen colleagues become
distressed, and they feel used or abandoned by the management. There is not an
understanding of peoples needs. The management doesnt understand that it
really is a rather hard job. It is physically hard, very hard physically. And if you
feel back pain or in another way feel physically exhausted then you can feel the
engagement as being up here or totally down. If people lie down and say they
cant or wont but go to work anyhow. And then there is the psychological side
of it as it is quite tough sometimes, and some feel let down by the working
conditions which are existent. An example could be that there is too much to do
compared to the amount of people to do it. And then you are in a situation where
you feel that what you do is not enough. It is not because you are not good
enough, it is simply because you are sold out, there are no more hands. It is
extremely frustrating and some break down and become afraid, and yes, also
frustrated, unhappy. Then there is the situation where the child is dead or the
mother is close to dying, or the entire process is so terrible that you feel
extremely affected psychologically and maybe even guilty even though its not
your fault. But that is how we are, we make ourselves responsible for many
things. It is typical of midwives, they take the responsibility. Everything has to
be perfect, everything has to be so right, and it is real people we deal with so
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nothing must go wrong. I have been through it and you become so distressed.
But it hasnt affected my .. it hasnt been so bad, I have had good support
from my surrounding and I have some fantastic colleagues. But I think you can
feel abandoned by the management. They sit up there and are not aware of us
having a need to deal with a specific experience. A birth or
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In the group interview, the relationship between engagement and burnout was
not addressed directly but the issue of why midwives stay at work despite the
high demands and the challenging work conditions they face was touched. The
two statements below name the central reason: helping to give birth.
Group interview
IP 5: No, that is why we come to work, to receive the children.
Group interview
IP 2: A good and successful delivery restores your faith in your occupation.
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losing the sense of responsibility and serving on a minimum level without taking
the needs of others (clients or colleagues) into account. Risk avoidance is
referred to as always choosing the easy tasks, which has a negative impact on
colleagues because it leaves them with the difficult cases. Constant complaints
were discussed in regard to their contaminating effect on others at the ward. An
exaggerated feeling of responsibility is described as responsibility felt for
actions of others which the person cannot directly influence. An exaggerated
feeling of responsibility puts the person in a state of constantly ruminating about
possible, negative outcomes.
Findings from both the single interviews and the group interview on engagement
in midwifery refer to three different facets of the phenomenon: the professional
self, work spirit, and the care for others. Engagement as being a professional self
is the description of a midwife who is a model in terms of professional
knowledge and sharing this knowledge. A professional midwife is one to look
up to and one who is engaged in all kinds of developmental activities to reach an
even higher standard.
An engaged midwife is described as having a high work spirit, reflected in being
the pacemaker for others especially in times when work morale is low. Work
spirit shows in a positive attitude towards the job, being happy for the tasks, and
expressing passion while fulfilling the primary task. A person with high work
spirit was further described as one who is an inspirational source for others,
triggering good spirit and engagement in them.
In regard to the description of caring for others, an engaged midwife is the one
who is sensitive towards her colleagues and the clients she cares for. An
engaged midwife is described as being truly empathetic, realizing and reacting
to the needs and demands of others. The description about engagement given by
the midwives is rich and diverse. The picture of an engaged person is painted as
an ideal model of the perfect colleague. This almost unrealistic description
might be expression for the high professional demand midwives feel and claim
upon themselves. In the group interview, the aspect of professional self was
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5.1 Introduction
In the following chapter, person-related and work-related factors that are
important for the understanding of the relationship between motivation and
burnout in midwifery are discussed. As person-related factors, biological age
and generation membership are discussed. Work time, work family balance, and
job routine are the work-related conditions described at this point.
5.2 Person-related factors
Biological age has been shown to have an impact on being able to handle the
outer conditions of the job and on the congruence of work and family demands.
Generation membership is defined as a commitment to certain values and
perspectives in regard to the primary task, leading to different ideologies and
identities in midwifery practice.
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It worries me a little bit that relatively few midwifes have a job after they get
older which is probably because they feel uncertain about the new technology
and the like
Biological age is further named as being relevant when talking about technical
changes in regard to the primary task. The increasing computerization has cost
some drop outs of older midwives who were thought to be unable to learn how
to handle the technical challenges related to working with the computer and
electronic monitoring devices. The midwives accuse a combination of high
responsibility in midwifery and low security when handling new techniques for
causing a feeling of incompetence and uncontrollability of events. With
increasing age, midwives report an observation of colleagues being inverse
flexible in learning new techniques and missing the openness to be able to adjust
ones own work routines.
The main differences are seen in how the job is approached and valued in regard
to the effort put into the job and as well as the expected rewards. The young
generation of midwives are described as not having patience enough to handle
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the demanding aspects of the job and to stay committed to it regardless of the
imbalance between effort and reward, whereas the older midwives stick to their
profession. The new generation seems to act very differently than the former:
They do not want to work full time, they put more emphasis on being engaged in
research projects and further personal development and they want to have a
financial reward for the job they do instead of being content with the nonfinancial recognition they get from the clients. From the perspective of a
midwife with long job experience, this sounds like the wrong choice. For her,
the non-material recognition is valued as an important part of the job, which
pays for the other inconveniences.
Another aspect of generational differences is the preferred work form; either
team work or working alone.
Interview 2: 46 years old, 20 years work experience as midwife
The members of the older generation of midwives want to work alone whereas
the young ones like to work together. They like to be two in a maternity room
and learn from each other. I think the older generation of midwives have a
feeling of what if I mess it up, then I dont want my colleagues to see it. I try to
say that we can learn from each other, let me go with you or you can go with
me. Look at me, see what I do, and then ask me afterwards why I did as I did.
We must start a dialogue.
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and analyzing things, and they are, of course, nice to be with, but acute, basic
obstetrics is missing in some areas, and I fear that they some day will run into an
acute problem. It is very important that a recently educated midwife is included
in a good group which supports her. Otherwise she is left high and dry. She
really is.
Newly educated midwives are thought of as not being educated well enough to
react to acute problems when helping to give birth. This might be understood as
the standpoint of a single, older-generation midwife but is discussed further in
Chapter 8 with regard to the importance of implicit knowledge in midwifery and
other future challenges in midwifery from the perspective of the findings of the
present case study.
One of them described what it meant for her to go from the regular three shift
system to day work.
Interview 2: 46 years old, 20 years work experience as midwife
Im a person who really needs to be alone sometimes. And I miss that time
alone. I miss my mornings where I could do things at my own pace and then take
the night shift. I miss the periods with quiet shifts. We have 24-hour shifts where
we only have three hours but we are listed to have 14 hours. That is a surplus. If
I have been on home duty I have never done any work at home. I know that
many midwives do that. Clean the windows and as they feel they are paid for
working at home. I have always felt that I should be good to myself when I had a
24-hour shift. I have slept as long as I could, I have read some books, and I have
enjoyed my needlework and just pottered about as it didnt matter if I was there
when I had finished something. Do some laundry. It doesnt matter if you take
out the clothes when it is done or three hours later. I didnt find the 24-hour
shifts hard. I didnt. I really enjoy the unpredictability. Of course, Im like the
others; we are tired when we are being used too much for longer periods of time.
But you also get time off in lieu of wages and the like. And that I never get
anymore.
Although one would expect that working day shifts only is regarded as a relief to
the demanding three shift system, this midwife describes the negative aspects of
this change for her. Compared to the three shift system in the day shift only
system, she feels that she does not have as much recreational time on her own as
she used to have before. She describes that she actually does not have the time
any more when nobody is at home. It is kind of a double-bind situation: in order
to have more quality time for family and friends, the midwife has to sacrifice
the time being alone without any demands from her children or husband.
Daytime work is compared to the three-shift-system as more inflexible but also
easier to plan. Another negative aspect of daytime work is the loss of
unexpected extra time earned when not called in for emergency duty. These
days are counted irrespective of being called in or not. Being on a day schedule,
these unforeseen free days do not happen anymore.
For those midwives who work the regular three shift system, the planning of the
shifts is an important topic.
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Shift planning done centrally causes speculations about being unfairly dealt
with. The wish to have influence on the planning of shifts has been discussed in
depth and especially in regard to re-organizing the ward into smaller work
groups which then are responsible for organizing their shift schedules
themselves.
However, not all interviewed midwives believe that having more influence on
planning the shifts is the most important topic.
Interview 8: 50 years old, 24 years work experience as midwife
A working group had, among other thing, worked with shift planning. We had
expected a lot of that as many of my colleagues think that shift planning is our
largest problem. I think not.
According to this midwife, shift planning might be a problem, but it might in the
long run not solve the real problems at the ward. One problem she refers to is
the use of a lot of the precious time which should be used for educating younger
midwives in how to react in acute situations in practice instead. From her
perspective, it would be for example better to think about how changing client
demands (e.g. to be informed about each little step while giving birth) can be put
together with decisive demands in an acute situation. She sees a need for
younger midwives to be better prepared for making quick decisions when the
situation demands it. The interview section below illustrates her critique of
wrong choice of priority which she interprets as a fundamental problem at the
ward in the future.
Interview 8: 50 years old, 24 years work experience as midwife
And there I suddenly was with a trainee who .. she was nice and everybody
liked her. And then the woman starts bleeding and she turns to the woman and
says she bleeds too much and it is a bit dangerous and that we must set up a
drop. That is just a thing which is very dangerous. One thing is that you have to
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be very didactic when you tell a patient what you are doing but you must also
say that it has to be that way and we do it now.
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The midwives are quite open about their reduced capacities while working at
night, especially if they have to work several night shifts in a row (which on
paper is not the regular situation anymore).
Interview 1: 38 years old, 14 years work experience as midwife
I dont think that I provide optimal care or engagement at night. Well, yes .
Generally, fatigue makes you uncommitted, or generally not committed during
the entire working day
Interview 3: 43 years old, 6 years work experience as midwife
Who is not tired and burned out during the night, or what!
If I had three night shifts in a row I would probably also burn out. I can only
handle one at a time (laughs).
Interview 7: 48 years old, 12 years work experience as midwife
My biggest problem, the thing which burns me out the most, are the night shifts.
This is actually something critical for me, these night shifts.
All three midwives report how demanding it is for them to work at night
especially to overcome their tiredness in order to do their work and be as alert as
during a day shift. It is interesting to note that two of these midwives mention
burnout in this context. Here, the term burnout is used to describe physical
exhaustion as a result of the night shift. However, it seems as if this exhaustion
is an immediate reaction to the night shift and can be overcome rather quickly if
followed by an adequate recovery time. These can be days off and consultancy
days with a regular day working time.
Interview 8: 50 years old, 24 years work experience as midwife
If you could only be sure about two days a week, where you just need to work
from 8 am to 4 pm. The possibility to withdraw, it would be easier for midwives
with children, those who are pregnant we dont have any; we dont have an
out-patient clinic where you can do some day work, for instance.
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a rather strict time frame. These days are attractive for a greater number of
needy groups (older midwives, midwives with small children and pregnant
midwives) and are not a picture of the usual condition of the rest of a midwifes
work week (usually a midwife who works full time has one consultation day per
week).
However, also part time work can be demanding as the part-timers are often
assigned to the most straining or family-unfriendly shifts.
Interview 4: 45 years old, 20 years work experience as midwife
When you are a midwife working part-time you also get many inconvenient
shifts, meaning evening, night, weekend and 24-hour shifts. I dont know if we
have relatively more of such shifts. but it doesnt help my family much
that Im home Monday, Tuesday, Wednesday and Thursday when they are
away. That is not what they need.
The disadvantage of part time work is seen in the fact that part time workers are
often put into the regular three shift schedule at those points where there is a
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For those working in the regular three-shift-system, it is not easy to accept that
the family has to carry the burden of the job demands. One example mentioned
is the demand to work through the main parts of summer vacation without
having the opportunity to spend more than two weeks together with family
One form of natural job routine is the regular consultation of pregnant women.
These consultation days are very important for the midwives. The consultation
days are predictable regarding work flow and work time. Maybe even more
important than predictability, the consultation of the pregnant women is
essential for the holistic understanding of the work of a midwife (leading a
pregnant woman through her pregnancy and finally helping to give birth). There
is also a lot of monitoring and controlling functions in the course of a regular
work day at the ward. This became very obvious while being a participant
observer at the ward. For activities directly related to the primary task of a
midwife (e.g. helping to give birth), routine tasks are harder to perceive but not
absent: every birth is followed by a number of routine check ups even though
each birth is unique.
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6.1 Introduction
Resources and resource allocation emerged as an important subject to talk about
in the course of the single interviews. Inadequate resources in terms of
insufficient manpower at the ward are thought of as having immediate
consequences for the quality of work which is highly valued by the single
midwife. In the following, the availability of resources and allocation practice
are discussed. Further, the balance between resources and job demands is
reflected on, as is the aspect of feeling secure in regard to these resources.
6.2 Amount of resources and resource allocation practice
Midwifery, being part of the public health care system, is treated the same way
as other parts of the health care system when it comes to resource allocation. To
measure the resources in midwifery, the number of births per year is divided by
the number of midwives at the ward. In 2002 and 2003, when parts of the data
collection took place, resources at the ward were described by the participating
midwives as being low. 49 midwives (without student midwives) were
employed at the ward. Approximately 2,600 births per year had to be taken care
of.
Interview 2: 46 years old, 20 years work experience as midwife
I think it is a problem that we must coordinate with the others as we are
compared on the basis of different parameters. We are not able to discuss
nursing in the same way as they do at a ward for cancer patients or a ward for
patients with heart diseases or intensive care. We should be compared on the
basis of the way we take in the patients, with intensive care or the emergency
room. I think that is where burnout and the motivation and job satisfaction can
be seen among midwives. Just because we are part of a huge organisation they
compare us economically with the other wards. They compare our figures with
figures presented by the other wards, and if you ask a politician how he defines
a birth then he will define it as the moment the child comes out. And if I have
2,600 such births then I can keep on talking about the many consultations, the
out-patient visits where the pregnant woman thinks she is in labour and then she
isnt, and she comes in to an examination. And then there is all the rest. No, we
talk about births, such and such a number. It can be estimated as an average,
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how long it takes as they dont need help all the time, but the woman think they
have that need, and then we are caught in the middle. But that is the reason why
you dont have the same time with the family as you had in the old days.
The interview quote above refers to the problem of being compared on the basis
of incomparable parameters. Looking at the way how clients are admitted,
midwifery comes closest to the way an emergency ward or an intensive ward
functions. It is experienced as problematic when resources are calculated on the
basis of birth rates, because many of the time consuming tasks of a midwife do
not terminate with the birth of a child. The calculation of resources is done on
the basis of fulfilment of the primary task (here helping to give birth), not taking
into account that many cases in midwifery are of observational nature (e.g. acute
problems during pregnancy such as no signs of life, bleeding, or nausea) or for
consulting reasons. For the midwives, this leads to a dilemma between an own
professional standard, the wishes of the client, and the allocated resources to do
the work. In the course of participant observation, it became obvious that these
sideline or secondary activities, not accounted for when resources are calculated,
take a lot of the daily work time of a midwife. Moreover, a lot of former
administrative work nowadays is done by the midwives themselves, e.g.
journaling of births, answering telephones at the ward, ordering material. It is
not unusual that these tasks can only be fulfilled by working overtime.
Interview 1: 38 years old, 14 years work experience as midwife
It is a strange, strange job as it cant be compared with other jobs. You keep
comparing with nurses and other groups within the health care sector, but our
job is a special area where you constantly work with people who experience a
crisis. Not that a crisis has to be a bad thing. Giving birth to a child is some sort
of life crisis suddenly being a parent.
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Most of the midwifes work is work that has to be done immediately. There is
no space for delay. On the job, the midwife must always be ready to provide the
best possible service. The demand for resources experienced by the midwives
differs to some extent from the official appraisal of resource demand. From the
midwifes perspective resource allocation is experienced as insufficient not only
in amount but also flexibility. There are written standards about the use of
resources which are described as being good in theory but do not actually
function, given the recent allocation practice. Because of the spontaneous nature
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Midwives react very strongly when resources are too low and the provision of
100% service is no longer secure. The participating midwives express frustration
about not being able to meet their own occupational standard of 100% service.
Interview 9: 44 years old, 18 years work experience as midwife
But that is part of it all. I think that we are often ill, and absence is not always
covered. If you are so unfortunate to have a 24-hour shift such a day where you
are called in and must cover some fixed shifts and you can see that if the shifts
had been covered you wouldnt have to work so hard. It is very tough. I feel that
if the shifts are covered and you are called in then it is OK, not
Given the fact that the delivery of children is impossible to plan ahead in terms
of time and complications, resources must be enough to stay flexible. There is
an established system of emergency call, but unfortunately due to low resource
availability (positions vacant) and high absence rates, regular shifts are
frequently covered with those midwives being on call. The demand of having a
person in the background being on call to take care of the extra demand is
therefore not often fulfilled because the one who is supposed to be on call is
already substituting on the regular shift. According to the interview participants,
it is common practice to use the midwife on call as a substitute for a midwife
who is on sick leave because there are no extra resources available.
Consequently, the flexibility needed to deliver 100% service is not always
given.
Interview 2: 46 years old, 20 years work experience as midwife
You dont have the chance to finish it properly. You leave them when you have
congratulated them and the child has been weighed and measured, and then
another person comes in and takes over. You dont have your own group of
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pregnant women as you would have if you chose to see the process instead of
the financial side of it. If you asked yourself how things could become more
rational, then the pregnant woman should follow a group of midwives, and one
of these midwives would be with her during the delivery. That would make it
much easier for both parties as many problems would be solved in advance.
There are so many things a woman in labour should not think about and one is if
she can trust me. That has been revealed during the pregnancy and it is OK as
she can say that she wants another midwife. All the things that we say we cant
afford in Denmark today. Everything has to be rational, it is a huge impediment.
A woman in labour comes by and a midwife comes by and helps her. That is the
way it is. You dont know the patients as you did before when you had small
delivery wards.
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client. This is seen as a tremendous difference between small places to give birth
and larger hospital organisations.
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Midwives are forced to deliver bad service at the point when resources are not
sufficient. This point is described as being at the border a midwife is willing to
accept. Not only is providing 100% service an important aspect of their
occupational identity and fulfilling the personal wishes of a woman in labour,
but it is seen as a guarantee of a high standard of security for mother and child.
In the group interviews, the question of at what point low resources are
experienced as critical was discussed in order to investigate in more depth the
relation between resources and feelings of security. The intensity and directness
of the following statements is an expression of the importance of the subject.
Shortness of resources is discussed as one important reason for feeling
uncomfortable with the service one can give and for growing frustration.
Group interview (to the question what is threatening for feeling secure about
doing the job)
IP 3: It is a critical situation where well, I would call it critical if I didnt
feel secure about what happened in the various delivery rooms. I would be very
sad if I forgot to do something. I know that we all forget things sometimes, but
if I did it often I would feel very insecure. I have been in situations with dead or
sick children. It is something profound in me. The output should be healthy
children - that is what it is all about, no matter if the resources are scarce. I also
think it is the reason why we have so many extra shifts. It is my impression that
when we could get help from temp agencies nobody had any energy left. It is so
confusing that you take on extra shifts and it helps, but doesnt help sufficiently.
So I think that many midwives say that it is not worth it, and you are always
here anyway..
Group interview
IP 2: A critical threat against safety is that you are suddenly alone on the shift,
and you dont know what comes next . of course there are doctors but you are
the first to deal with the problems. . It is not always the most severe problems.
They also come unannounced as they are the most acute problems as they bleed.
These problems you must evaluate on your own, you have two telephone calls at
the same time and maybe you also have two women in labour. And it takes time
before the colleague called in arrives, and maybe you dont even have time to
call her. That is my nightmare and that makes me feel insecure as I wouldnt
know what to do in such a situation. I would wonder if I did the right thing.
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Frustrations about low resources were mentioned when talking about important
steps for client information, e.g. smoking cessation programs. These preventive
actions for pregnant women and their families are cut down because resources
are not available. The midwives regard their preventive work as very important
because they can approach families at a sensitive point in their life, having high
impact upon them. During pregnancy, certain preventive steps can be taken
which diminish the chance of complications during the birth process and also of
sudden child death during the first months of life. Not being able to put further
effort and resources into the instruction of clients who need more supervision
further diminishes the sense of doing a holistic job.
A success story about how to use limited resources to educate pregnant women
in form of group consultations is told in one of the interviews. To be able to
decide within a given frame about how to use the own work capacity is a degree
of freedom and participation. The story sheds light on the engagement midwives
at the ward put into the job. This kind of engagement is often extracurricular
engagement, time not paid for.
Interview 8: 50 years old, 24 years work experience as midwife
. a teamwork concerning our group consultations. We have those who started
it after the county had decided that it should be an offer in our county. So I
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thought we must do it as good as we can with the few resources available and it
was a huge success. I have invested all my energy in that project and I will keep
on doing it.
In the group interview, the stressful aspects of the midwifes job because of low
resources were confirmed.
Group interview
IP 1: Yes, it is tough. I think that you at many workplaces where the employees
are stressed and burned out, can let go of it all, walk away and say you cant
take it anymore. We are in another situation, we cant let go and go away if it all
becomes too much. We must be able to handle the situation as a midwife, keep a
stiff upper lip and then move on. There is no other option. Afterwards, it is
rather stressful. When you go home, it all becomes too much and that taxes you.
When you are in the middle of it, you cannot break down; there is no room for
that.
Midwifery was described as work without space for personal weaknesses and
feelings while active. When time is busy at the ward, there is no time to reflect
on a particular situation; this must take place when the situation is over and the
midwife is already at home. In regard to resource allocation, this aspect is
important to keep in mind. The health and well-being of a midwife are described
as being seriously threatened when resources are cut down to a point that
stressful situations like the one described above are the rule and no longer the
exception.
6.4 Summary
The question of resources in midwifery emerged as a central theme in both the
single interviews and the group interview. Resource allocation practice is
described as being insufficient. It is regarded as problematic to be compared
with other wards on the basis of incomparable parameters, e.g. birth rate being
the numeric factor of resource calculation, not cases. In the course of participant
observation, it became obvious that secondary activities such as journaling after
birth, consultation of pregnant women coming to the ward, answering the
telephone etc. which are not accounted for when resources are calculated, take a
lot of the daily work time of a midwife. Another important difference between
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midwifery and other wards in a hospital is seen in the acute nature of the task
and the working with clients in a crisis; the transformation into a (larger) family.
The fit of resources and demands was brought up referring to different aspects.
First, resources are meant to be one decisive factor regarding the quality of
service which can be given to the client. For the participating midwives, the
provision of 100% service is described as being of great importance. Not being
able to do the work in a responsible and sufficient manner because of low
resources is regarded as not acceptable, causing frustration for the midwives.
The low flexibility of resources was also addressed, pointing to the fact that
midwives on emergency call are frequently called in to cover the regular shifts.
One last aspect discussed in regard to the demand to deliver 100% service is the
impact of the structure of modern maternity wards onto the primary task. The
participating midwives expressed at different points that the 8-hour schedule
leads to a segmentation of the task with negative impacts for both clients and the
midwives themselves. The demand to provide 100% service is more difficult to
fulfil when shifts change in the middle of a birth process.
Second, low resources are made responsible for a diminished feeling of security.
Security is established through expertise won while fulfilling the primary task.
The expertise is sabotaged when resources are too low to be able to do the work
in a responsible manner. Knowing they are not able to serve100% is described
as a negative impact, leading to stress reactions known as fight (expressed in
working over own limits), flight (expressed as staying absent from work or as
taking a leave of absence), and freeze (as described as staying in the delivery
room no matter how busy the rest of the ward is). Not being able to ensure high
security while helping to give birth is experienced as threatening. Similarly, not
being able to be with a woman giving birth because two others are in the same
state of needing the midwifes service who is alone at the ward, not knowing
what to expect and with an ever-present lurking threat are named as highly
unbearable work conditions. Last but not least, resources for client education are
valued as important for the holistic job experience and as supporting factors for
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7.1 Introduction
In the following chapter, emotional demands and feelings in midwifery are
described. The interview partners talked about emotional demands connected to
the primary task in midwifery and feelings as reactions to traumatic birth
incidences. In regards to emotional job demands, three aspects are discussed: (1)
reactions to differences between professional conviction and client demands, (2)
the demand to serve the best way regardless of own feelings and condition, and
(3) to give as a core demand when helping to give birth. Feelings as reactions to
traumatic birth incidences have a different connotation. This second aspect
focuses on the midwifes immediate (in the sense of not controlled) feelings
when confronted with traumatic birth incidences. Here, her reactions, both as a
professional and as a person are described. The support from colleagues and
family as well as formal psychological help after traumatic incidences is
presented. Last but not least, the aspect of formal versus felt responsibility is
discussed.
7.2 Emotional demands
Emotional demands are those job demands which require emotional
involvement of the midwife regardless of her momentary feelings and condition.
It is emotion work, following from the nature of the job.
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nowadays has a greater risk of being made legally responsible for actions
connected to the birth process. This last aspect is further discussed in relation to
felt responsibility (Section 7.3.2).
Interview 3: 43 years old, 6 years work experience as midwife
I believe that I would much rather change the women. I think there is a huge
difference between women today as compared to when I started as a midwife 67 years ago.
They have started to become women whom you cant get close to. They are all
faade and whimpering, whimpering, whimpering ! They tell you that they
want things done in this and that way. They feel that we are down here and they
want us to do exactly what they tell us to do. The situation has become more or
less out of scale, dont you think? About 220 years ago, the midwife was
standing up here looking down on the woman while she was guiding her through
the birth. Before, the scale was more or less in equilibrium but now I believe
there is some imbalance.
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Besides the bewilderment felt about the behaviour of some birthing women
nowadays, the participating midwives talked about their frustration when
helping to give birth. The group of midwives describe a generation shift when
looking at their clients and the way the clients approach birthing. There is a
perceived trend to demanding more and more service from the midwives and at
the same time not accepting her leading position throughout the birth process.
Especially the aspect of epidural anaesthesia and planned caesarean sections was
discussed in the interviews. The participating midwives expressed acceptance
but not understanding for this sort of client demand. The group of midwives
taking part in the interviews represent a with nature approach of midwifery,
believing in the natural strength and ability of women to give birth the natural
way. This belief stands in contrast to a perception of a changing attitude in
younger generation women who do not want to trust this natural birthing
process. The client and her family are in this respect experienced as demanding
and frustration is the feeling connected to this experience.
7.2.2 Demand to always give 100 percent service regardless own feelings
and condition
As discussed already in Chapter 6, midwifery is a human service profession
where delay of service is not acceptable. A woman in labour and her family are
in transition to a new phase in life, in the middle of a critical life incident.
Naturally, she is self-centred, not having in mind that there might be some
others also in expectancy to give birth.
Interview 6: 58 years old, 33 years work experience as midwife
The midwife must smile and welcome even the third pregnant woman although
she deep inside herself was hoping that the next woman giving birth could wait
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two hours so she could recover from the last birth. It is in a situation like this
where things get difficult; however, I think that they are doing a great job! None
of our clients has made any complaints about midwives being in a bad mood or
too busy to offer any service. It is not my impression at all.
Interview 8: 50 years old, 24 years work experience as midwife
... when you have been at work for 16 hours, and another pregnant woman
shows up, you must show the same degree of commitment which you showed to
the first two women giving birth.
The midwifes role is described as committed to serve even after long work
hours. It is the own work ethic and the expectation from the outside to serve
even when it is beyond the available strength and power. The same professional
service and empathetic engagement should be given to each woman.
A further aspect described in the interviews is to give something of yourself.
Connected to the understanding that midwifery functions on the basis of giving
100% and not less, it is thought that true 100% giving is not possible without
being involved as a person.
Interview 3: 43 years old, 6 years work experience as midwife
But you are forced to raise yourself up and say ahhh. And all the time being
cheerful, sweet, and caring. And this might be what others mean by getting
burnout quickly. The reason might be that you are in high gear all the time
anyhow, and maybe you are not always the type. You cannot be like this all the
time.
To deliver the same standard of service regardless of ones own feelings and
energies is an unchangeable demand in midwifery. There is not much space for
having a bad day. Needing to be happy, understanding, and caring is considered
as a probable reason for burnout. A difference between the demanded and the
actual emotional condition is thought to lead to emotional turmoil after some
time.
Interview 5: 49 years old, 8 years work experience as midwife
A midwife is not allowed to have a bad day at work. You cannot say ok, I will
just take a backseat today. You are on and you are being evaluated every time
and forced to give everything you can. You give a part of yourself every time
which cannot be done half. You cant walk into the maternity room and tell your
client that you are having a really bad day. Such remarks are useless. So just
forget everything about that.
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The demand to give something of ones self is related to the demand to serve
100% in the sense that it is not asked if the midwife is ready to give or not, it is
described as part of her professional work role. The interview participants refer
to the aspect of giving as an implicit, but at the same time, very demanding part
of their job. The picture of giving something of oneself is strong, expressing the
emotional quality with which this situation is connected.
Interview 1: 38 years old, 14 years work experience as midwife
To the question: As I understand, is there a possibility both of getting energy
because of the primary task or to lose energy; can it go both ways? Is this
something you can relate to?
I would answer yes to that. It works both ways. I believe that I really believe
that you can have a positive birth process with couples having children where
everything fits together. And they are having a wonderful birth and a lovely
child, and their way of coping is just fantastic. It can really make you high.
But generally speaking, I believe that your involvement in the birth is so deep
that it drains you of energy which can make it difficult for you to have a private
life with children because you pay so much attention the whole day that it makes
it difficult for you to face family demands. You also need someone to care for
you. After all, your involvement is much deeper than it really should be; and
when you get home, you are completely drained of energy. However, it is
difficult to say whether it is the job or the way we are working. If it is the work
shifts and irregular working hours day and night and a family life at the same
time, or if it is because you use all your attentiveness and empathy to facilitate
the birth is difficult to say. I believe that things are connected though it drains
you of energy. You are very tired when you have been standing for 8 hours
trying to help a woman giving birth to a child. You are completely physically
and mentally exhausted when you get home.
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As way out of the spiral of giving 100% and at the same time working on the
edge in regard to low recovery time, the draw back from clients is named. Not
being in the mood to serve women in labour anymore is described as serious
reaction to the extensive demand experienced over time.
Interview 9: 44 years old, 18 years work experience as midwife
Sometimes I feel that I cant stand these women anymore. They suck everything
out of me and give me nothing in return. Then I simply dont want to help them
anymore.
The topic of treating all women with the same eagerness and concentration,
while not showing any signs of exhaustion was also discussed in the group
interview. Here the midwives confirmed that working in midwifery demands
that they play a certain role where they need to display strength and power in
order to lead through the critical life event.
Group interview
IP 1: .but we are in a different situation, we can not let go and go our way and
let them stay alone, because we think we have had enough. There is nothing like
this. As midwife you have to tackle a situation like this and you grit your teeth.
There is no other possibility.
IP2: You must be nice and kind and always speak politely to the clients even if
you are facing a breakdown. You must not show your emotion to the clients. A
midwife hides herself in the white hospital coat and acts normally so she is
able to deliver a decent product when the clients show up.
The interview participants describe the midwife as the one who is supposed to
give the best service she can give. The personal demands of the midwife need to
stay behind. It is the client who has the whole attention. The midwives describe
and accept that the professional role at times demands that they keep going even
when their own resources are low. In the second interview quote the midwife
talks with some distance about the direct (woman in labour) and indirect (child
to be born) recipient of her service. The delivery of a child is described as to
deliver a decent product. The aspect of resignation and distance felt towards
clients was not discussed further in the group interview.
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This first statement from one of the interviews reflects a modern attitude of the
birthing generation towards the birth process. Today, in the western world, most
children are born without any major complications and even when they arise, a
lot of help is available. Although this is a very positive development, it might
have given rise to very high expectations, not giving room to the possibility that
sometimes difficulties and even fatal outcomes are unavoidable. The midwives
are therefore sometimes confronted with women who expect that all kinds of
negative developments or outcomes during the birth process can be avoided. The
midwives, however, know that things can go wrong and that they not always
have a chance to avoid that happening.
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At the same time, the midwives describe their own work ethic as a demand to
provide perfect service even though they do not think that they necessarily have
influence on the process to the end.
Interview 4: 45 years old, 20 years work experience as midwife
.This is also typical midwife, you take it upon yourself. Everything must be
perfect, everything must be fantastically right, and it is living people we work
with, nothing may go wrong. I have myself experienced that you get very sad
when something happens.
Interview 2: 46 years old, 20 years work experience as midwife
And Im not only being evaluated on my skills. Im also evaluated on my
humanity. Moreover, Im being evaluated on something which I dont have a
chance of influencing.
The foregoing statement refers to a feeling of humility and belief in some higher
order. The midwives themselves use expressions like there is more between
heaven and earth (see below) or not having an earthly chance to make a
difference in the process in order to express their belief in something above
their own capacity. In a secularized world with a longing for human control
over nature, it is hard to transmit that every birth is a little miracle hitting the
edge between life and death. It might not be by chance that the book about the
100th anniversary of the Danisch Midwife Association (Den Almindelige Dansk
Jordemoderforening, DADJ) has the title Fast ansat ved mysteriet (Employed
in the miracle of life, free translation by the author).
Also in the group interview, the topic of dealing with traumatic birth incidents
was addressed. Here the midwives discussed the difficult situation of not having
the possibility to talk openly about mistakes that might have happened during
the birth process. They refer to air traffic controllers who can talk about near
misses without having to face any negative consequences, but instead can use
the open talk about these incidences to learn and prevent similar situations.
Group interview
IP 1: However, what really is the taboo is the usual problem that you refuse to
acknowledge any faults at all. It is the serious discussion going on and on
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forever about her fault-localization. The air line business offer all their
employees openness which means that you can report everything, and they
dont blame you for anything afterwards, whereas the health care sector doesnt
offer their employees the same kind of openness, though it is getting better now.
It is still something they want to remain in the delivery room with respect to
traumatic incidences because the hospital fears it may ruin its reputation.
The participating midwives know that there are situations in midwifery that are
not possible to control from every side and there are also critical situations that
happen because somebody was too late to react. The situation in midwifery
today, as described by the participating midwives, is as follows: In competition
to be the safest place to give birth, near misses (to use the technical term from
air traffic control) are kept under the seal of secrecy. Midwives, being part of a
traumatic birth process, face a double burden. They have to emotionally deal
with the incident and they are not allowed to talk openly about what has or could
have happened.
Group interview
IP 1: Some of us have tried to receive a letter where someone is complaining
about you. Sometimes you are so lucky that things couldnt have been done any
differently, or it may be that things could have been done differently. I find it all
right that we are held responsible, but the fact that you risk someone taking legal
action against you, or you risk a fine, is scary. We are not talking about gross
negligence but about situations that cannot always be controlled. Your whole
world can break down under such circumstances!
Things are becoming more and more Americanized which is becoming more
and more obvious, and I find that very difficult to tackle. however, it is just
as if it doesnt get into their heads which I believe is dangerous because it can
knock them off their feet!
The midwives feel that they are faced more and more with an accusation culture.
The midwives discussed this aspect as an Americanized way of looking for
somebody who is not only responsible but also convictable. This leads to a
climate of not talking about incidents which are inherent to the job and which
need openness in order to be able to react in a good manner the next time
something similar happens.
Group interview
IP 1: And thats a very difficult situation! I believe that there is a tradition
among midwives to tackle difficult situations. We know that there are more
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things in heaven and on earth that are beyond our control and responsibility, and
more than we can tackle. So it is not our fault! Sometimes when you walk home
from the hospital, you can ask yourself about what you could have done
differently; but after a while, you realize that it wasnt your fault. Fortunately,
we come out as healthy 8 individuals on the other side, but I believe that when
someone is complaining about you because they believe that you have made a
mistake, it can sometimes make you break down.
But if we get some time where we have the possibility to talk about it, it might
be possible to get through some things without the big professional help.
The interview participant describes the fact that midwives know that there is
more between heaven and earth and this knowledge enables to stay whole as a
person even after having been part of a traumatic birth situation. Moreover,
openness is needed to stay whole as a person and to be able to get over such an
incident. When traumatic incidences are condemned to be kept in silence, it is
the midwife who is left with the burden of tackling the question of responsibility
and guilt alone. It is regarded as important by the participating midwives to talk
about the traumatic incident as part of the therapeutic process, to learn from it,
and to share grief and sorrow about the outcome.
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The midwives refer to two different situations facing traumatic birth processes:
foreseen and unforeseen. The foreseen situation, for example when the child has
died before the birth process started, is easier for the midwives to handle with a
professional approach without being strained by feelings of responsibility or
guilt. In contrast, this professional mind-set is much harder to hold on to in
unforeseen traumatic situations. As one midwife described it, the worst case is
when a woman delivers a stillborn child even though she and her unborn child
were apparently in good condition when they came into the hospital. Here, a
feeling of uncertainty can arise and the midwives might start asking themselves
if they could have done something different in order to avoid the fatal outcome.
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Another difficult situation can develop in those cases where a doctor is called in
and the midwife passes on the responsibility to him/her. According to the role
definition, she is at that point no longer responsible. Instead, she takes the role
of the womans advocate in communication with the medical doctor, telling
him/her how the process has gone so far and what her recommendation would
be. She can discuss further steps but cannot make decisions contrary to the
doctor. This is regarded as a difficult position, because the midwife is involved
but does not have the power to make the final decision. The ambivalence of
giving responsibility away by calling the doctor but at the same time still feeling
emotionally responsible for the birth process, can be unsatisfactory and might
lead to insecurity about ones own action. In any case, when a child dies or gets
seriously hurt in the process of delivery, it is experienced as worst case, as
catastrophe.
Interview 1: 38 years old, 12 years work experience as midwife
Some years ago, I assisted a woman in a twin birth at a time where I was
pregnant myself, and where everything went wrong with child B. Despite that
the woman was open by 4 cm, I recommended a caesarean section. However,
the doctor was not of the same opinion as me. The woman opened quickly and
child A was taken with a ventouse; however, child B didnt come down which
made it impossible for the mother to deliver him. When he finally came down, it
was with the bottom first and we took a scan which showed that his heart rate
was fine but the amniotic fluid was green. After we had tried to get him out for
half an hour, the doctor finally recommended a caesarean section and the
woman was given an epidural which she never should have had. And she had a
child in a very poor condition. He suffered from brain damage and was almost
dying but survived. It was a terrible story. But to be in a situation where you
disagree with the doctor and where you dont have the authority to make a
difference is terrible. I later realized that I could have called for one of the chief
physicians at home but it takes a lot of courage to say to a doctor that you
completely disagree with him, and that you are going to call one of the chief
physicians. Today, I would have done it, but at that time, I wasnt so sure
because I was in doubt. The rule is that when the birth process is normal, the
midwife is responsible. And when the birth process isnt normal, the midwife
calls for a doctor and the birth situation is no longer her responsibility. In a
situation like that, it is difficult to be the womans advocate in a process you had
to let go of.
The interview section above refers to the conflict of being torn between formal
and felt responsibility. Formally, the midwife was not responsible for the
outcome of the case. She had called for a doctor early in the process and it was
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the doctors decision to wait with the c-section against the recommendation of
the midwife. Nevertheless, the midwife still feels responsible for the process and
asks herself what she could have done differently to prevent this traumatic
outcome.
It is said by the midwives that some of the traumatic incidents with unresolved
feelings of responsibility can develop their own psychological power, inducing
insecurity and fear. They can accompany a midwife all through her professional
life, being something like critical life incidences. In situations with high
emotional impact, it might not really matter who was responsible. The feeling of
having lost control over the birth process stays the same.
Another aspect of felt responsibility is the ambivalence over how much
involvement and care needs to be given to a mother or a couple who has been
through a traumatic birth process, at the end losing the child or ending up with a
handicapped child.
Interview 7: 48 years old, 12 years work experience as midwife
You may back out saying that youve had enough and want to stop. However, I
must admit that there are certain incidences which I find it difficult to let go of.
There are incidences where I have given them my telephone number and asked
them to call me if they need to talk. Some of our clients really have a need for
talking very often. Sometimes I have called the clients after a couple of months
just to hear how they were doing. You always have a talk with them after a
month. Thats the least you can do. You also pay them a visit after a month to
hear how they are doing. Anyway, it can last for years. The last incidence I had
lasted for 1.5 years. At last I just called to hear how they were doing. She always
sounded so happy every time I called her, and she really needed it. They are so
grateful to you because it has been such a traumatic and difficult situation in
their life.
There is a mandatory follow up call or visit from the midwives side a month
after the traumatic birth incident. There also is a felt responsibility to follow up
with those families who seem to need more support over a longer period of time.
A formal demand (call one month after the incident) becomes an informal
obligation to follow up and care for those who seem to need it. The regular
working time usually does not cover the invested resources (emotionally,
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mentally and time). So the midwife is torn between wanting to give more
support to those who she feels need it and investing her own time and resources
in order to do so.
No, Im more of the opinion that it is about what can be tolerated or not
working as a midwife is a job and you have to act professionally. Of course it is
both traumatic and terrible when a child dies, and it can make you sad for about
a week. But then it is expected that you start all over again and help other
women with their delivery. The first time youre involved in a traumatic
incidence, your colleagues may show up a short time after and ask you if youre
all right and if things went well and so on. However, after some time, they
forget that you have had a traumatic incident where you either lost the child or
watched it die. It has also something to do with the fact that it is not the same
people youre working together with all the time. If you are at work on the same
day one of your colleagues is involved in a traumatic incident, it is brought to
our attention of course. But you havent been part of the whole birth process and
the experience, which can be a problem when you have to discuss a traumatic
incidence you have just heard about through your colleagues a whole week later.
And all of a sudden you are on duty with the one who had the traumatic
incident! After three weeks or so , the whole incident is over and done with.
However, the traumatic incident is not over for the one who went through it. It
keeps haunting her for a long time after.
The interview participant talks about the difference in time it takes to heal from
the inside in relation to the time given to heal as a professional. One problem
with traumatic incidents is seen in the difference between ones own feeling
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The job of the midwife demands a very intense way of being involved in the job.
The high load of emotionality is experienced both as gift and as challenge.
Being a midwife keeps you emotionally attached beyond the regular work time.
The midwife takes emotionally strong experiences (positive and negative) home
with her, which than can cost a lot of personal resources and resources of the
personal network (husband, children, friends, and relatives).
Interview 4: 45 years old, 20 years work experience as midwife
With respect to out-of-control and terrible deliveries, I also believe that your
colleagues feel and know that something is wrong. They have either heard about
it or even participated, or it may simply be the case that they feel that something
is wrong. I think that we are very good at observing when something goes
wrong and giving each other social support and a hug when it is needed. I really
believe we are good at that. To observe when something goes wrong and to be
there so that the person involved really feels that you are physically present.
Another important aspect is the discussion about what did you do, and tell us
what happened next, and who did this and who did that, and he (the doctor, sen)
didnt have to do it like that etc. To try and have a discussion about how well
your colleague coped with the situation! If its possible at all, try to be there and
offer your colleague social support when she comes out from the delivery room
after a terrible incident. There is always somebody there to offer you social
support, and if you dont feel like talking, the person will just remain silent and
be there for you. I think thats very important. Going home sometimes makes
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things much worse. Its not everybody, who has someone to offer them social
support. I just have to say this and that, and then my husband knows what to ask
and how to ask; but not everybody has that opportunity. Its not everybody who
has a husband or a husband who can give their wife social support and is good at
listening! Some midwifes just walk home and sit there alone! They dont get any
feed-back until they return to work again, and then you risk that your colleagues
have forgotten about your experience, or maybe your colleagues at work that
day havent heard about it! Thats no good at all!
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hope it will continue after the pilot phase. Collegial support happens on a
different level than professional psychological support. Collegial support as
described by the participants has an affirming character. Affirmation is given
about the actions and steps that have been taken throughout the traumatic birth
process. This mainly has a relieving and supporting function. Healing from
traumatic incidences takes a longer time and more effort in working things
through and maybe accepting ones own fallibility. Social support in this sense
is not described as a sustainable form of support throughout mourning and
healing. Healing processes take time and need professional support. Both forms
of support have an important role in the processing of traumatic incidences.
Interview 4: 45 years old, 20 years work experience as midwife
The kind of supervision where a midwife is called directly by the supervisor and
which our supervisor tries to manage, is missing as a formal structure. But
sometimes she is not present or she has no time for offering social support or
maybe she hasnt heard about the traumatic incident. She calls you and asks if
you need to talk, if you want her to come home to you, or if you want to come to
her instead, or if you need a psychologist. We want to do something extra.
However, it doesnt always work
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In relation to the responsibility a midwife has and feels - the support she gets
when something happens during a birth - is experienced as insufficient.
Collegial support is there in the moment and is experienced as helpful.
Debriefing is experienced as a first step of getting over a traumatic incident but
is not viewed as particularly helpful on a deeper level of emotional trauma.
Psychological help offered to the single midwife is being tested at the moment at
the case site by a psychologist employed at the ward and might be an important
step in finding a sufficient way to support midwives after a traumatic birth
incident.
Besides the difficulties and shortcomings related to the support and healing after
traumatic incidents reflected in the statement below, it should be mentioned that
one midwife described a growth in coping capacity over the years. She describes
a feeling of getting used to and being more able to handle traumatic incidences
with growing experience on the job.
Interview 5: 49 years old, 8 years work experience as midwife
I really believe that your mental resources increase concurrently with your
education. The first time you experience a stillborn child, you feel terrible
several days after. Im sorry to admit it, but after you have helped delivering the
tenth stillborn child; your attitude has become more professional. It still affects
you emotionally, but you dont break down so easily anymore. I believe that you
grow concurrently with your independence, and I also believe that it takes a lot
to upset a midwife! People dont expect that, because they believe that giving
birth is always a happy event! Giving birth is a happy event in most of the cases;
however, there are many situations where the adrenaline pumps in your veins
and you have to be very alert all the time, and thats not always a happy event!
But you get used to that as time goes by.
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do, it is typical midwife to say: because of this, I will do it and come on; we can
get over it together. This is what we do.
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Your faith and way of doing things are shaken during such emotional crises.
You need to start all over again.
The aspect of healing and how healing can best be achieved added a new
perspective to the discussion about how to handle traumatic birth incidences.
Healing adds a second dimension to the question of how to deal traumatic birth
incidences in a healthy way. Being able to express sorrow and having time to do
so is experienced as important step towards becoming whole again.
7.4 Summary of findings concerning the role of emotional demands and
feelings in midwifery
In the course of the interviews, emotions were mentioned in relation to
emotional demands connected to the primary task in midwifery and as feelings
as reactions to traumatic birth incidences. The first aspect discussed in regard to
emotional demands in midwifery is the difference between ones own
professional image in regard to service given to the clients and the clients
appreciation of the service. The midwives report a rising trend among the
current birthing generation of coming with their own ideas about the birthing
process which can often stand in contrast to the midwives beliefs, professional
knowledge and experience. Emotions related to this aspect range from
bewilderment to frustration. Frustration is also expressed about the recent
birthing generation not giving recognition to the service they get from the
midwives. At the same time, the participating midwives refer to their job as
demanding 100% service for the clients. Connected to this demand is emotion
work in situations where ones own feelings and conditions stand against the
explicit job demand of treating each woman in labour with the same eagerness,
concentration, and not at least empathy. The midwives refer to the demand of
giving 100% service as giving something of yourself, which is used as a
metaphor for using intuition, empathy and feelings whilst fulfilling the primary
task. This demand is experienced as tiring, especially in situations when time to
recover is not available. As reaction to this demand, the midwives described a
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reaction of drawing back from clients as way out of the vicious cycle of reaction instead of action.
Experiences with the handling of traumatic birth incidences were discussed as
partly incompatible understandings by client and midwife. The participating
midwives felt humility towards something beyond human influence when at the
same time clients nowadays were described as often demanding high level of
security throughout the birth process.
The midwives also report often feeling left alone after having experienced a
traumatic birth incident. The demand to return to work as usual as quickly as
possible and a missing support system for coping with these experiences were
discussed. References to air traffic controllers were made, who have the option
to talk about near misses in order to learn from mistakes and prevent them in
the future. The midwives instead experience an atmosphere which does not
allow them to talk openly about near misses or even mistakes. They therefore
feel a double burden of feeling left alone with their coping and an atmosphere of
denial.
As a theme in its own right, emotional reactions to traumatic incidences were
discussed. First, the feeling of responsibility for ones own actions in the
birthing process as well as for those of others was addressed. Feelings of
responsibility and guilt were drawn out by the participating midwives. A
difference was made between foreseen and unforeseen traumatic birth
incidences. Unforeseen incidences were seen as being tragic and more traumatic
for the midwife in regard to her professional ego. The midwives also reported
difficult situations in which they feel torn between formal and felt responsibility.
Although, formally, they are no longer responsible once they have called a
physician to take over a difficult case, the feeling of responsibility towards the
woman giving birth often remains. Another aspect of felt responsibility
discussed was the question of how much support and consultation needs to be
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given to a woman and her family who have lost a child in the course of birth
after they leave the hospital. The mandatory support one phone call one month
after the incident is regarded as not being sufficient by some midwives. Some
therefore choose to invest a lot more time for follow-up, which often is not
covered by their regular working time. These midwives feel a discrepancy of
formal rules and feelings of responsibility.
The third point of discussion in respect to traumatic birth incidences was the
support given to midwives and the healing process after having been part of a
traumatic incident. The midwives stated clearly that the support they receive to
recover from traumatic incidences is insufficient, especially when looking at the
responsibility they have while helping to give birth. Some midwives mention
that they can understand how these unresolved experiences over time can lead to
burnout for some of them. Moreover, the interview participants reported a gap
between time given to heal and the actual time of a healing process after severe
trauma. The organizational demand is to be back on track after a short period of
time (2-3 days) whereas personal time to heal often exceeds the rather short
break a midwife is allowed to be absent from normal duty. The high emotional
involvement of the midwife doing her duty can lead to spill-over effects to other
life spheres (especially home and family). The personal social structures
available to a midwife are seen as either possible sources of support or
hindrance in respect to coping with traumatic birth incidences. Support given
from the worksite is deemed insufficient. Although the informal collegial
support is experienced as helpful, many report that it is not enough. The
supervision by colleagues who went through special training for these purposes
did not have the expected effects because there seems to be a need for more
consistent and more professional supervision and collegial supervision is also
discussed by the midwives as critical in regard to be open about own fallibilities
towards a colleague you daily work with. Nevertheless, some midwives also
report having been able to develop coping skills in dealing with these situations
by retreating to the skills and abilities of the professional role and not the
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Chapter 8: Discussion
8.1 Introduction
Findings from the present case study using participant observation, single
interviews and a group interview as method are numerous. Due to the qualitative
approach, a thick description of the research field has been reached, giving
access to a complex understanding of the multifaceted relationship between
motivation (engagement) and burnout in midwifery. Thinking out of the box of
traditional research in both fields yielded expected and new insights. Burisch
(2002, p.16) concludes his description of a longitudinal study of burnout in
nursing with the following sentence: It seems entirely possible, however, that
major breakthroughs can only be expected from much more in-depth studies of
individual cases (italics set by the author, sen). This conclusion is also shared
in two other theoretical reviews of burnout research (Schaufeli & Enzmann,
1998; Rsing, 2003) and putting this into research practice was taken seriously
in the present case investigation. The in-depth investigation of the relationship
between motivation and burnout in one particular field of human service work
can be described as an explorative approach to a research field (burnout
research) which has been studied over the last 30 years. The case approach
opens the door to a more thorough understanding of the relationship between
motivation and burnout in a specific context and new ideas have indeed emerged
as a result of the present case investigation. The results introduced in Chapters 4
to 7 are discussed in the following.
Figure 8.1 summarizes the different findings and sets the primary task in
midwifery, described as helping to give birth, in the center of discussion. On the
horizontal axis, midwifery in Denmark is described along the demands and
resources inherent in the primary task. Furthermore, person and client related
factors influencing the fulfilment of the primary task are discussed. On the
vertical axis, the structural and organizational setting is represented in regard to
the research question. Assumptions about how to understand the relationship
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between motivation and burnout are drawn from the discussion which is
understood as proposals and guidelines for future research in the field.
Challenges and accomplishments of the present approach are reflected upon and
recommendations for the support of motivation at work and the prevention of
burnout are given on the basis of the outcomes of the case study.
Figure 8.1 Primary and secondary tasks, agents, and structural and conditional aspects of
midwifery.
8.2 The nature of the primary task in midwifery and the relevance for the
research question
The present investigation showed that midwifery is described by the midwives
as a highly demanding work sphere with a high probability of work related
stress. At the same time, it became clear that the engagement of the midwife is
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nurtured by the positive experience connected to the primary task. The primary
task is described as the core drive and the only reason to accept the unfavourable
conditions of the job. Putting the primary task into the center of the discussion
links the variety of findings of the present case investigation in a significant
way. The following discusses essential characteristics of the primary task, task
related demands and resources as described by the midwives. It refers to related
research, pointing to the aspects in common and to the uniqueness of the present
approach.
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rumination about how to proceed, using each other to confirm actions taken and
to give support for decisions made.
In the center of the primary task stands the relationship between midwife and
client. In contrast to other human service settings, this relationship is described
as being intimate and at the same time of rather short duration. Due to modern
hospital organisation in Denmark, midwife and client see each other for the first
time at the labour ward even though midwives have an active role in prenatal
care as they see the pregnant women several times throughout pregnancies. The
midwife, being the facilitator in the process of birthing, needs some outstanding
communicative skills in order to establish a trusting relationship (rapport),
described as essential for a good birth. As soon as the child is born, the contact
between midwife and client formally ends. In relation to the intimacy shared
between client and midwife, this abrupt cut seems to be inappropriate and stands
in contrast to the emotional involvement demanded. Midwives share the idea of
giving best service when their task of helping to give birth is embedded in a
system which provides continuity of care deVries et al. (2001). Midwifery
practice in Denmark today is forced to make compromises in regard to this
principle. This is mainly due to the organization of birth in larger birthing units
as part of or connected to a hospital.
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reward and recognition. The three reward categories defined by Siegrist can be
described as following with regard to the midwives studied: (1) income which is
seen by the midwives as too low; (2) work security, which is objectively high at
the moment (many positions are vacant) but is viewed as somewhat lower by the
midwives themselves. The discrepancy between the objective state and the
subjective appreciation might be due to the role unclarity felt by the
participating midwives. Due to frequent, recent changes in the maternity ward at
the particular case site, the participating midwives expressed some confusion
about the definition of their own work role. Confusion here refers to ones own
state of mind in the sense of willingness to do the job under these conditions
not as confusion in regard to the role while fulfilling the primary task. (3) The
third category is the recognition from leaders or colleagues which was not
explicitly discussed in the present case investigation. Nevertheless, support from
leaders was mentioned by some midwives as being good; others felt low support
from the leading side. Furthermore, the midwives mentioned the importance of
recognition from clients as being very important for them. Especially the older
generation of midwives described it as highly rewarding to get recognition from
the client. A further, important aspect which might be seen as a category of
reward in midwifery is the meaningfulness of the task. Helping to give birth is
essentially meaningful as it facilitates the childs first entry into life. It is a
challenging, and at the same time, fulfilling task. Even though the participating
midwives reported a form of getting used to being present at the mystery of
birth, the meaning drawn from this task has shown to have great importance for
the participating midwives. To be present at birth outweighs many of the
unfavourable work conditions in midwifery. This strong emphasis on the
meaningfulness of work would explain a contradictive finding in the PUMA
study where high levels of meaning of work and high quality of leadership were
associated with higher levels of burnout in the 3-year follow-up survey (Borritz
et al., 2005): Good leadership quality and meaningful work might keep people
with a high level of personal burnout on the job (which was the case for the
group of midwives participating in the present case investigation, see Table 3.1).
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task organized in smaller sections, reaching from prenatal care to postnatal visits
and when midwives were recognized personalities in their community. Today,
the midwifes job is under redefinition. In the United States, where the
medicalization of birth is much stronger than in most European countries
(DeVries et al., 2001), a new job group, the doula 9, was established to serve as
with-women advocates in the birthing process. A doula is a person trained and
experienced in childbirth who provides continuous physical, emotional and
informational support to the mother before, during and just after childbirth
(http://www.dona.com). From the authors perspective, a doula does what
midwives like to declare as their core job of supporting a mother while giving
birth. Instead, the greater focus nowadays on medical care (e.g. more check ups
in the process of giving birth) takes away awareness and time to be spent on the
support of the woman in labour. The technological development in midwifery is
making more and more sophisticated check ups throughout pregnancy possible.
In regard to technological development there is an ongoing discussion about
what comes first. Is the technological development reason for a changing
perception of birth practice or is it the other way around? A more profound
discussion of the issue is found in the book Birth by Design (DeVries et al.,
2001). From a midwifes perspective so much can be said: the time that needs to
be spent to use the machines as instrument is higher than the time needed to use
the own body as instrument. One example is the use of ultrasound to check the
weight and height of the unborn child compared to the use of the own hands. In
fact holds the group of midwives investigated in the present case an ongoing
competition about how closed they come to estimate the birth weight of the
unborn. The form of contact to the client is also different when using more
distant methods. The bodily awareness of a midwife is assumingly lower when
she is mainly using technical devices. In Denmark, the country of the present
study, midwifery still defines helping to give birth as the primary task but the
9
The word doula comes from ancient Greek, meaning Womans servant.
(www.dona.com).
224
way this is done in modern hospital settings matches the occupational ideology
of those midwives who participated in the present study only to a certain extent.
The midwife is forced to be more flexible in jumping in and out of a birthing
situation and to rely on technical devices monitoring the process. This kind of
work profile has been typical for a medical doctor, who steps in and out of a
situation and leaves the remaining monitoring and caring to the nurses. Seen
from this perspective, there is a high probability for a felt ambiguity in role
definition in the recent midwife generation. The recent generation of midwives
is caught in the modern dilemma of being able to provide high technology
medicine at childbirth but not willing to step back from the low-technology
tradition of natural childbirth. How this dilemma is to be solved is interesting to
follow up upon. De Vries (1993) suggests that today an occupational group
gains power to the extent that it can reduce risk and uncertainty for clients. A
loss in status happens where other practitioners offer seemingly superior means
of risk reduction or where birth is redefined as a less risky event. The
recognition of a profession can be summarized as a problem of risk, knowledge,
and power. Even if this has not been discussed as pointed in the present case, it
has become clear that there is a need to renounce some of the traditional
convictions in order to keep primary status as birth attendant. This is further
discussed in the next section also in regard to different midwife generations.
8.3 Person related factors with relevance for the research question
Even if the chosen approach to investigate the relationship between motivation
and burnout in human service work makes use of a subjective approach,
personal characteristics (such as motive dispositions, personality factors, coping
style; etc.) of the interviewees were of minor interest. Nevertheless, individual
characteristics were referred to in the course of the interviews which can be
related back to research concepts from burnout research, e.g. Freudenberger &
Richeslons concept of idealised self-image (1980). The description of
engagement given by the midwives is similar to what Freudenberger and
Richelson describe as an idealised self-image, seeing ones self as a person who
225
the group of midwives, taking the fact that burnout develops over a longer
period of time and that older midwives might be more prone to develop health
impairments in a highly demanding work environment due to increased recovery
time and reduced flexibility in reacting to change.
Generation differences were discussed by the midwives as being meaningful for
the development of burnout. Older generation midwives are described as being
more prone to burnout because they have a different style of approaching work
than younger generation midwives. The more recently educated are described as
being more pragmatic about the fulfilment of the primary task. They might also
start with lower expectations towards the primary task, knowing the modern
hospital organization functions in a certain way and not knowing the difference
to older times in midwifery. The glorification of former times was obvious at
different points. This might be due to the fact that the midwives who
volunteered to take part in the present investigation of the case mostly belong to
the older generation of midwives, all of them having been in the job for at least
eight years. Some of them have experienced different forms of birthing and
experience the recent structure of their work sphere as disillusion from the
occupational ideology they started with.
In regard to biological age, recovery time and declining flexibility to handle
change was discussed. Different occupational ideologies and identities do not
necessarily correspond with biological age but rather with time at the job. These
different ideologies are meant to make a difference when talking about the
relationship between engagement and burnout. The findings from the case study
in midwifery propose that older generation midwives are better able to balance
high job demands with the energy they get out of the fulfilment of the primary
task. Younger generation midwives were described as being more sensitive to
negative working conditions, i.e. being more critical and at the same time
drawing less from the positive experiences in their work as a source for
balancing otherwise unsatisfactory working conditions. The reaction of younger
generation midwives to the high work demands can also be interpreted as
227
fulfilment of the primary task and the appreciation of this service from the
clients. In part, non-reciprocity is close at hand because the birthing situation is
unique (in the sense of happening one or two maybe three times in life) for the
client but is an everyday chore for the midwife. The emotional triangle (Figure
2.2, Chapter 2) illustrates the non-reciprocal situation of client and midwife.
Giving birth for most women is connected to a variety of different emotions:
fear and anxiety, shame, hope, pride, gratitude, relief. For the midwife, positive
as well as negative feelings are connected to the fulfilment of the primary task,
reaching from bliss to fear, from compassion to anger, or from relief to guilt
(Figure 2.2). The participants in the present case study also mentioned that each
birthing situation is unique for them as well, demanding particular reactions
from their side. The frustration felt in relation to the demands from clients and
the missing appreciation of service given by the midwives stands against high
expectations and demands towards ones self. The participating midwives used
the expression to give something of yourself when they referred to the kind of
service they give helping a woman giving birth. This high demand towards
ones self, expressed as an occupational ethic, stands in contrast to the
recognition received from the recent birthing generation. Zapf et al. (2001)
relate the importance of recognizing client-related stressors in the development
of burnout. Furthermore, Brucks (1998) points to the shortcoming of work
psychological research, focussing mainly on the instrumental part of the primary
task, whereas emotional labour (as often caused in the relation between client
and human service provider) remains implicit. In the medical field in general,
professional expertise is in the focus of attention even though emotional labour
describes an important part of the successful fulfilment of the task (Hahn, 1988,
in Brucks, 1998). Also in the present case, the participants reported how
important emotional labour is for the fulfilment of the midwifes job. Yet this
part of the work is implicit in the sense of not being officially defined as part of
the primary task and therefore not recognized in organisational structures; as for
example, in sufficient time given to recover from demanding work situations or
230
task and the potential to change it in addition to the influence on the relationship
between motivation and burnout.
232
the handling of critical incidents in air traffic control was given as one example
for a well functioning structure to approach critical incidents. In both fields, a
decline in security can lead to serious consequences. Furthermore, in both fields,
the control of the action is not immediate, meaning that the midwife and the air
traffic controller have no final influence on the ultimate process. In the case of
birthing, a lot of unforeseeable things can happen, described by the participating
midwives as natures way. In air traffic control, it is the pilot who has the
immediate control over action. Finally, both fields demand a high alertness and
good monitoring skills. A difference can be seen in the controllability of events,
being higher in air traffic control because of scheduled traffic. However, the
parallel to air traffic control puts further emphasis on the importance of
sufficient resources. A work setting with a high demand to monitor
uncontrollable events and a need to be alert in order to guarantee high security is
sensitive to insufficient resources and exhausted personnel. The high burnout
rates for midwives found in the PUMA baseline survey (Kristensen et al. 2005)
are alarming and can be interpreted in the light of declining resources and
reduced security while fulfilling the primary task. This leads to reactions of
flight (staying absent from work), fight (over-dedication, exaggerated feelings of
being responsible), and freeze (very focussed on task fulfilment, low flexibility,
low tolerance for uncontrollability). Furthermore, low resources diminish the
chance of being able to recover sufficiently from high demands. The
participating midwives mentioned being tired and exhausted as preconditions for
burnout.
Decline of
ressources
Reactions of fight,
flight,and freeze
234
235
being upside- down, and a feeling of numbness for more than 24 hours after
having been on a night shift schedule. For some of the interview participants,
work at night was such a serious problem that the thought of quitting the job was
described as appealing. A sufficient recovery time after having been on night
shift is valued as essential. One midwife mentioned the importance of being
good to ones self when being at home after an exhausting shift, not feeling
obliged to care for all the things in the house which need to be done. However,
midwives described themselves as being used to care for others. It might cost
them some extra energy to relax at home after a night shift (see also Section
8.2.1).
One last aspect mentioned in the course of the interviews and a particular point
for observation, was job routine in midwifery. Even though midwifery is
described as a work sphere with high uncontrollability, there are at least some
reasonable parts of recurrent routines. Routine work is described as being both
annoying and relaxing. The weekly consultation day is described as being a
welcome break in the weekly shift schedule. The consultation days have two
positive points to offer: they are accountable in terms of time and effort and not
less important they nurture the desire to be part of a holistic birth experience,
where prenatal information and contact is thought to be an important part. The
annoying part of routine is described as recurrent tasks that need to be done but
are of more administrative character, e.g. writing of birth journals. In relation to
the primary task the singularity of each birth process is much more in focus than
the fact that many of the tasks the midwife needs to do while helping to give
birth are to a certain extent routine tasks.
237
Both terms (tacit and implicit) are used in the present monograph in order to describe
knowledge not accessible through conscious processes. Tacit knowledge relates back to
Polanyi who published his groundbreaking work on Tacit Knowledge already in 1966. In
psychological research the terms implicit and explicit are recently used as referring to the
different modes of storing information in memory (Kuhl, 2000; Rothschild, 2000).
239
routines at a high point. Old job routines are not easy to give up in a field of
work with high uncertainty, high demand for security, and a high relevance of
implicit knowledge. Implicit knowledge in midwifery is described as embodied
knowledge. Embodied knowledge is knowledge stored in the body, using the
body as an instrument and as a knowledgeable agent. This kind of knowledge
can be observed in simple daily routines like bike riding which one first has to
learn before it becomes a routine of self-acting movement. In midwifery
embodied knowledge is for example seen in the way a midwife uses her fingers
to measure and estimate the dilation of the uterus, it is an embodied measure.
The change of job routine following from technological development has
consequences for the implicit and explicit competence of a midwife. Change in
job routine is often accompanied with insecurity and anxiety, especially in a
field in which mistakes can have serious and even fatal consequences.
Therefore, a natural and most of all very human reaction to change is rejection.
Change is not the most comfortable situation to be in. Change in an already
uncontrollable setting leads to a feeling of even higher uncontrollability.
Menzies (1975) elaborated the avoidance of change in nursing and observed that
nurses were clinging to the familiar even if this was not the most appropriate
option. In the present study, staying with the familiar gets an extra connotation
because the primary task is described as not routine-based but is rather based on
individual cases (e.g., each birth representing a single case). Furthermore,
experienced midwives rely to a certain degree on their implicit knowledge in the
sense of feeling the decision to take. This form of tacit knowledge is a valuable
competency in order to sustain the uncontrollability and uncertainty which is a
fundamental character of birthing. Implicit knowledge is thought to have high
importance in a work environment with a high frequency of acute situations,
which cannot be handled on the basis of one single job routine. On the other
hand, the meaning of implicit knowledge in midwifery has serious consequences
for actions following from implicit decision making. Often the implicit
dimension is described in a positive light and it is forgotten that the implicit
240
Herbig (2001) solved the problem with simulating a critical situation in nursery
and let the study participants react to this situation as if it was a real case. In the
present case it was initially planned to use a recently developed test to
investigate implicit motivation in midwives (Operant Motive Test, Kuhl &
Scheffer, 2001). The final research aim suggested a different approach first. In a
next step it is valued as highly interesting to look for forms of in-depth
investigation of implicit processes at work. Nevertheless, the findings of the
present study have revealed the importance of tacit knowledge in midwifery and
the bodily expression of this knowledge form on a surface level. One example is
the reported increase in felt security with years of experience which goes beyond
better mastery of the task because of experience. The feeling of security was
described by the midwives as being based on embodied knowledge, the feeling
of what is right and what needs to be done. This base of knowledge is meant to
have the character of an implicit knowledge base. In motivation research, first
steps towards implicit processes have been made and promise useful insights
(Brunstein et al., 1995; Niitamo, 1999; Kuhl, 2000; Scheffer, 2001). Findings
from this research point to the importance of congruence between implicit
motives often established in early phases of human life (beyond language) and
explicit motives established in relation to the concrete context of life. A person
can for example have a high implicit motive of attachment to others and has
explicitly chosen to work in a context where this attachment motive comes to its
right, e.g. human service work. Higher incongruence between the two showed to
be related to reduced well-being (Brunstein et al., 1995). This path of research is
thought to be interesting in a work environment which relies considerably on
implicit processes.
242
the perspective of a modern client. Client and midwife start with different
presuppositions. The clients longing for control over the process of giving birth
has reached a different quality with modern birthing practice. At the same time,
there is a longing amongst some older generation midwives to reach back in
time and reactivate birthing practices that have become buried in the
organization of childbirth in greater, modern birthing units. The gap between
midwife ideology of natural birth and client demand for controllability was
discussed in the single interviews. The participating midwives reported
bewilderment and frustration about the attitude of some women of the recent
birthing generation towards natural childbirth. The demand of total control from
the womens side stands in contrast to the experience and beliefs of the midwife.
The attitude of a midwife is nurtured by the belief of not being able to solve the
paradox of total control in an uncontrollable process. The knowledge of the
importance of letting go and the belief in something bigger than their own
competence is questioned by the demand from the client and the growing
technical control throughout pregnancy and in the process of giving birth. This
is in fact a question of belief which often leads to frustration when not solved to
the satisfaction of both sides. In the case of midwifery, a re-thinking of
occupational ideology and identity might be one way to reduce friction between
midwives and clients. Another way could be to enable midwives to convince the
recent birthing generation with their arguments being based on experience of
best practice. A woman in labour might not be listening to a midwife she has not
met before. In the crisis of giving birth she might be more trusting on and
listening to her own feelings of pain and fear. Being able to instantly establish
rapport is a high skill but seems to be important in the way midwifery is
organized today. The foregoing discussion might also be interpreted as a strong
argument for re-thinking the way labour wards are organized (e.g. segmentation
of primary task by shift schedule).
Even if the midwives have a more accepting attitude towards the
uncontrollability of the birth process, the impact of traumatic incidences is
243
as one midwife described it - a person who actually was known for being able to
cope with all the obstacles of the job in a professional way has a sudden
breakdown.
Furthermore, knowledge about the tacit dimension proposes a different
procedure then established at present for intervention procedures offered to
midwives after being part of a traumatic birth incident. The procedure of
psychological debriefing makes use of a process of narrative healing. The retelling of the traumatic incident is thought to have healing effect (Rothschild,
2000). This might be true for the explicit dimension but the implicit dimension
probably needs some other form of healing as the implicit dimension is not
accessible to language; it uses emotional, bodily, sensory information types, all
being speechless (ibid). One approach to understanding the implicit processes
after trauma is formulated in the SIBAM model (Levine, 1992, in Rothschild,
2000). SIBAM is the acronym for: Sensation, Image, Behaviour, Affect, and
Meaning. The model proposes that during or after a distressing/traumatic
incident, experiences become disconnected, e.g. image and affect of a traumatic
incident are disconnected and cause in consequence visual flashbacks. In the
context of the present study, traumatic incidences are referred to as having the
power to cause long term effects, such as burnout. Even though the occurrence
of traumatic birth incidences is seen as being a natural part of midwifery, there
is not much information about how they can react when confronted with the
situation. One participating midwife described her reaction as experiential
learning; as a process of getting used to the fact that traumatic birth incidences
happen. It is assumed that the addition of an implicit perspective to the handling
of traumatic birth incidences will lead to better ways of coping with them.
In the field of German air traffic control, a Critical Incident Stress Management
program (CISM) was established to help employees to cope with stress reactions
related to critical incidences (Vogt et al., 2004). Even though burnout is not
named amongst the stress reactions, the procedure seems to be of interest to
245
of emotions possible to imagine is not explicitly addressed and cared for. The
narratives from the participating midwives expressed the great importance of
taking the impact of traumatic incidences on the single midwife seriously.
Generation differences or even gaps have been discussed; also in the recent
work of Hunter (2004). One shortcoming of the present investigation is that only
older generation midwives were interviewed. Future research needs to look at
whether the occupational ideology of younger and older generation midwives is
distinct from each other in a way that it has impact on the basic understanding of
the primary task. However, looking at the findings from the present case
investigation, role ambiguity (here understood as a difference between own
occupational understanding and formal job role) leads to frustrations, and
probably under certain circumstances, to burnout. As soon as the positive
experience related to the primary task of supporting a woman in labour
physically, mentally, and emotionally is reduced to a minimum due to rapid
technological development and the need to use it - with at the same time
unchanged conditions in regard to job demands - imbalance occurs. Greater
technical help or even caesarean operations diminish the midwifes part,
degrading her to be assistant in an otherwise automatic process. Clarity about
this entangled understanding of the primary task is thought to be helpful in
redefining the primary task and related to this, establish new job routines.
Nevertheless, in combination with the interviews finding that pregnant
womens views have changed throughout the last years, one could interpret the
difference in behaviour of younger midwives (mentioned by older generation
midwives) as an evolutionary fit to the unchangeable, recent challenges of the
job. It is reasonable that those who give birth and those who help to give birth
from the same generation have certain mindsets and tracks in common.
Following from that, there might not be the same emotional upset for a younger
generation midwife in accepting a clients wish for an alternative to a natural
birth. Following from that younger generation midwives do not experience the
248
same kind of friction with the client described by the older generation midwives
as being frustrating and as leading to a distanced attitude towards the client.
249
degree of acceptance and the belief in the outcome is low. This does not mean
that the findings are invalid, but it diminishes the reach of a project in practice.
Accordingly, methods to investigate context variables at the same time as the
phenomena of interest need to be developed further. A combination of distal
methods of investigation, using, for example, questionnaires combined with a
more proximal method (e.g., interview), might be a way to open the way for a
larger number of participants than possible in singular qualitative approaches.
Mixed method approaches (Creswell, 2003) are thought to overcome many of
the shortcomings connected with either method. The combination of quantitative
as well as qualitative data sources in a single study are meant to lead to a
thorough level of investigation. The present investigation was launched on the
basis of outcomes from a longitudinal investigation of burnout (PUMA).
Combining these two approaches in one investigation in the future will lead to
even more specific insights and understanding of the relationship between
motivation and burnout in human service work.
The investigated group of midwives is rather homogenous in terms of
demographic factors. Unfortunately, none of the younger midwives employed at
the ward volunteered to take part in the single interviews or the group interview.
The only contact with a newly educated and young midwife happened during the
work place observation part of the study, as she was the only one on that
particular shift who volunteered to be shadowed by the author. Two assumptions
can be made in regard to this. First, younger midwives might not have been at
the ward long enough to experience feelings of burnout and therefore think that
they cannot contribute valuable insights. Moreover, due to the short time on the
job they may not be confident about the positive side investigated in the present
case, engagement in the job, because engagement is described as an ideal state
which is first reached with a certain level of expertise. Second, younger
midwives might be more open for proximal methods, giving insight into their
daily activity at the ward whereas not being interested in or being too shy for an
in-depth approach such as a single interview. The discussion with the midwives
250
about at what point trust in the own performance while fulfilling the primary
task is established, made clear that younger generation midwives are not
regarded as being fully competent to tackle critical situations until they have
reached up to seven years of work experience. This might be the reason for that
the little group of midwives with a job experience of less than 5 years do not feel
confident about sharing their knowledge.
Two other forms of selection bias were already mentioned in Chapter 3 (see
Section 3.3.4). Firstly, the explicit voluntary nature of participation in the
interviews maybe led to only those partaking who want to transport personal
issues in regard to the subject. Since the present study both provokes yet
overlooks these tendencies through its in-depth approach, this bias would seem
to be an important consideration for future studies. Secondly, a healthy worker
effect is reasonable to expect as only those who are still at work were asked to
participate. A different but very fruitful approach would be to explore the
perspectives of those who are absent from work because of work-related
stress/burnout and put those findings into perspective with the findings of the
present case investigation.
In regard to the research methods applied in the present case study, the
following needs to be mentioned critically: two points of participant observation
are the minimum for getting a somewhat comprehensive understanding of a
work task. Even if data from the participant observation were only used as
source of confirmation of findings of the single and group interviews, it would
have been of extra value to have more days of participant observation at the
ward and to have another period of observation after the interviews were
finished. An extended period of initial observation would have given more
insight into personal style of different midwives. A second round of
observations after the single interviews were carried out would have been a
valuable source of information to be used in the sense of a more focused reality
check of outcomes of the single interviews.
251
252
8.6.3 Assumptions about the research field, directions for further research
and recommendations for midwifery practice
From the discussion of findings, the following assumptions and perspectives for
further research can be drawn.
1. The relationship between motivation and burnout in midwifery in
Denmark has shown to be influenced by:
the balance between demands and resources,
the attention given to the emotional demands of the primary task,
the relationship to clients and their demands, and
the tacit/implicit dimension of knowledge and feeling.
In further studies of the relationship between motivation and burnout, it
would be of great value to include these dimensions explicitly.
2. Besides already existent measures of the tacit dimension (e.g. Operant
Motive Test, Kuhl & Scheffer, 2001; Repertory Grid, Kelly, 1955;
Herbig, 2001), new paths of investigation need to be found, especially in
the field of occupational psychology, in order to investigate the implicit
dimension and get access to this base of knowledge, emotion, and
experience.
3. Emotional demands related to the fulfilment of the primary task need the
same attention as other factors in contemporary occupational psychology.
4. Trauma at work has a far-reaching impact on the professional confidence
and well-being of doing the midwifes job. Insufficient handling of
trauma leads to states of impaired well-being (not necessarily burnout)
and higher absence rates.
5. Sufficient time is crucial for quick and full recovery (unwind, cope, and
heal) after demanding days at the ward as well as after traumatic
253
255
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List of Figures
269
List of Tables
270
Appendices
A: Copenhagen Burnout Inventory (CBI, Kristensen et al. 2005a)
B: Demographic Questions
C: Interview guide for single interviews
D: Rules for Transcription
E: Comprehensive list of quality criteria for qualitative research
271
4. Do you feel you give more than you get back when you work with client?
5. Are you tired of working with clients?
6. Do you sometimes wonder how long you will be able to work with
clients?
Response categories: To a very high degree, to a high degree, somewhat, to a
low degree, to a very low degree
Last two questions: Always, Often, Sometimes, Seldom, Never/Almost never
Less than three questions answered: non-respondent
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Aim / agreements
Focus is on personal emotions and understanding; there is no right or
wrong; the interest is personal experience
Agreements: Use of memory stick to safe data; secrecy/anonymity;
authorization for use of citations will be asked before publication;
permission to discuss outcomes of single interviews in group interview
sessions
Interview has different themes. The researcher is responsible to hold the
focus.
Ask, if there are any questions.
1. Introductory Questions
Career (kind of education, reason to become midwife, way to get in, time
being midwife, time being in the present job)
Participation in PUMA (How have you been involved?)
Positive and negative experiences in relation to PUMA study?
If you think of an ordinary day, what motivates you to go to work?
2. Practice concept of motivation and burnout
How would you describe a person who is engaged in her/his work?
How would you describe a person who is burned out?
3. Personal meaning of burnout
What does burnout mean to you?
Have you ever felt burned out? If yes, can you describe the experience??
What did you do?
4. Personal motivation and aim
Can you describe what makes you involved in your work?
If the good fairy gave you three wishes that could improve your work
motivation, what would they be?
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276
Home address
Sunniva Engelbrecht
Lers Parkall 105
2100 Kbenhavn
Sunniva Engelbrecht
Katharinenkirchhof 1
20457 Hamburg
Tyskland
sen@ami.dk
0049-40-33395092
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Analysis
Are the principles and procedures for data organisation and analysis fully
described, allowing the reader to understand what happened to the raw
material to arrive at the results?
Were the various categories identified from theory or preconceptions in
advance, or were they developed from the data?
Which principles were followed to organise the presentation of the
findings?
Are strategies used to validate results presented, such as cross-check for
rivalling explanations, member checks, or triangulation? (If such
strategies are not described in this section, they should appear as validity
discussions later in the report.)
Findings
Are the findings relevant with respect to the aim of the study?
Do they provide new insight?
Is the presentation of the findings well organised and best suited to ensure
that findings are drawn from systematic analysis of material, rather than
from preconceptions?
Are quotes used adequately to support and enrich the researchers
synopsis of the patterns identified by systematic analysis?
Discussion
Are questions about internal validity (what the study is actually about);
external validity (to what other settings the findings or notions can be
applied), and reflexivity (the effects of the researcher on processes,
interpretations, findings, and conclusions) addressed?
Has the design been scrutinised?
Are the shortcomings accounted for and discussed, without denying the
responsibility of choices taken?
Have the findings been compared with appropriate theoretical and
empirical references?
Are a few clear consequences of the study proposed?
279
Presentation
Is the report easy to understand and clearly contextualised?
Is it possible to distinguish between the voices of the informants and those
of the researcher?
References
Are important and specific sources in the field covered, and have they
been appropriately presented and applied in the text?
280