Nurturing Maternity Staff

How to tackle trauma, stress and burnout to create a positive working culture in the NHS

Jan Smith

• Publisher: Pinter & Martin
• Year: 2021
• ISBN:
  9781780667386
• Topic: Medicine
• Subtopic: Health Care Delivery

That maternity staff are under pressure, with many leaving their jobs each year, is well known. Personal sacrifices, long working hours, lack of resources and an overstretched system take their toll, and occasionally staff are involved in traumatic and emotionally difficult situations. Many tolerate these conditions in the service of doing a job they love, but what happens to their mental health over time? Nurturing Maternity Staff explains how the system and individuals within it relate to each other, highlighting both the vital role compassionate leadership has in creating psychologically safe working environments, as well as tools individuals can use to optimise their own mental wellbeing.

Let's dare to dream maternity services could be different.

1

MENTAL WELLBEING IN MATERNITY

‘There is no health without mental health.’

The World Health Organization

Everyone has ‘off’ days when it might feel like a struggle to get going, or they feel low in mood or irritable. For some, a few days of struggling might turn into feelings that are difficult to manage and are pervasive, influencing their thinking and how they behave towards themselves and others. Over time, the way they experience the world alters.

This chapter aims to outline some typical mental health difficulties maternity staff might face and promote the importance of checking in with themselves and others. It encourages staff to seek support (from a professional, a family member, a colleague, or a friend). This is particularly important given the increasing strain placed on some parts of maternity services and the message that ‘resilience’ is key to the wellbeing of staff.

There is no evidence that I can find that current maternity staff are more or less able to cope with work pressures than those that went before them. However, ‘resilience training’ seems to be popular at the moment. I appreciate that the intention is to support staff to manage the pressures and workload they face. However, the perception of staff that have attended training, which they have shared with me, ranges from a subtle feeling that they are somehow lacking, to an overt feeling that they’re ‘not tough enough’ to work in maternity services, or they ‘aren’t cut out for this job’. Whether resilience is seen as a personality trait or the ability to cope with adversity, staff absorb into their psyche that they are not ‘enough’ in some way.

Many definitions of resilience emphasise that it is not only the ability to survive, but also to adapt. I have learned that resilience is an ability to learn from difficult conditions and integrate this into an individual’s learning, but that it also relies on several factors: context, the environment, and the individual. By way of example, Sam, a consultant obstetrician, shares her experience:

‘I love what I do, I really do. To many of my colleagues, I think they would probably describe me as a very resilient person if they had to. I’m able to work through a busy clinic, support women who are distressed quite competently and manage some pretty complex obstetric cases. However, I recently moved to a different hospital. I didn’t know how the appointment system worked, I couldn’t log on to my emails, and my clinic overran by two hours. I sat in the toilets, trying to calm myself down and not cry.’

Sam didn’t become any less resilient moving to a different hospital. Understandably, she had difficulty coping with her new environment. Each one of us has a breaking point, when we feel like we can’t go on. Many staff are already covering extra shifts and putting up with toxic working relationships. How much more are they able to take, and are they expected to take? Resilience training, for me, isn’t about teaching staff how to maintain their mental wellbeing in a healthcare system. I worry that it’s training them to tolerate a deeply broken system.

Burnout

Everyone experiences stress. But when does a ‘normal’ amount of stress spill over into something else, which can render staff physically or psychologically unwell?

Burnout syndrome is defined as a chronic negative work-related psychological state, composed of three elements, which are:

1.High emotional exhaustion (referring to the physical/emotional overloads, or depletion of emotional resources);

2.High depersonalisation or lacking empathy with patients;

3.Low personal accomplishment, which is characterised by a negative work attitude towards work and low self-esteem due to unrewarding situations, which negatively impacts professional performance.¹

In my experience, human-to-human connection is what staff find most nurturing and patients find so comforting. Yet when care becomes depersonalised, staff are starved of the very thing that nourishes them.

Jude, a midwife, discusses how being burnt out felt for her.

‘When I look back now, I can see that what I was experiencing was burnout. Initially, I became tearful over anything; it was more than just being sensitive. I then became emotionally exhausted, which was very physical, and I experienced ‘unexplained’ pains in my body. I began to dread going to work, and it took all the energy I had to get myself there. When I was on shift, I just couldn’t focus on anything. I was supporting a mum during labour who was very anxious. Usually, I would’ve been calm, gentle, and reassuring towards her, but I felt nothing. I thought there was something seriously wrong with me. I took some time off work, and I began to recover and connect with those around me again.’

As well as significantly affecting an individual’s wellbeing and quality of life, burnout can also have detrimental implications for the organisation involved by increasing absenteeism² and reducing service quality,³ compromising patient safety.

Although many healthcare professionals are at risk of burnout, the characteristics of maternity professionals distinguish them from other staff working within the healthcare system. Many economic, organisational and professional factors, like professional shortages and poor working conditions, compromise the wellbeing of the maternity workforce.⁴ This is further compounded by the significant emotional strain placed on them by potential complications, which can endanger the lives of mother and child.⁵ Also, there is a high prevalence (25–35%) of anxiety and post-traumatic stress disorder in maternity staff,⁶ making them potentially vulnerable to experiencing burnout. The highest rates of burnout are in newly qualified midwives⁷ and trainee doctors working in obstetrics and gynaecology.⁸ Furthermore, these medics are also at higher risk of experiencing anxiety, depression, suicidal thoughts, and substance misuse.

This is the next generation of maternity staff. Understanding why they are most affected and how to mitigate burnout is imperative if we are to retain the workforce and have safe, nurturing, and sustainable maternity services. Students on placement in maternity units can be a vital resource for more established staff and leaders to learn from. They come into practice after many hours of reading and academic work, so are in prime position to hold a mirror up to the environment they see. This is an invaluable asset to capture and be able to learn from to improve maternity for all who are in it. Improving the working conditions of maternity staff has been identified as essential to optimise their wellbeing. Furthermore, openness to communication, empathy, and individuals believing in their ability and skills to carry out their role (self-efficacy) have been identified as protective factors against burnout.^9,10

Moral injury

Healthcare workers usually enter their profession to provide the best possible care, irrespective of a patient’s gender, age, and condition. This desire is both their moral code and often their professional values. However, what if lack of resources, organisational issues, and toxic working cultures prevent staff from delivering the care they have been trained to provide? When this happens, their moral code can be shattered by making decisions that conflict with their professional values. The depths of their moral pain, which also signifies their humanity, indicate the degree to which their professional values have been violated.¹¹ Some staff have shared their experience of working for many years in a maternity system which has pulled them in too many directions. Before Covid-19 hit, there was already increasing recognition that healthcare professionals were experiencing moral distress, potentially leading to moral injury.¹²

During the pandemic, partners were unable to attend antenatal appointments and offer support throughout labour, and many staff were redeployed to other areas of healthcare. A report by Make Birth Better¹³ found that many maternity staff felt heartbroken not to be able to provide the care to women they were trained to deliver, which increases the risk of moral injuries and trauma-related symptoms.¹⁴ Some disclosed that their mental wellbeing had been negatively affected, and others explained how they felt traumatised. One midwife shared that she had ‘never wanted to leave the profession more’, and another said:

‘It’s difficult to be able to provide the care that I came into the profession to provide. I spend a lot of time apologising for the changes to services. I feel like Covid-19 has sadly overshadowed the beauty and wonder of birth and autonomy of the woman.’

Many staff who shared decision-making felt supported by their colleagues and team. These factors appeared to mitigate the potential impact of moral injuries significantly.

Moral injury is defined as the psychological distress resulting from actions, or lack of them, which violate an individual’s moral or ethical code.¹⁵ Often the individual feels shame and guilt because they have not been able to right the wrong committed, alongside negative thoughts about oneself/others,¹⁶ which are also symptoms of post-traumatic stress disorder (PTSD).¹⁷ Although the moral injury is not a mental illness, exposure and the meaning of the events can lead to mental health difficulties like PTSD, suicidal ideation, depression, and anxiety.^15,16

Currently, little is known about what interventions might help to treat those affected by moral injuries. However, research is underway to get a better understanding of what might help. Many events and situations can lead to staff feeling morally distressed and injured. It is well known that social support can have a positive effect on psychological distress. However, when shame is a core feeling within that distress, social contact is usually avoided, isolating that individual further.¹⁵ From my own experiences of supporting staff impacted by this, teaching them how to forgive themselves and foster self-compassion is crucial in helping them heal their broken spirit.

Stress response and anxiety

From time to time, we all feel anxious. In fact, at moments of stress, it can have positive benefits: it acts as an internal alarm to prompt action to prevent the worst scenario from happening. Like many mental health symptoms, how an individual experiences them varies from person to person. There are times when these feelings become more permanent and adversely impact an individual’s mental wellbeing and quality of life. This differs from a typical stress-response, which passes.

When we encounter a perceived threat, a part of our brain, called the hypothalamus, triggers an alarm system in our body. A combination of hormonal and nerve signals are sent to our adrenal glands to release a surge of hormones (adrenaline and cortisol) to prepare us to manage the perceived threat. The adrenaline will increase our heartrate and blood pressure, enhancing our energy levels. Cortisol increases glucose in our bloodstream, to fuel the brain: it is like a superpower for the stress response. It acts to limit functions in our body that aren’t essential to the fight-flight situation and supports the brain to think more clearly, which is needed at times of danger. Most of the time, when the stressful situation has passed, the stressful feelings (pounding heart, feeling jumpy, racing thoughts) tend to subside.

In the case of persistent feelings of stress, the internal alarm system can be triggered by anything (a smell, a situation, a place, a person, a noise), and it reacts as if it is a real threat when in fact it is a threat the individual perceives as dangerous. Anxiety is like the stress response going into overdrive. Often, a natural reaction to anxiety is to try and assert control and reduce fear. Control might feel like a temporary solution. However, working in maternity services can be unpredictable, and control becomes redundant in these situations as a coping strategy for anxiety.

In the case of midwives, evidence has...

Table of contents

• Cover
• Title Page
• Copyright
• Contents
• Author’s Note
• Introduction: Maternity Staff Matter
• 1. Mental Wellbeing in Maternity
• 2. Working in a Traumatised System
• 3. Person-Centred and Compassionate Leadership
• 4. Speaking Our Truths
• 5. The Tide of Change
• 6. Embracing Difference
• 7. Dare to Dream
• Conclusion
• Contributors
• Acknowledgements
• References
• Index