Comment
Our findings show that interviewees overwhelmingly felt that the
COVID-19 pandemic has magnified the existing and escalating staffing
crisis, impacting on the ability to provide safe and personalised care.
Even pre-pandemic, there were growing concerns about the wellbeing of
maternity staff, with high levels of anxiety, depression and burnout
noted amongst UK obstetricians and midwives (7, 8). In line with our
findings, recent research demonstrates that being unable to practise the
person-centred and autonomous midwifery care they aspired to is often
cited as a reason why midwives consider leaving the profession, although
lack of autonomy, pay and conditions are also relevant factors (9,10)
Maternity professionals are subject to a broad range of occupational
factors that can inhibit their ability to be compassionate, resulting in
compassion fatigue and inability to provide quality care (11). The
problem does not lie within the job itself – providing relational care
may in fact protect against burnout (8). The inability to work in ways
that are congruent with vocational identity and professional
requirements risks psychological and physical safety for women and
babies. These stressors result in a culture of self-sacrifice where
maximum levels of effort are required to maintain care, with minimal
resources (12). They include working long hours/beyond allotted hours
without breaks, lack of time, lack of professional autonomy, challenging
clinical situations, lack of support, high levels of fear relating to
compromised safety and potential retribution, and witnessing the
mistreatment and/or traumatic treatment of women whilst feeling unable
to intervene (9,10). Many of these pressures may be exacerbated by
insufficient staffing (10). In line with this, safe staffing may
mitigate the impact of these stressors on psychological wellbeing (9).
As these stressors increase and the ability to provide compassionate
care decreases, workers may experience a lack of professional
accomplishment, emotional exhaustion, cognitive dissonance, and moral
distress (12). As a result, they can withdraw from women and their
commitment to the profession. This is aptly described as ‘fighting a
losing battle’ (10).
Our findings demonstrate how COVID-19 has exposed fundamental flaws in a
system where organisational priorities and professional values come into
daily conflict. It is increasingly evident that the NHS functions as a
result of the goodwill of its workers, which is rapidly running out. It
appears from our data that the coping mechanisms (for example, peer
support within a well-established, sustainable team, and the freedom to
offer compassionate, relational care) that made this working environment
manageable are breaking down, leading to burnout and a critical tipping
point of collapse. There is growing anecdotal evidence that an
increasing number of those working in maternity services are questioning
why they come to work every day and are looking elsewhere for employment
that is associated with less fear, and less potential for psychological
harm.
Our data indicate the extent to which these underlying fault lines have
been magnified by the pandemic, to the point where they have become
unsustainable. This unique opportunity for a post-pandemic rebuild of
the maternity services needs to start by examining how such
long-standing flaws in maternity service design and delivery can be
built out, to avoid a similar collapse of wellbeing and morale under
future organisation-wide stressors. Understanding the protective factors
which sustain psychological and physical wellbeing amongst maternity
staff, such as flexible and autonomous practice, the ability to provide
person-centred, relational care, and strong peer networks, should
underpin future efforts to train, recruit and retain this valuable
professional workforce.
(1757 words)
Authorship as per BJOG Criteria:
SC was a research site lead, coordinated and undertook interviews,
transcribed data, contributed to the analysis framework, analysed
interviews, interpreted analysis, contributed to the concept for paper,
coordinated and took responsibility for drafting and revising the paper,
approved the final version, and agrees to be accountable for all aspects
of the work.
GM transcribed data, contributed to the analysis framework, analysed
interviews, interpreted analysis, contributed to the concept for paper,
contributed to writing the paper, supported the coordination of drafting
and revising the paper, approved the final version, and agrees to be
accountable for all aspects of the work.
SD was responsible for study conception, design, ethics, and transcribed
data, contributed to the analysis framework, analysed interviews,
interpreted analysis, contributed to the concept for paper, contributed
to writing the paper, supported the coordination of drafting and
revising the paper, approved the final version, and agrees to be
accountable for all aspects of the work.
JC contributed to the analysis framework, analysed interviews,
interpreted analysis, contributed to the concept for paper, contributed
to writing the paper, supported the coordination of drafting and
revising the paper, approved the final version, and agrees to be
accountable for all aspects of the work.
AS contributed to the analysis framework, analysed interviews,
interpreted analysis, contributed to the concept for paper, contributed
to writing the paper, supported the coordination of drafting and
revising the paper, approved the final version, and agrees to be
accountable for all aspects of the work.
CK contributed to project design, obtaining ethics approval,
coordinating and managing data collection, developing a framework,
revising the paper critically for important intellectual content,
approved the final version, and agrees to be accountable for all aspects
of the work.
DP contributed to data acquisition, analysis of data, developing a
framework, revising the paper critically for important intellectual
content, approved the final version, and agrees to be accountable for
all aspects of the work.
CF contributed to data acquisition, developing a framework, revising the
paper critically for important intellectual content, approved the final
version, and agrees to be accountable for all aspects of the work.
Joanne Cull is funded by a National Institute for Health Research (NIHR)
Wellbeing of Women Doctoral Fellowship. The views expressed in this
paper are those of the authors and not necessarily those of Wellbeing of
Women, the NHS, the NIHR or the Department of Health and Social Care