What this is
- This study examines the relationships among the nursing work environment, traumatic stress, and () in Chinese midwives.
- Midwives face significant emotional challenges due to their high-stress work environment, impacting their well-being.
- Understanding these relationships is crucial for developing targeted interventions to improve midwives' .
Essence
- A supportive nursing work environment correlates with higher compassion satisfaction and lower and among Chinese midwives. Traumatic stress negatively impacts compassion satisfaction and positively correlates with .
Key takeaways
- The nursing work environment score positively correlates with compassion satisfaction (r = 0.610) and negatively with (r = -0.390) and (r = -0.296). A healthier work environment enhances midwives' emotional well-being.
- Midwives reported moderate levels of compassion satisfaction (35.18 ± 7.703) and (25.33 ± 4.334), and low levels of (21.50 ± 5.464). These findings indicate the need for interventions to support midwives' mental health.
- Traumatic stress frequency and impact are positively related to (r = 0.254, r = 0.452) and (r = 0.281, r = 0.380), while negatively related to compassion satisfaction (r = -0.145, r = -0.383).
Caveats
- The cross-sectional design limits causal inferences regarding . Future studies should consider longitudinal approaches to better understand these relationships.
- Self-report questionnaires may introduce bias, particularly concerning the underreporting of or due to social expectations.
- The convenience sampling method may not represent all midwifery conditions, as the study was geographically limited to Henan Province, China.
Definitions
- Professional Quality of Life (ProQoL): Emotional and psychological well-being derived from caregiving, encompassing compassion satisfaction, burnout, and secondary traumatic stress.
- Burnout: Emotional exhaustion and reduced professional efficacy, often resulting from prolonged stress and high emotional demands.
- Secondary Traumatic Stress: Emotional distress resulting from exposure to the traumatic experiences of others, characterized by symptoms like insomnia and fear.
Simplified
Introduction
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.
Methods
Study design
A cross-sectional, correlational survey of midwives was conducted.
Setting and participants
Data were collected from a voluntary convenience sample of midwives from 59 hospitals in Henan Province, China, from November to December 2023. The inclusion criteria were as follows: 1) working as a midwife with at least one year of experience in the delivery room and 2) registered nurses who also hold midwifery endorsements. The exclusion criteria were as follows: 1) midwives who were on leave, such as maternity leave or career breaks and 2) nursing students interning in the delivery room. The strengthening the reporting of observational studies in epidemiology (STROBE) criteria [25] were followed in the conduct and reporting of this study.
G*Power 3.1 software was employed for sample size calculation [26]. The parameters were set as follows: an effect size of d = 0.15, an alpha level of 0.05, and a power level of 0.95. The findings revealed a minimum sample size of 213. Our sample size met this requirement.
Data collection process
We published our research objectives and content in a WeChat group (created by a delivery room head nurse group during a conference), distributed the electronic questionnaire, and invited delivery room head nurses to help distribute the questionnaire to midwives who met the inclusion criteria. The electronic questionnaire was designed by a social media platform called Questionnaire Star (Questionnaire Star is a secure, widely used online platform for data collection in China, with features that limit duplicate responses). Before the questionnaire started, there was a guiding statement indicating that our research was voluntary and confidential, and the first question was,“Do you agree to participate in this study?” After“Yes”was clicked, the participants could start completing the questionnaire. Finally, a total of 247 midwives completed the investigation. Because of low quality responses (for example, all options were consistent, such as 1, 1, 1, 1, 1 or 5, 5, 5, 5, 5), 15 were excluded; ultimately, 232 valid questionnaires were collected, for a valid response rate of 93.93%. Since there are very few male midwives in China, all of the participants in this study were female.
Ethical considerations
The Department of Ethics Committee, Zhengzhou University, provided ethical approval (No: ZZUIBRB2020−52). Before the study, we obtained informed consent from all midwives. Participants were informed of voluntary participation, they can withdraw at any moment. Additionally, the study was anonymous, their personal information was protected.
Measurement
Data analysis
IBM SPSS 26.0 was used to analyze the data. To determine if the data were normally distributed, the Q-Q test was used. Due to the fact that all the measurement data did not follow a normal distribution, the Mann-Whitney U test and the Kruskal-Wallis H test were employed to analyze participants’ compassion satisfaction, burnout, and secondary traumatic stress associated with demographic and professional characteristics, and p < 0.05 indicated a statistically significant difference. Spearman’s correlation analysis was used to analyze the relationships among participants’ nursing work environment, traumatic stress, compassion satisfaction, burnout, and secondary traumatic stress, and a difference of p < 0.05 was considered statistically significant. Moreover, multiple linear stepwise regression analysis was used to investigate the impacts of participants’ demographic and professional characteristics, traumatic stress, and nursing work environment (as independent variables) on compassion satisfaction, burnout, and secondary traumatic stress (as dependent variables).
Results
Demographic and professional characteristics of the participants
The mean age of the participants was 35.69 years (range: 22–54 years, SD = 6.904). Among the 232 participants, 100% were female, 87.1% were married, and 82.3% held a bachelor's degree. Most participants worked in a three-level hospital (66.8%) and had a supervisor nurse title (58.2%). See more demographic details in Table 1.
| Characteristics | Category | n (%) | Compassion satisfaction | Burnout | Secondary traumatic stress | |||
|---|---|---|---|---|---|---|---|---|
| Mean ± SD | Z/F | Mean ± SD | Z/F | Mean ± SD | Z/F | |||
| ()p Value | ()p Value | ()p Value | ||||||
| Ages (in years) | ≦30 | 59 (25.4) | 35.54 ± 7.901 | 0.93 | 25.10 ± 4.521 | 1.204 | 21.15 ± 5.965 | 0.341 |
| 31-40 | 120 (51.7) | 34.61 ± 7.995 | (0.628) | 25.61 ± 4.133 | (0.548) | 21.56 ± 5.203 | (0.843) | |
| ≧41 | 53 (22.8) | 36.08 ± 6.782 | 24.94 ± 4.601 | 21.75 ± 5.547 | ||||
| Marital status | Single | 24 (10.3) | 35.79 ± 7.616 | 2.461 | 24.96 ± 5.137 | 1.226 | 20.33 ± 5.903 | 2.24 |
| Married | 202 (87.1) | 34.98 ± 7.730 | (0.292) | 25.41 ± 4.253 | (0.542) | 21.70 ± 5.448 | (0.326) | |
| Divorced or windowed | 6 (2.6) | 39.67 ± 6.743 | 24.00 ± 4.050 | 19.33 ± 3.445 | ||||
| Educational level | Associate degree | 41 (17.7) | 34.54 ± 6.903 | −0.735 | 24.76 ± 3.992 | −0.885 | 21.41 ± 5.749 | −0.051 |
| Bachelor's degree | 191 (82.3) | 35.32 ± 7.875 | (0.462) | 25.45 ± 4.404 | (0.376) | 21.52 ± 5.416 | (0.959) | |
| Hospital level | Three | 155 (66.8) | 36.20 ± 7.427 | −2.955 | 24.94 ± 4.180 | −1.826 | 21.32 ± 5.485 | −0.794 |
| Two | 77 (33.2) | 33.13 ± 7.888 | (0.003) | 26.12 ± 4.554 | (0.068) | 21.87 ± 5.437 | (0.427) | |
| Professional title | Primary nurse | 14 (6.0) | 34.64 ± 8.705 | 0.508 | 24.43 ± 4.926 | 1.329 | 20.79 ± 4.509 | 6.817 |
| Senior nurse | 65 (28.0) | 35.02 ± 7.783 | (0.917) | 25.05 ± 4.185 | (0.772) | 20.68 ± 5.745 | (0.078) | |
| Supervisor nurse | 135 (58.2) | 35.16 ± 7.704 | 25.46 ± 4.244 | 21.59 ± 5.426 | ||||
| Deputy chief nurse | 18 (7.8) | 36.39 ± 7.114 | 26.06 ± 5.207 | 24.33 ± 4.715 | ||||
| Employment form | Staffing at public | 71 (30.6) | 35.69 ± 6.863 | 2.226 | 25.00 ± 4.554 | 2.268 | 21.38 ± 5.131 | 0.615 |
| Personal agency | 116 (50.0) | 35.45 ± 8.080 | (0.527) | 25.59 ± 4.398 | (0.519) | 21.59 ± 5.778 | (0.893) | |
| Contractor | 42 (18.1) | 33.83 ± 8.076 | 24.98 ± 3.879 | 21.62 ± 5.277 | ||||
| Temporary worker | 3 (1.3) | 31.67 ± 6.658 | 27.67 ± 2.082 | 19.00 ± 5.000 | ||||
| Duties | No | 186 (80.2) | 34.65 ± 7.858 | −1.806 | 25.23 ± 4.344 | −0.565 | 21.17 ± 5.609 | −2.001 |
| Head nurse | 46 (19.8) | 37.33 ± 6.700 | (0.071) | 25.72 ± 4.319 | (0.572) | 22.83 ± 4.654 | (0.045) | |
| Years as a midwife | 1-5 | 187 (80.6) | 34.58 ± 7.831 | −2.227 | 25.52 ± 4.457 | −1.152 | 21.42 ± 5.458 | −0.433 |
| ≧6 | 45 (19.4) | 37.69 ± 6.660 | (0.026) | 24.53 ± 3.721 | (0.249) | 21.84 ± 5.535 | (0.665) | |
| Major shifts | Day shift | 90 (38.8) | 37.61 ± 6.347 | −3.737 | 24.74 ± 3.928 | −1.405 | 21.58 ± 4.972 | −0.437 |
| Day-Night shift | 142 (61.2) | 33.64 ± 8.102 | (< 0.001) | 25.70 ± 4.548 | (0.160) | 21.45 ± 5.771 | (0.662) | |
| Frequency of night shifts per month | <5 | 85 (36.6) | 35.40 ± 7.593 | −0.189 | 25.25 ± 4.367 | −0.347 | 22.53 ± 4.755 | −2.426 |
| ≧6 | 147 (63.4) | 35.05 ± 7.790 | (0.850) | 25.37 ± 4.329 | (0.728) | 20.90 ± 5.766 | (0.015) | |
| Personal monthly Income | ≦5000 | 132 (56.9) | 33.65 ± 7.785 | 13.976 | 25.33 ± 4.533 | 0.663 | 21.02 ± 5.401 | 3.685 |
| (in Chinese Yuan) | 5001-10000 | 96 (41.4) | 37.15 ± 7.123 | (0.001) | 25.26 ± 4.135 | (0.718) | 22.00 ± 5.483 | (0.158) |
| ≧10000 | 4 (1.7) | 38.50 ± 8.660 | 26.75 ± 2.217 | 25.50 ± 5.745 | ||||
| Weekly working time | ≦50h | 154 (66.4) | 36.00 ± 7.514 | −2.095 | 25.14 ± 4.232 | −0.987 | 21.71 ± 5.195 | −1.032 |
| >50h | 78 (33.6) | 33.56 ± 7.865 | (0.036) | 25.71 ± 4.533 | (0.323) | 21.08 ± 5.971 | (0.302) | |
| Number of deliveries per week on average | 1-10 | 153 (65.9) | 34.54 ± 8.096 | −1.819 | 25.30 ± 4.440 | −0.092 | 21.64 ± 5.471 | −0.52 |
| ≧11 | 79 (34.1) | 36.42 ± 6.759 | (0.069) | 25.38 ± 4.149 | (0.927) | 21.23 ± 5.475 | (0.603) | |
| Heath condition | Very good | 59 (25.4) | 39.15 ± 5.539 | 24.274 | 23.46 ± 4.606 | 26.623 | 20.80 ± 6.122 | 2.318 |
| Good | 75 (32.3) | 35.51 ± 7.318 | (< 0.001) | 24.72 ± 3.754 | (< 0.001) | 21.43 ± 4.998 | (0.314) | |
| Not good | 98 (42.2) | 32.54 ± 8.087 | 26.92 ± 4.040 | 21.98 ± 5.394 | ||||
| Sleep quality | Very good | 23 (9.9) | 40.65 ± 5.540 | 15.685 | 23.87 ± 4.957 | 12.989 | 19.35 ± 5.951 | 8.422 |
| Good | 50 (21.6) | 36.16 ± 7.675 | (0.001) | 24.00 ± 3.974 | (0.005) | 20.40 ± 5.660 | (0.038) | |
| Neutral | 95 (40.9) | 34.26 ± 7.552 | 25.72 ± 4.227 | 21.92 ± 5.071 | ||||
| Not good | 64 (27.6) | 33.81 ± 7.817 | 26.31 ± 4.238 | 22.52 ± 5.463 | ||||
Nursing work environment, traumatic stress and professional quality of life measurement scores of the participants
As shown in Table 2, the average score for the nursing work environment was 121.12 (SD = 21.106), and the scores for the frequency of traumatic stress and the impact of traumatic stress were 7.18 (SD = 4.077) and 24.17 (SD = 9.256), respectively.
According to Stamm, results revealed moderate levels of compassion satisfaction (35.18 ± 7.703) and burnout (25.33 ± 4.334), and low levels of secondary traumatic stress (21.50 ± 5.464).
| Mean ± SD | High, n (%) | Moderate, n (%) | Low, n (%) | |
|---|---|---|---|---|
| Nursing Work Environment Scale | 121.12 ± 21.106 | |||
| Career development | 23.80 ± 4.806 | |||
| Leadership and management | 17.76 ± 4.547 | |||
| Doctor and nurse relationships | 18.95 ± 3.565 | |||
| Recognition atmosphere | 15.49 ± 1.980 | |||
| Professional autonomy | 19.77 ± 3.255 | |||
| Basic guarantees | 11.50 ± 4.403 | |||
| Sufficient manpower | 13.85 ± 3.056 | |||
| Traumatic Stress Scale for Midwives | ||||
| Frequency | 7.18 ± 4.077 | |||
| Impact | 24.17 ± 9.256 | |||
| Professional Quality of Life Scale | ||||
| Compassion satisfaction | 35.18 ± 7.703 | 47(20.3) | 171(73.7) | 14(6.0) |
| Burnout | 25.33 ± 4.334 | 0 | 166(71.6) | 66(28.4) |
| Secondary traumatic stress | 21.50 ± 5.464 | 0 | 91(39.2) | 141(60.8) |
Correlational results
Table 3 displays the correlations between the primary study variables. The nursing work environment score was positively correlated with compassion satisfaction (r = 0.610) but negatively correlated with burnout (r = −0.390) and secondary traumatic stress (r = −0.296). The results revealed that midwives who reported a healthier nursing work environment reported higher compassion satisfaction levels, lower burnout levels, and lower secondary traumatic stress levels. Midwives’ scores on the frequency and impact of traumatic stress were positively related to burnout (r = 0.254, r = 0.452) and secondary traumatic stress (r = 0.281, r = 0.380) but negatively related to compassion satisfaction (r = −0.145, r = −0.383).
| Compassion satisfaction | Burnout | Secondary traumatic stress | |
|---|---|---|---|
| Nursing work environment | = 0.610**r | = −0.390**r | = −0.296**r |
| The frequency of traumatic stress | = −0.145*r | = 0.254**r | = 0.281**r |
| The impact of traumatic stress | = −0.383**r | = 0.452**r | = 0.380**r |
Factors associated with participants’ compassion satisfaction, burnout, and secondary traumatic stress
The nonparametric test results are shown in Table 1. Hospital level, years as a midwife, major shifts, personal monthly income, weekly working time, health condition, and sleep quality had different scores for compassion satisfaction. Health condition and sleep quality had different scores for burnout. The secondary traumatic stress scores varied according to duties, frequency of night shifts per month, and sleep quality. There was a statistically significant difference (p < 0.05). Next, we used compassion satisfaction, burnout, and secondary traumatic stress as dependent variables. For the independent variables, we chose those that were statistically significant (p < 0.05) in the univariate analysis and (p < 0.05) in the Spearman’s correlation analysis for the multiple linear regression analysis. Table 4 presents the multiple regression results. The nursing work environment, the impact of traumatic stress, major shifts, health condition, and the frequency of traumatic stress had statistically important effects on compassion satisfaction, and the nursing work environment, the impact of traumatic stress and the frequency of traumatic stress accounted for 51.0%, 25.2% and 12.6%, respectively, of the variance in compassion satisfaction. For burnout, three variables (the impact of traumatic stress, health condition, and the nursing work environment) were statistically significant predictors, and the nursing work environment and the impact of traumatic stress explained 19.4% and 38.8%, respectively, of the variance in burnout. Moreover, the impact of traumatic stress, the nursing work environment, and the frequency of night shifts per month had a statistically significant effect on secondary traumatic stress, and the nursing work environment and the impact of traumatic stress accounted for 17.2% and 33.8%, respectively, of the variance in secondary traumatic stress. Moreover, the variance inflation factor (VIF) of all independent variables was below 5 (range: 1.094–1.351), indicating that there was no serious multicollinearity problem.
| Variables | B | SE | β | t | p Value | 95% CI (LL, UL) | VIF |
|---|---|---|---|---|---|---|---|
| Compassion satisfaction | 21.616 | 3.781 | |||||
| Nursing work environment | 0.186 | 0.02 | 0.51 | 9.099 | 0 | (0.146,0.226) | 1.351 |
| The impact of traumatic stress | −0.210 | 0.046 | −0.252 | −4.566 | 0 | (−0.300, −0.119) | 1.31 |
| Major shifts | −1.767 | 0.795 | −0.112 | −2.222 | 0.027 | (−3.334, −0.200) | 1.094 |
| Heath condition | −1.276 | 0.495 | −0.134 | −2.580 | 0.011 | (−2.251, −0.302) | 1.156 |
| The frequency of traumatic stress | 0.239 | 0.105 | 0.126 | 2.28 | 0.024 | (0.032, 0.445) | 1.325 |
| Burnout | 23.491 | 2.085 | |||||
| The impact of traumatic stress | 0.182 | 0.027 | 0.388 | 6.64 | 0 | (0.128,0.236) | 1.17 |
| Heath condition | 1.042 | 0.307 | 0.194 | 3.391 | 0.001 | (0.436,1.647) | 1.121 |
| Nursing work environment | −0.040 | 0.012 | −0.194 | −3.197 | 0.002 | (−0.064,-0.015) | 1.256 |
| Secondary traumatic stress | 24.431 | 2.812 | |||||
| The impact of traumatic stress | 0.199 | 0.038 | 0.338 | 5.298 | 0 | (0.125,0.274) | 1.17 |
| Nursing work environment | −0.044 | 0.016 | −0.172 | −2.697 | 0.008 | (−0.077, −0.012) | 1.167 |
| Frequency of night shifts per month | −1.449 | 0.67 | −0.128 | −2.164 | 0.031 | (−2.769, −0.130) | 1.008 |
| R= 0.475 Adjusted R= 0.464 F = 40.926= 0.000Compassion satisfaction:22p | |||||||
| R= 0.334 Adjusted R= 0.326 F = 38.192= 0.000Burnout:22p | |||||||
| R= 0.207 Adjusted R= 0.197 F = 19.894= 0.000Secondary traumatic stress:22p | |||||||
Discussion
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.
Limitations
First, the research's cross-sectional design limits the inferences that may be made regarding ProQoL, and prohibits inference of causality. Second, due to the use of multiple self-report questionnaires, there may be bias in the results, such as participants considering the risk of social expectation bias, particularly underreporting of burnout or secondary traumatic stress. Third, we used a convenience sample, the study was limited to Henan Province, China, so the sample was geographically homogeneous, leading to selection bias; this sampling method highlight the potential overrepresentation of tertiary hospitals (66.8% of the sample), which may not reflect midwifery conditions in smaller or rural hospitals, moreover, this sampling method was potential for selection bias-for instance, more overburdened or burnout midwives were less likely to respond.
Conclusions
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.
Supporting information
Acknowledgments
The authors extend their gratitude to the midwives who participated in this study and to everyone else who contributed.
Data Availability
All relevant data are within the paper and itsfiles. Supporting information
Funding Statement
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.