Correlations among the nursing work environment, traumatic stress, and professional quality of life in Chinese midwives: A cross-sectional study

Midwifery is an emotionally demanding profession, as the delivery room constitutes a high-stress, high-risk, and high-intensity environment [1]. As key professionals in the field of maternal and newborn health, midwives support women during their transition to motherhood [2]. In this role, midwives not only share moments of joy with childbearing women but also witness trauma and loss. The close relationship between midwives and childbearing women is a central feature of midwifery practices [3], serving as a significant source of professional fulfillment. However, midwives face psychological stress from traumatic birth events, including maternal death, fetal or neonatal death, obstetric emergencies, and postpartum complications [4]. Traumatic birth events in the delivery room may result from either direct involvement in emergency situations or indirect witnessing of adverse events [5]. According to the literature, it is common for midwives to witness traumatic birth events. Studies have revealed that 94% of midwives in Israel [6] and 98.2% of midwives in Italy [4] have witnessed traumatic birth events. Prolonged exposure to traumatic birth events may adversely affect midwives’ professional quality of life (ProQoL) and mental health.

ProQoL reflects an individual's emotional and psychological well-being derived from their caregiving role [7]. It consists of three key components: compassion satisfaction, burnout and secondary traumatic stress [7]. Burnout is characterized by feelings of hopelessness and difficulty in efficiently managing one's job [7]. It can have a series of negative impacts on patients, medical institutions, the nursing profession, and the individual physical and mental health of nurses [8]. Secondary traumatic stress refers to work-related exposure to individuals who have experienced traumatic events [7]; it is characterized by insomnia, fear, nightmares, and avoidant behavior [9]. The pressure caused by such trauma increases instances of malpractice, leads to a loss of motivation, and reduces compassion in the nursing process [10]. In addition, health care professionals can also derive pleasure from helping patients; such pleasure is called compassion satisfaction [7]. Compassion satisfaction reflect positive aspect of ProQoL, burnout and secondary traumatic stress reflect negative aspect of ProQoL.

Job demand-resources theory holds that the dynamic balance between demands and resources in the work environment determines employees’ occupational health and work outcomes [11]. The job of a midwife is characterized by high emotional demands and high exposure to trauma, and a good working environment can provide better work resources, enhance the emotional recovery ability of midwives, and thereby promote ProQoL. The nursing work environment encompasses the organizational features of the workplace that either facilitate or restrict professional nursing practice [12]. Prior studies have demonstrated that the nursing work environment is related to nurses’ well-being, perceived patient-centered care, patient outcomes, and quality of care [13–15]. The supportive work environment, characterized by professional development, collaboration, professional autonomy and values, and meaningful recognition and acknowledgment, can be regarded as a motivation factor and is associated with increased job satisfaction and low levels of burnout and secondary traumatic stress [14,16–19]. Conversely, overburdened and unsupported environments exacerbate negative emotions and decrease ProQoL [20–22]. Thus, the investigation of nursing work environment and related influencing factors is warranted to improve ProQoL among the nurse population.

Midwives, who are essential to the care of mothers and newborns, face unique challenges. They must face and resolve many birth-related situations independently. Traumatic stress caused by complicated delivery makes them face emotional challenges such as psychological distress. In China, compounding these challenges is the lack of human resources for midwifery [23] and the recent introduction of the “three-child” policy in 2021 [24], “three-child” policy has increased the birth rate among older mothers, thereby increasing the complexity of deliveries and potentially elevating midwives’ exposure to traumatic events; moreover, the personalized needs of patients are also increasing. These factors create a pressing need to understand the determinants of ProQoL in Chinese midwives and develop targeted interventions to support their well-being. However, there is a paucity of research examining the relationships among the nursing work environment, traumatic stress, and ProQoL in Chinese midwives.

The aim of this study was to fill this gap by examining these associations in the context of Chinese midwives, with the goal of informing effective interventions that improve midwives’ ProQoL, and promote their well-being, ultimately promoting the quality of care for childbearing women.

This study investigated the status of ProQoL in Chinese midwives, as well as the associations among the nursing work environment, traumatic stress, and ProQoL. In our study, compassion satisfaction and burnout levels were moderate, whereas secondary traumatic stress levels were low (according to the norms provided by Stamm). Compared with those reported in a survey of Italian midwives [4], the levels of compassion satisfaction, burnout, and secondary traumatic stress among Chinese midwives in this study were comparable. Compared with a study of midwifery students at a university in northwest England [32], our study revealed similar levels of secondary traumatic stress, lower compassion satisfaction, and greater burnout. These variations may be attributed to differences in health care systems, cultures, sample sizes, work environments and study methodologies. Notably, China's hierarchical health care system may shape midwives’ ProQoL. Unlike in Western contexts with greater midwifery autonomy, Chinese midwives operate within an obstetrician-led framework, potentially limiting decision-making authority and increasing job stress while reducing professional fulfillment factors linked to compassion satisfaction and burnout [33]. Although high workloads and standardized processes may mitigate secondary traumatic stress, they may also reduce emotional engagement, differentially impacting ProQoL compared with more autonomous settings.

The ProQoL of midwives are influenced by multiple factors. Multiple linear regression analysis revealed that major shifts and health condition were important influencing factors of compassion satisfaction. Additionally, health condition was identified as a key factor influencing burnout, while the frequency of night shifts per month emerged as a significant predictor of secondary traumatic stress. The findings of this survey indicate that better health conditions positively influence compassion satisfaction while negatively affecting burnout, which is consistent with other studies [34,35]. Midwives in poor health condition may lack the energy and motivation required for their demanding roles, leading to increased burnout. Additionally, midwives in better health condition are better equipped to provide high-quality care, which enhances their compassion satisfaction when helping others [35,36]. This study also revealed that midwives working on a day-night shift reported lower compassion satisfaction than those working on a day shift did, which aligns with previous research [37]. Disrupted biological rhythms, sleep deprivation, and fatigue associated with shift work can impair midwives’ ability to empathize and derive satisfaction from helping child-bearing women. Additionally, the frequency of night shifts can influence secondary traumatic stress; however, a contrasting study revealed no significant associations between these factors [38]. Frequent night shifts may disrupt social life and sleep patterns; when facing trauma, individuals may be more stressed. Therefore, nursing managers should be aware of midwives’ health condition and consider implementing more flexible and supportive scheduling practices to mitigate these effects.

The ProQoL of midwives was correlated with traumatic stress. Multiple regression models revealed that traumatic stress is an important predictor of compassion satisfaction, burnout, and secondary traumatic stress. Most previous studies evaluated exposure to trauma and ProQoL [4,6,39]. In contrast to secondary traumatic stress, traumatic stress is less severe [40]. Traumatic stress in midwives reflects the psychological distress triggered by directly encountering or witnessing obstetric emergencies [30,41], which is a subjective psychological response caused by objective experiences. Secondary traumatic stress is an emotional and psychological response indirectly generated by exposure to the trauma of others [7,42]. Traumatic stress symptoms could serve as a prodromal marker for psychological conditions such as secondary traumatic stress [30,41]. The intimate relationship with child-bearing women is a double-edged sword [6]; such emotional relationships can increase job satisfaction for midwives while also exposing them to traumatic birth events. Thus, frequent witnessing of, and being affected by, traumatic birth events may influence the job satisfaction of midwives and influence the development of compassion satisfaction. Additionally, the impact of traumatic stress, rather than its frequency, emerged as a stronger predictor of burnout. The frequency of traumatic stress did not seem to reflect a stronger impact [6]. Burnout is characterized by elevated levels of emotional exhaustion and is not caused by trauma itself but rather by chronic stress [10]. The greater the emotional relationship with child-bearing women, the greater the impact of trauma has, and a strong sense of responsibility makes midwives feel remorse and guilt, which contributes to burnout [30]. Moreover, the impact of traumatic stress is also an influencing factor of secondary traumatic stress, which means identifying the effects of trauma early and reducing the occurrence of secondary traumatic stress. Hence, it is necessary to develop effective strategies for coping with trauma, such as trauma management and trauma-informed care education (such as structured debriefing sessions following traumatic deliveries, resilience training programs, and routine psychological support) for midwives [43], to improve their ProQoL.

The ProQoL of midwives are linked to the nursing work environment. The regression analysis revealed that the nursing work environment significantly influences compassion satisfaction, burnout, and secondary traumatic stress, corroborating earlier studies [44,45]. A healthier nursing work environment enhances midwives’ ProQoL. Career development can help midwives achieve personal and professional growth, enhance job satisfaction, and better manage emotional stress in their work, thus avoiding emotional exhaustion; this shows that nurse managers should establish a platform for midwives’ professional development, including training, further study, and career advancement. The characteristics of effective leadership and management include encouragement, patient listening, and providing feedback. It is important to continuously improve the nursing management evaluation system. The doctor-and-nurse relationship is the provision of medical care for patients by nurses and doctors through open communication and coordination under the promise of equality, autonomy, and mutual respect [46]. Good relationships provide emotional support for midwives, helping them cope with work-related stress. Hospital organizations should promote collaboration and support between doctors and midwives through training, communication, and team-building activities. Meaningful recognition may come in various forms, including affirmations by patients and their families, affirmations by other medical staff, satisfactory pay, and value from work, which can be empowering tools to promote retention and reduce turnover [47]. Hospitals should recognize the work performance of midwives through recognition, awards, and performance feedback. Professional autonomy refers to independently making clinical decisions and taking responsibility for one's own professional behavior. Job autonomy enhances work engagement and positively affects job satisfaction [48], thereby improving midwives’ ProQoL. Professional autonomy can be enhanced by increasing public awareness of midwives’ roles and competencies, as well as by recognizing their authority [49]. Basic guarantees, including salary, benefits, and leave policies, directly impact the economic well-being and career stability of midwives. These guarantees enhance their sense of belonging, reduce burnout, and serve as a buffer against excessive workload and emotional pressure. Therefore, it is important to optimize salary structures, enhance welfare plans, and implement reasonable vacation policies. Sufficient human resources mean a manageable workload. When faced with an unmanageable workload, individuals often experience significant time pressure, which can lead to a sense of overload, further exacerbating the risk of burnout and secondary traumatic stress [50]. Thus, it is particularly important to optimize human resources.

In conclusion, the findings have significant implications for nursing management and policy development. Interventions aimed at improving midwives’ health, optimizing shift schedules, and providing trauma-informed care training and effective trauma management are crucial for improving ProQoL. Additionally, fostering a supportive work environment through effective leadership, adequate staffing, and meaningful recognition can enhance ProQoL. Future studies should employ longitudinal designs, qualitative study and diverse populations to thoroughly investigate the long-term impacts of traumatic stress and work environments on midwives’ ProQoL.

This research provides valuable insight into the nursing work environment, traumatic stress and relationships with ProQoL in midwives. The findings suggest that nurse managers should focus on the physical and psychological well-being of midwives, develop targeted interventions, foster a healthy work environment, and implement trauma management and trauma-informed care education to improve their ProQoL. The findings also provide valuable evidence for midwives’ well-being, adding to the limited knowledge in the field.

The authors extend their gratitude to the midwives who participated in this study and to everyone else who contributed.

All relevant data are within the paper and itsfiles. Supporting information

This research was supported by Henan Provincial Health Commission (LHGJ20220551), Henan Provincial Health Commission (SBGJ202103077), Henan Federation of Social Sciences (SKL-2024-325). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.