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Ph.D.

Thesis

Sunniva Engelbrecht

Motivation and Burnout in Human Service Work


The Case of Midwifery in Denmark

National Institute of Occupational Health

Roskilde University
Faculty of Psychology, Philosophy and Science Studies

Ph.D. Thesis

Motivation and Burnout in Human Service Work


The Case of Midwifery in Denmark

Sunniva Engelbrecht

Main supervisor: Professor Peter Olsn, Roskilde University


Project supervisor: Dr. Birgit Aust, National Institute of Occupational Health, Copenhagen
Painting on cover: Muriel Engelbrecht
Copenhagen, April 2006

To Muriel and Tali

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
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3.2.4 Dialogue as a guideline for research ................................................... 87


3.3 Formal and methodological frame of the Ph.D.-project ...................... 89
3.3.1 Formal basis of the Ph.D. project ........................................................ 89
3.3.2 Description of the PUMA investigation.............................................. 90
3.3.3 The role of the researcher.................................................................... 93
3.3.4 Ethical considerations........................................................................ 101
3.3.5 Case study as research approach ....................................................... 103
3.3.6 Entering the field ............................................................................... 105
3.4 Research methods .................................................................................. 108
3.4.1 Description of the research field ....................................................... 109
3.4.2 Participant observation ...................................................................... 117
3.4.3 Qualitative research interview (single interviews)............................ 121
3.4.4 Group interview................................................................................. 129
3.5 Quality criteria used in the present study ........................................... 133
3.5.1 Proximity to the object of study ........................................................ 133
3.5.2 Reflexivity ......................................................................................... 134
3.5.3 Triangulation ..................................................................................... 135
3.5.4 Validity .............................................................................................. 136
3.5.5 Transferability ................................................................................... 136
Part II: Introduction of the result chapters (4-7)......................................... 138
Chapter 4: Engagement and burnout in midwifery .................................... 140
4.1 Introduction............................................................................................ 140
4.2 Reactions to the results of the PUMA study........................................ 140
4.3. Subjective descriptions of burnout...................................................... 145
4.3.1 Work-related burnout ........................................................................ 145
4.3.2 Emotions related to burnout .............................................................. 147
4.3.3 Behavioural aspects of burnout ......................................................... 149
4.4 Subjective descriptions of engagement at work.................................. 152
4.4.1 Professional self as sign of engagement............................................ 152
4.4.2 Work spirit as a sign of engagement ................................................. 153
4.4.3 Care for others and ones self as a sign of engagement .................... 155
4.5 The relationship between engagement and burnout .......................... 157
4.6 Summary of findings on engagement and burnout in midwifery ..... 161
Chapter 5: Person-related and work-related factors................................... 165
5.1 Introduction............................................................................................ 165
5.2 Person-related factors............................................................................ 165
5.2.1 Biological age.................................................................................... 165
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5.2.2 Generation membership .................................................................... 167


5.3 Structure of working time..................................................................... 169
5.3.1 Working in shifts and shift planning ................................................. 169
5.3.2 Work at night..................................................................................... 172
5.3.3 Part time work ................................................................................... 174
5.3.4 Work-family balance......................................................................... 175
5.3.5 Job routine ......................................................................................... 176
5.4 Summary of findings ............................................................................. 177
Chapter 6: The significance of resources in midwifery ............................... 179
6.1 Introduction............................................................................................ 179
6.2 Amount of resources and resource allocation practice ...................... 179
6.3 Balance between resources and job demands ..................................... 181
6.3.1 Balance of resources and demand to serve 100 percent.................... 181
6.3.2 Expertise, resources and security ...................................................... 184
6.3.3 Resources for client education .......................................................... 187
6.4 Summary................................................................................................. 188
Chapter 7: The role of emotional demands and feelings in midwifery...... 191
7.1 Introduction............................................................................................ 191
7.2 Emotional demands ............................................................................... 191
7.2.1 Reactions to rising demands from clients ......................................... 191
7.2.2 Demand to always give 100 percent service regardless own feelings
and condition...................................................................................... 194
7.3 Emotional reactions to traumatic birth incidences ............................ 198
7.3.1 Experience with the handling of traumatic birth processes .............. 198
7.3.2 Feeling of responsibility and guilt..................................................... 201
7.3.3 Support and healing after traumatic incidences ................................ 205
7.4 Summary of findings concerning the role of emotional demands and
feelings in midwifery............................................................................. 211
Chapter 8: Discussion ..................................................................................... 215
8.1 Introduction............................................................................................ 215
8.2 The nature of the primary task in midwifery and the relevance for the
research question................................................................................... 216
8.2.1 Essential characteristics of the primary task ..................................... 217
8.2.2 Demands and resources related to the primary task.......................... 218
8.3 Person related factors with relevance for the research question ...... 225

8.4 Assumptions about client-related factors of relevance to the research


question .................................................................................................. 229
8.5 Structural and situational demands and conditions of work in
midwifery ............................................................................................... 231
8.5.1 Impact of political decisions in the health care system..................... 232
8.5.2 Organisation of working time ........................................................... 235
8.5.3 Midwifery as a master piece of the female work role....................... 237
8.5.4 Relevance of implicit knowledge...................................................... 239
8.5.5 The significance and impact of traumatic birth incidences............... 242
8.6 Summary and conclusion of the explorative case investigation ........ 246
8.6.1 Strengths and limitations ................................................................... 249
8.6.2 Transferability of findings and reach of the study ............................ 252
8.6.3 Assumptions about the research field, directions for further research
and recommendations for midwifery practice ................................... 253
List of Figures .................................................................................................. 269
List of Tables.................................................................................................... 270
Appendices ....................................................................................................... 271

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
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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
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Hamburg, December 2005

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
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of the midwifes job, having negative impact on work-life balance. However, it


was suggested that being more involved in the planning of shifts would improve
the situation somewhat.
Resources at work in form of number of employees proved to be a central theme
in the single interviews and in the group interview. Resources were described to
be low. Low resources were described to be a critical element in regard to the
level of responsibility they feel to secure a safe and successful birth and were in combination with high demands - thought to lead to work-related burnout.
Resources were further described as being a critical factor in regard to the
service given to the client. Low resources were described as being a stress factor
because ones own standards of service quality - especially in regard to security
and time spent with the client in order to establish a trusting relationship
(rapport) - cannot be ensured.
Emotional demands and feelings in midwifery were described as having
significant impact on the relationship between motivation and burnout.
Imbalance between clients demands and the occupational ideology and belief of
the midwife was described as frustrating and the own job role is experienced as
being called in question. Modern clients in midwifery were described as wellinformed and demanding in regard to the treatment they wish to receive even if
this stands in contrast to the recommendation of the midwife. Giving of
yourself was used as expression for the intensity of emotional availability while
helping to give birth which is described as being tiresome when time to recover
is low. The feeling of responsibility and guilt, and (not always successful)
coping with traumatic birth incidences was discussed in depth in respect to their
negative impact on health and well-being. Midwives referred to traumatic
incidents as a natural part of the job but described problems of transmitting
this belief to the emotional realm. Established procedures of debriefing and
collegial supervision after traumatic birth incidences were viewed as being
insufficient. This insufficiency was accused of sometime leading to post11

traumatic stress symptoms, which might contribute to the development of


burnout.
In conclusion, the findings of the present explorative investigation of the
relationship between motivation and burnout in midwifery point to the necessity
to understand the relationship between these two phenomena in their ecological
context: the cultural, organizational, situational, and personal background. The
findings gathered in this explorative study shed light on the particularities in
midwifery in a Danish community hospital with regard to burnout. The study
therefore contributes to a better understanding of the particular conditions of
work in midwifery that play a role in the relationship between motivation and
burnout. Even though the case approach chosen in this project is focussed on
one particular setting, transferability of findings to other comparable settings
(e.g., other maternity wards) is regarded as high because of the description of
findings in relation to the primary task. Moreover, many new paths of
investigation in the field are found in this explorative case study. Accordingly,
the present Ph.D. thesis closes with new assumptions about the field of research
to be investigated in further research projects.

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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
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2. At f indblik i forholdet mellem motivation og udbrndthed indenfor


jordemoderfaget i Danmark.
Projektet bestr af to dele: et metodeafsnit og en empirisk undersgelse. Den
frste del omhandler forfatterens teoretiske forforstelse (Gadamer,
1969/1990) og skildrer hele problemstillingen mht. metode. Dette uddybes til en
vis grad for at belyse referencerammen og for at eksemplificere den eksplicitte
problemstilling mht. forskningen indenfor et etableret forskningsomrde, som
f.eks. udbrndthed. I den empiriske del undersges forholdet mellem motivation
og udbrndthed ved hjlp af deltager observation, personlige interviews og
gruppeinterview efterfulgt af en caseundersgelse. Detaljerede transskriberede
interviews blev analyseret ved brug af fnomenologisk metode (Giorgi, 1985;
Malterud, 1996). Ved brug af en kvalitativ tilgang baseret p et subjektteoretisk
perspektiv (Dreier, 1993 & 1994 i Pedersen, 2002) kunne forfatteren kaste lys
over en bedre forstelse af forholdet mellem motivation og udbrndthed
indenfor jordemoderfaget.
Caseundersgelsen viste flgende resultater: for det frste beskrev deltagerne i
caseundersgelsen jordemoderfaget som et meget krvende arbejde mht.
arbejdstider, arbejdstempo, ansvar, lav beslutningsrderum, krvende gravide
kvinder og flelsesmssige krav. De typiske karakteristika for en jordemoder er
at arbejdet krver et hjt engagement som en forhndsbetingelse for
jordemoderfaget, hvilket kommer til udtryk i en exceptionel og professionel
personlighed, et godt arbejdsklima og en stor omsorg for andre, som ofte frer
til en overdreven pligt- og ansvarsflelse samt et hjt engagement.
Person- og arbejdsrelaterede faktorer indenfor udbrndthed blev defineret af
jordemdre, som deltog i undersgelsen. Det viste sig, at alder og
generationstilhrsforhold (=tilhrsforhold til en gruppe, hvis medlemmer er
uddannet p samme tidspunkt og har den samme alder) spiller en betydningsfuld
rolle mht. udvikling af udbrndthed. Den yngre generation af jordemdre har
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iflge undersgelsen en anderledes arbejdsidentitet end den ldre generation


mht. at acceptere de hje arbejdskrav og de lave ressourcer. Mht.
arbejdsrelaterede emner, blev arbejdstiden diskuteret. Skifteholdsarbejde blev
betragtet som et kritisk og i princippet et uforanderligt forhold i
arbejdsvilkrene, som har en negativ indflydelse p arbejdslivets balance.
Imidlertid blev det foreslet, at hvis jordemdrene havde en strre
medindflydelse mht. planlgningen af vagterne ville dette forbedre
arbejdsvilkrene vsentligt.
Arbejdsressourcer i forhold til antallet af ansatte var et vigtig emne i bde de
personlige interviews og gruppeinterviewet. Ressourcerne var lave. Lave
ressourcer var et kritisk element mht. den ansvarsflelse, som jordemdrene
fler de skal have for at sikre, at en fdsel foregr sikkerhedsmssigt forsvarligt
og bliver vellykket, og blev - samme med hje krav mistnkt for at kunne fre
til arbejdsbetinget udbrndthed. Derudover blev ressourcer beskrevet som
vrende en kritisk faktor mht. den service, der ydes til den fdende. Lave
ressourcer blev beskrevet som en stressfaktor da ens egne normer for
servicekvalitet srligt mht. sikkerhed og tid brugt p den fdende med henblik
p at etablere et tillidsfuldt forhold ikke kan sikres.
Emotionelle krav og flelser indenfor jordemoderfaget havde en betydelig
indvirkning p forholdet mellem motivation og udbrndthed. Ubalance mellem
den fdendes krav og den arbejdsmssige ideologi og troen p jordemoderen
blev opfattet som frustrerende og der sttes sprgsmlstegn ved ens egen
arbejdssituation. Moderne fdende kvinder indenfor jordemoderfaget blev
betegnet som velinformerede og krvende mht. den behandling de nsker at
modtage ogs selv om dette str i kontrast til jordemoderens anbefaling. At give
dig selv blev brugt som et udtryk for den flelsesmssige intensitet, som
jordemoderen skal udvise overfor den fdende, hvilket beskrives som vrende
trttende nr der er for lidt tid til at restituere sig bagefter. Flelsen af ansvar og
skyld, og (ikke altid lige succesfuldt) coping i forbindelse med traumatiske
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fdselsforlb blev diskuteret indgende af hensyn til deres negative indvirkning


p helbredet og velbefindende. Jordemdre refererer til traumatiske
fdselsforlb som en naturlig del af jobbet, men beskrev problemerne i at
overfre denne tro til den emotionelle kategori. Etablerede procedurer mht.
debriefing og til at flge op p kollegaer, der havde oplevet et traumatisk
fdselsforlb blev karakteriseret som utilstrkkeligt. Denne utilstrkkelighed
blev beskyldt for at fre til post-traumatiske stress-symptomer, der muligvis kan
vre en medvirkende rsag til udvikling af udbrndthed.
Det m herefter konkluderes, at resultaterne fra undersgelserne af forholdet
mellem motivation og udbrndthed indenfor jordemoderfaget pviser
ndvendigheden af at forst forholdet mellem disse to fnomener i deres
kologiske kontekst: den kulturelle, den organisations- og situationsmssige
samt personlige baggrund. Resultaterne fra denne undersgelse kaster lys over
enkelthederne indenfor jordemoderfaget p et dansk kommunehospital mht.
udbrndthed. Undersgelsen bidrager hermed til en bedre forstelse af de
srlige arbejdsforhold, der gr sig gldende i jordemoderfaget, og som spiller
en rolle i forholdet mellem motivation og udbrndthed.
Selv om problemstillingen i denne afhandling fokuserer p et bestemt
hospitalsmilj, m overfrbarhed af resultaterne til andre sammenlignelige
omgivelser (f.eks. andre fdeafdelinger) regnes for at vre hj pga. beskrivelsen
af resultaterne i forhold til hovedopgaven. Desuden har afhandlingen bidraget
med mange nye mder at undersge det pgldende omrde p. Tilsvarende har
antagelserne i denne Ph.D.-afhandling bnet muligheden for yderligere
fremtidige forskningsprojekter indenfor bestemte omrder.

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Chapter 1: Introduction

1.1 Research interest, research field and research question


Human service work is to a high degree dependent on the people who deliver the
service. To be good in providing good human service is dependent on very
different factors such as education, skills, competencies, abilities, motivation,
goal-orientation, passion, joy, interest, resources and not at least health and wellbeing. Quality in the human services is especially vulnerable to an impairment
of any kind, hindering a person to deliver 100% service. The organizational
structure of work and the conditions under which work is done are more or less
enabling or hindering for the personal condition to be brought in.
Burnout is often described as metaphor for suffering from doing people work
(Schaufeli & Enzmann, 1998; Kristensen et al., 2005a). Burnout as explicit
outcome of work related stress in human service work was first discussed in the
seventies (Freudenberger, 1974; Maslach, 1976). These first empirical
descriptions of burnout were based on observations made in the field of human
service work. Today, more than 5,500 empirical studies exist with the key word
burnout in the title (Schaufeli & Enzmann, 1998). Nevertheless, we still cannot
get a hold onto what is responsible for burnout in human service work (Burisch,
2002). A recurring theme in burnout research is the assumption that people who
experience burnout must have been very engaged and enthusiastic about their
work (Pines et al., 1981; Schmitz, 1998, 1999). Besides methodological
weaknesses has this assumption shown to lead to equivocal results (Rsing,
2003). Traditionally, people in human service occupations have been regarded
as being more prone to burnout than other job groups because of high
communicative and emotional demands connected to doing people work. (e.g.
clients, patients, customers). At the same time, many people working in human
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service professions seem to be highly engaged and motivated to do the work


they have chosen. However, the relationship still remains somewhat unclear.
Even though the theoretical body of work on motivation and burnout in human
service work is large, not much empirical research on the relationship between
these phenomena can be found (Rsing, 2003).
In Denmark, burnout has not been investigated in depth until the start of the
PUMA project (1999) (Danish acronym for Project on Burnout, Motivation and
Job Satisfaction) an ongoing six-year prospective intervention study in the
human services sector (Kristensen et al., 2005a). One of the job groups with the
highest levels of personal, work related , and client related burnout and high
sickness absence at baseline and also later at three year follow up measured with
the Copenhagen Burnout Inventory (CBI, Kristensen et al., 2005) were
midwives. This has been both expectation and surprise. Midwifery is a field of
work with high work demands (e.g. shift work, time pressure, high uncertainty,
high physical demands) and therefore it was expected that some of the negative
consequences in midwifery would show in lower levels of health and well-being
in this job group. Otherwise it has been a surprise that the burnout score is the
highest among 15 job groups in Denmark investigated in the PUMA study. At
the same time midwives are known as an engaged job group with a highly
satisfying and meaningful primary task. The coincidence of having a highly
engaged work group with at the same time alarming high levels of burnout was
predestination for this group to be investigated in more depth in the present
Ph.D. project.
Following from that the research question of the Ph.D. project has been
formulated as:
How to understand the relationship between motivation and burnout in human
service work-midwifery as case.

18

The aims of the present Ph.D. project are:


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.
1.2 Research approach
In order to investigate how the relationship between motivation and burnout in
midwifery can be understood a qualitative in depth approach was chosen. The
complex meaning between structural, organisational, work related, client related,
and personal factors leading into motivation or burnout can first be understood
when as many facets as possible are investigated. A case study approach as
chosen in the present project sets the frame to structure the investigation along a
defined case. The group of midwives at a maternity ward in a Danish
community hospital on Zealand was defined as case. Knowledge was gathered
with three different methods: participative observation, single interviews, and a
group interview. The group interview serves the purpose of communicative
validation (member check) as findings from the single interviews are supported,
supplied or a rebellious position is outlined. Participant observation is used to
supply observations from the work environment to the narratives of the
midwives.
The present investigation is explorative in the sense of opening up new
perspectives to look upon the two phenomena (motivation and burnout) in the
context of midwifery and the relationship between the two. One important goal
of this approach is to investigate into the unknown. To honour this goal, a
phenomenological approach to the material has been chosen. Phenomenological
data analysis empowers the researcher to be open for new interpretations
emerging from the data material. Already established theory is regarded and

19

formulated as being part of the authors fore-understanding 1 understood as the


backpack of practical and theoretical knowledge with which is looked upon the
case. It plays an important role in setting the frame for interpretations in the
present project. Existing theory is valued as important knowledge but is also
looked upon with firm scepticism (Brucks, 1998). Scientific knowledge is
defined as truth in process, to be confirmed over and over again in different
settings as well as in new developments of society. With the vast amount of
already existing publications in the field of burnout and motivation and the even
faster growing volumes of scientific work, a definition of the theoretical
reference frame as explication of one part of the authors initial understanding is
needed. From the tremendous body of work on motivation, four different
approaches to motivation are used for reflection: the personality oriented
concept of implicit and explicit motives, the concept of commitment as
introduced by Meyer & Allen (1997), the concept of flow (Csikszentmihalyi,
1990), and the three dimensional model of engagement as published by
Schaufeli et al. (2000, 2001). The theoretical description of burnout is more
unequivocal. Comprehensive work and reviews published on burnout (e.g.,
Schaufeli & Enzmann, 1998, Rsing, 2003; Kristensen & Borritz, 1998;
Sderfeldt, 1997) are part of the material used to reflect the empirical
knowledge gathered through observations, interviews and group interviews.
Within an approach to investigate into the unknown there must be space for
new, unforeseen insights. A meta-goal of the present project is to exemplify how
an open, qualitative approach in an otherwise well-defined research field can
lead to impeccable scientific results, which lead to new perspectives and
assumptions to look upon the phenomenon in context.

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

1.4 Structure of the monograph


The present monograph is a combination of a traditional research report
(introduction, theory, method, results, discussion) and a presentation of
knowledge gathered within a dialogical, explorative case approach.
Following the introduction, where the research interest, research field and
research question along with reflections on relevance of the present investigation
are introduced, the second chapter presents the theoretical reference frame as
part of the authors fore-understanding regarded as important for investigating
the research question. Theory presented in Chapter 2 is understood as explicated
fore-understanding which later is used as frame of reference for findings
gathered in the present case investigation. Chapter 3 contains information about
the epistemological reference frame and the research process. The methods used
to investigate in the field and the form of data-analysis is described. Further, the
quality of the study is estimated through reflecting on the qualitative standards
of the investigation. Methodological guidelines (Malterud, 2001, Flick, 2002)
are introduced as reflection of the research perspective. The third chapter also
covers a reflection of the researchers role throughout the research process. The
insights of the qualitative approach to understanding the relationship between
motivation and burnout in human service work are presented throughout the
following four chapters. In Chapters 4 to 7 the findings from the qualitative
case investigation are presented in form of research themes illustrated by
original citations. In Chapter 4, the subjective understanding and definition of
the investigated concepts (burnout and motivation) as stated by the participants
is summarized. In Chapter 5, background information is reported concerning
work and person inherent factors, which are mentioned as having an impact on
the relationship between motivation and burnout, as seen from the subjective
perspective of the case study participants and from participative observation. In
Chapter 6, the role of resources for being and feeling secure in the job is
described. In Chapter 7, the role of emotional demands and feelings in
midwifery is outlined. Especially the last two chapters open up unforeseen
relations and new ways of thinking about the relationship between motivation
22

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

Motivation and Burnout in Human Service Work


The case of midwifery in Denmark
Chapter 1: Introduction
Research interest, research question and field of research, relevance of research question, structure of
the monograph

Part I: Theoretical preconception and epistemological background


Chapter 2: Theory
Introduction of concepts of burnout, motivation and engagement, work family
conflict, and emotions at work

Chapter 3: Epistemological reference frame and methods


Research paradigm and choice of method, methodological guidelines, role of the
researcher, research process, methods of data collection, data-analysis, estimation
of qualitative standards of the investigation

Part II: Results from the case study


Chapter 4: Engagement and burnout in midwifery
Outcomes of the PUMA investigation, personal definitions of engagement,
burnout and the relationship between the two

Chapter 5: Person-related and work-related factors


Age, work time, work family balance, job routine

Chapter 6: The significance of resources in midwifery


Resources and resource allocation, balance between resources and job demands

Chapter 7: The role of emotional demands and feelings in midwifery


Emotional demands, emotional reactions to traumatic birth incidences

Chapter 8: Discussion and future perspectives


Summary and discussion of the findings, relevance of the findings, transferability of
results to other settings, practical implications for the field of midwifery, future
research perspectives

24

Chapter 2: Theory

2.1 Introduction and organisation of the chapter


In the following chapter, a summary of the most relevant and most discussed
issues in the field of burnout and motivation is given. The chapter is divided into
five parts. After the introduction, main insights from the last 30 years of burnout
research are summarized and reflected on (2.2). The historical development of
burnout research, the theoretical and operational definitions of the phenomenon,
the measurement of burnout, the challenges and shortcomings of recent burnout
research and implications for the future are discussed. In the second section
(2.3), five approaches to motivation are introduced. Motivation is an umbrella
term for very different approaches. Therefore, the approaches to be introduced
are thought to be the most relevant in regard to the research aim of the present
Ph.D. project. In the third section (2.4) the one existing study on burnout in
midwifery is summarized as well as a choice of the most relevant and recent
empirical studies on the relationship between motivation and burnout in human
service work. Fourth (2.5), recent research on work family balance is
introduced. In section 2.6 different concepts and aspects of emotions at work
are reflected on. Finally, in section 2.7 the theoretical reference frame
representing the fore-understanding of the author of the present Ph.D. project is
summarized.
2.2 Burnout research throughout the last 30 years
The concept of burnout has undergone an impressive career from observational
description to a scientifically defined term to an everyday description of mood
state. In the context of the present work, it is regarded as important to take a
look at the historical development of the concept and the publics reception of
the term.

25

2.2.1 Historical development from phenomenon to syndrome


Already in the 1950ies Isabel Menzies led a case study in nursing with the aim
to facilitate desired social change (Menzies, 1975). Her psychodynamic
approach using in-depth interviews, observations, and other informal contacts
with the staff of the hospital brought her attention to a high level of tension,
distress, and anxiety among the nurses. The symptoms she described following
from her observation relate very much to what was 20 years later labelled
burnout (Pedersen, 2002). This is one example that the phenomenon of burnout
has been present long before the expression burnout was coined to describe the
phenomenon. However, Herbert Freudenbergers publication on staff burnout in
1974 is commonly referred to as the starting point for the broader recognition of
burnout. Freudenberger made the observation that volunteers entering the field
of social work usually walk through a phase of more or less severe wear out
after approximately one year. Freudenberger began to use the term burnout to
describe the experience of emotional depletion and loss of motivation and
commitment. At almost the same time, Christina Maslach (1976) began to
investigate how people in emotionally demanding jobs such as doctors, nurses,
police officers cope in everyday work. Through interviews she found three
themes that seemed to be important: emotional exhaustion, detached concern
towards clients and a feeling of reduced personal accomplishment. This early
work was dominated by qualitative descriptions of symptoms and the situational
context. Interviews, case-studies and on-site observations were the way to
approach the phenomenon in this phase (Maslach et al. 2001). These first
cautious but impressive steps towards doing mostly qualitative burnout research
are from a recent perspective (Schaufeli & Enzmann, 1998) often described as
provisional form of doing burnout research.
The empirical phase of burnout began in the 1980s with the publication of the
Maslach Burnout Inventory (Maslach & Jackson, 1982). This quantitative
approach to burnout has become the predominant burnout measure. Other
instruments developed throughout the same time period, e.g. Burnout Measure
26

(Pines, Aronson & Kafry, 1981), OLBI, Oldenburg Burnout Inventory


(Ebbinghaus, 1986, in Rsing, 2003) never reached the same popularity as the
MBI. The MBI was first designed to measure burnout in human service work
but with the growing interest from work and organizational psychologists, a
more general view of burnout as a prolonged reaction to job stress in different
occupations developed and raised the quest for a more general measurement
tool. In 1996 the MBI-general Survey was published (MBI-GS; Schaufeli et al.,
1996) which allows burnout to be studied independently from its specific job
context. The MBI is translated into many different languages and is used as a
global instrument to measure burnout. Burnout is, amongst others, one of the
best-known concepts in modern psychology. The catchy nature of the
phenomenon, the short and handy operational definition of burnout and a vast
amount of publications has furthered and manifested the interest in burnout. The
clinical and the empirical approach to burnout coexist ever since burnout was
described.
However, until recently most of the many burnout studies were cross-sectional
and therefore did not allow causal inference (Kristensen & Borritz, 1998).
Lately the methodological rigor of burnout research has improved (Schaufeli &
Buunk, 2004). Especially since the late 1990s an increasing number of
longitudinal studies have been conducted (Borritz, 2005).
One of the newer developments in burnout research is the extension of the
burnout concept by the positive antithesis job engagement, so that the full
spectrum of workers well-being can be studied (Maslach et al., 2001; Schaufeli
et al. 2002; Schaufeli & Buunk, 2004).
Being developed from field observations rather than from theory, most burnout
research has been rather atheoretical. Throughout the last years, the voices for a
theoretical and empirical re-formulation of burnout became louder (Sderfeldt,
1997; Schaufeli & Enzmann, 1998; Kristensen & Borritz, 1998; Burisch, 2002;
Rsing, 2003). According to Schaufeli & Buunk (2004) a growing number of
27

comprehensive conceptual approaches have proposed to link burnout to


mainstream psychological theories. Nevertheless, there is a quest for more
theory-driven approaches to burnout. With the introduction of a new tool to
measure burnout (Kristensen et al., 2005a) the discussion about the main
dimensions of the burnout concept has been taken up again and is currently
ongoing (Schaufeli & Taris, 2005) (see also below).

2.2.2 Burnout: symptoms, definitions, and measurement


The following section gives an overview of the symptoms, definitions, and ways
to measure burnout. After 30 years of burnout research has seen from sociology
of science perspective reached the status of being an established field of
research. However, burnout has neither reached the status of a disease
(recognition in the classification systems for diseases (ICD-10 or DSM-IV) nor
the status of an institutionalised field of research (Rsing, 2003). Sderfeldt
(1997) refers to the Danish philosopher Uffe Juul Jensen in order to describe
how burnout is recognized inside and outside the scientific community. Jensen
uses the distinction between ideal and practice concepts of diseases. The ideal
concept refers to the situation where a concept exactly specifies those
phenomena that are connoted by it. A practice concept refers to practical
abilities, exertion of practical routines of some kind, never exactly delineated
(Sderfeldt, 1997, p. 44). A disease is regarded as a historical phenomenon,
starting as a classification of symptoms, leading into a syndrome, and eventually
being called a disease. Historically, syndromes either disappear or become
diseases. A practice concept of a disease is an ongoing, negotiable process of
describing a phenomenon. This perspective helps to approach burnout as an
open concept; a phenomenon in progress, and a subjective term. Nevertheless,
many different approaches to describe burnout exist. In the following, a list of
symptoms is introduced, the common definitions of burnout are summarized and
approaches to measure burnout are discussed.

28

2.2.2.1 Symptoms of burnout


Schaufeli & Enzmann (1998, 12-24) give a comprehensive list of symptoms of
burnout (see Table 2.1). The list consists of more than 130 symptoms of
burnout. These symptoms are far from being specific for burnout and refer to a
rather broad range of symptoms. Nevertheless, the description of symptoms is
the first step towards a practice concept of a phenomenon. Schaufeli & Enzmann
(1998) organized the symptoms along the following matrix, giving a structure
and showing at the same time the breadth of symptoms connected with burnout.
Table 2.1 List of symptoms of burnout (Schaufeli & Enzmann, 1998, p. 21-24)

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.

2.2.2.2 Working definitions of burnout


Definitions of burnout always focus on a certain facet of the phenomenon. State
and process definitions of burnout can be distinguished. In the following table,
selected definitions are listed chronologically regarding year of publication. The
list of definitions is not comprehensive but it summarizes the most known and
probably most often cited burnout definitions. Beyond that, a rather broad
spectrum of international burnout definitions is gathered in the table below,
referring to English, Scandinavian and German publications on burnout.

31

Table 2.2 Chronological listing of common burnout definitions


Year of
Author
publication
Freudenberger
1974
1980

Freudenberger &
Richelson

1980

Cherniss (in Schaufeli


& Enzmann, 1998,p.
34)

1986

Maslach & Jackson

1988

Pines & Aronson (in


Pines, 1993)

1989

Burisch (1993,in
Rsing, 2003, p.
63/65)

1997

Maslach & Leiter


(Rsing, p. 73)

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.

Table 2.2 Chronological listing of common burnout definitions (continued)


1998

Schaufeli & Enzmann

2001

Schaufeli &
Greenglass, 2001, p.
501 (in Kristensen et
al., 2005a)
Kristensen

2005

Burnout is a persistent work related state of mind in


normal individuals that is primary characterised by
exhaustion, which is accompanied by distress, a
sense of reduced effectiveness, decreased
motivation, and the development of dysfunctional
attitudes and behaviours at work. This psychological
condition develops gradually but may remain
unnoticed for a long time by the individual involved.
It results from a misfit between intentions and reality
in the job. Often burnout is self-perpetuated because
of adequate coping strategies that are associated with
the syndrome.
a state of physical, emotional and mental
exhaustion that results from long-term involvement
in work situations that are emotionally demanding.
The core of burnout is fatigue and exhaustion, which
is attributed to specific domains or spheres of a
persons life. Personal burnout is the degree of
physiological and psychological fatigue and
exhaustion experienced by the person. Work-related
burnout is the degree of physiological and
psychological fatigue and exhaustion which is
perceived by the person as related to his/her work.
Client-related burnout is the degree of physiological
and psychological fatigue and exhaustion which is
perceived by the person as related to his/her work
with clients.

The most influential description of burnout is the operational definition by


Maslach & Jackson (1986), describing burnout as a syndrome with three
components, emotional exhaustion, depersonalisation and reduced personal
accomplishment. Burnout is defined as a process, starting with emotional
exhaustion, than leading into feelings of depersonalisation and later the feeling
of reduced personal accomplishment. The operational definition of burnout
introduced by Maslach & Jackson, 1986, the Maslach Burnout Inventory (MBI),
has led to the use of this instrument in the vast majority of research studies in
this area (90% of the publications on burnout use the Maslach Burnout
Inventory, MBI, Rsing, 2003). Looking at the more recent definitions of
burnout of Maslach & Leiter (1997), it is interesting to note that the wording is

33

different. Here, burnout is described as an erosion of the soul, using complex


words such as values, dignity, and spirit. This is an example of a softer,
less distinct definition of burnout. This form of describing burnout sounds a bit
like a homecoming to the pioneer phase of burnout research. One of the most
recent definitions of burnout, described as working definition of burnout, is
formulated by Schaufeli & Enzmann (1998) (see Table 2.2). This rather long
and comprehensive definition is a compilation of different burnout definitions,
all sharing common basic assumptions: (1) the three dimensional syndrome as
defined by Maslach, burnout as a state of emotional exhaustion,
depersonalisation and resulting in a reduced feeling of personal accomplishment.
(2) Burnout as work related without defining what is meant by work. (3)
Burnout is further defined, as a process, often undiscovered for a long period in
time, not stopped by effective coping mechanisms. Last but not least (4) one
cause for the development of burnout is seen in the misfit between expectations
and realities on the job. This definition is useful in the sense that it summarizes
some of the unequivocal findings in burnout research.
The chronological listing shows further that: (1) Similar definitions of burnout
appear in a short time interval to each other and are persistent over time. In all
definitions, emotional exhaustion is regarded as the core of burnout. Burnout is
also defined as developing over time. (2) In mainstream burnout research the
reception and definition of burnout has not evolved much in the last 30 years of
research, even though societal changes have been tremendous. There is a clear
parallel between Pines & Aronsons definition of burnout from 1988 and
Schaufelis & Enzmanns definition from 1998 (Kristensen et al., 2005a).
Referring back to the idea of a practice concept of diseases, developing over
time, changing, or disappearing, the concept of burnout has been rather steady.
Besides the mainstream of burnout research, there are voices calling for a
different understanding of burnout (Kristensen et al., 2005a; Pedersen, 2002).
(3) In more recent definitions of burnout, there is no restriction to the sphere of
people work. This was one of the core assets of the operational definition of
34

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).

2.2.2.3 Measurement of burnout


Most scientific research work in the field of burnout is based on the Maslach
Burnout Inventory (MBI, Maslach & Jackson, 1986). The MBI is a self-report
paper and pencil test, asking about the three facets of the burnout syndrome as
defined by Maslach & Jackson (1986). The MBI measures burnout in regard to
the three independent key dimensions: emotional exhaustion (depletion or
draining of emotional resources caused by interpersonal demands),
depersonalisation (development of negative, callous and cynical attitudes toward
the recipients of ones services) and reduced personal accomplishment (the
tendency to evaluate ones work with recipients negatively). Originally, the
burnout concept was thought to be restricted to professionals who deal directly
with recipients, but in 1996 the concept of burnout was broadened and defined
as a crisis in ones relationship with people at work. The three original
dimensions of the MBI were broadened to encompass not just problems with
regard to people work: Exhaustion now refers to fatigue irrespective of its cause.
Cynicism reflects an indifferent or distant attitude towards work instead of other
people and lack of professional efficacy encompasses both social and non-social
aspects of occupational accomplishment (Schaufeli & Buunk, 2004).
The career of the MBI is impressive. Translations into many languages are
existent and the MBI is used in different countries around the globe. In regard to
using the MBI for diagnostic purposes, it should be noted that there does not
exist a cut-off point indicating where serious burnout starts. However, In the
Netherlands clinically validated cut-off scores have bee developed recently that
allow discrimination of burnout cases from non-cases (Schaufeli et al., 2001,
in Schaufeli & Taris, 2005). The MBI must be seen as an instrument for research
purposes and not suitable for making individual diagnoses.

35

Recently, Kristensen et al. (2005a) introduced a new tool to measure burnout:


The Copenhagen Burnout Inventory (CBI). The instrument was developed in the
course of the PUMA Study, a longitudinal study of burnout in human service
workers in Denmark, which also gave the incentive to this PhD thesis. Although
in the starting phase of the PUMA study, the MBI was considered as the main
measurement tool for burnout, after careful consideration and testing, it was
decided to not use the MBI but to develop a new measurement tool instead. The
authors (ibid) name the following reasons for this decision: (1) The MBI is
based on a circular argument by stating that burnout is restricted to persons in
human service job. Even though extended versions exist, the main feature of the
test stayed the same. (2) The relationship of the MBI to the concept of burnout is
unclear. Burnout research has been engaged in a lively discussion about burnout
being constituted of three independent dimensions (as proposed by the
measurement with the MBI) or of burnout being a phenomenon with the
exhaustion, depersonalisation, and diminished personal accomplishment as
characteristics. (3) The understanding of burnout being a syndrome with the
three constituting characteristics is neglecting the possible interpretation of
depersonalisation being a coping strategy and diminished personal
accomplishment being an effect. The last argument to be named is (4) the
wording of the MBI was not accepted by the Danish participants, causing
negative reactions and even anger. Many good reasons to develop an instrument
that takes some of the criticism mentioned into account.
With the Copenhagen Burnout Inventory, Kristensen et al. (2005a) introduce an
interesting and different operational approach to burnout based on a
comprehensive review of theoretical and empirical material. After a detailed
testing of three instruments (Burnout Measure (BM), Pines et al., 1981; MBI
and MBI-GS, Maslach et al. 1981, 1986.) and a review of research work in the
field, it was decided to develop a new instrument but remaining in the general
frame of reference of burnout research (Kristensen et al., 2005a). The CBI is

36

designed after careful investigation of existing instruments to measure burnout


on the background of theoretical assumptions.
The authors of the CBI claim in accordance with many other burnout researchers
that exhaustion is the core of burnout (ibid). However, Kristensen et al. (2005)
point out that burnout is not the same as the already existing concepts of fatigue
and exhaustion. They write In our understanding of the concept the additional
key feature is the attribution of fatigue and exhaustion to specific domains or
spheres in the persons life. (ibid, p.197). The three main domains most
important in this respect are defined by the authors as the personal domain, the
work domain and more specific the work with client domain.
The CBI is therefore designed with three different scales: (1) a scale measuring
general exhaustion, called personal burnout, (2) a scale on work-related burnout,
and (3) a scale on client-related burnout. The questions of the personal burnout
scale are inspired by the Burnout Measure questionnaire, the question of workrelated burnout are inspired by the subscale on emotional exhaustion of the
MBI/MBI-GS questionnaires. The questions on client-related burnout are newly
formulated. The burnout scales of the CBI correlate with each other but the
correlation is only partial, supporting the idea of three independent burnout
scales (Borritz et al., 2005). The already existing studies have shown, that the
various occupational groups revealed different patterns on the three scales,
indicating that the measurement of burnout in different domains is possible
using the CBI. Especially the dimensions work- and client related burnout refer
to the concept of schemata and causal attributions people use to explain the
experience of symptoms, such as headaches, nausea, coughs, chest pain ,
prolonged fatigue, etc. (Kristensen et al., 2005a). Symptoms are explained in the
light of already existing schemata (Bishop, 1991; Eysenck & Keane, 1990; in
Kristensen et al., 2005a). The way by which people build schemata is through
causal attribution to internal or external factors. The same symptom can
therefore be interpreted in different ways.
Already now the CBI has been translated into a number of languages and studies
are on the way to elucidate the acceptability and validity of the CBI. An
37

investigation of burnout amongst dentists in Australia (Winwood & Winefield,


2004) compared outcomes measured with the MBI and the CBI. The authors
report that the basic psychometric properties for the CBI appear to be equivalent
to those of the MBI. The results of the MBI were not found to be in line with the
suggested concept of burnout, i.e. that high scores on the MBI Exhaustion
subscale would be associated with high scores on the Depersonalization subscale
and low scores on the Personal Accomplishment subscale. Therefore the authors
conclude that the value of these two MBI subscales is called into question.
Furthermore Winwood and Winefield propose that the CBI, with its simpler
conceptualization of burnout as fundamentally a fatigue phenomenon, should be
investigated further.
However, the discussion of advantages and disadvantages of the CBI and the
MBI and their respective theoretical and conceptional foundations has only just
started. Several articles in the July-September 2005 issue of the Work & Stress
journal comment the introduction of the CBI and the reasons for its
development. The recent discussion shows that the long hold basis of the
burnout concept is currently being debated from within the scientific community
of burnout research. For many of the open questions it is helpful to draw to the
many studies conducted in the past, other issues need to be studied further with
new investigations using different approaches. This PhD thesis does not directly
contribute to the ongoing discussion about how many dimensions should be
used to measure burnout, as it was not the goal of this study. However, this indepth study of the understanding of burnout and its manifestation in Danish
midwives does shed some light on the subjective perception of burnout in
human service work as concluded in Chapter 8. Furthermore, is with reference
to the subject theoretical approach to burnout research (Pedersen, 2002) a
different perspective introduced in the present thesis (see below).

38

2.2.2.4 Strengths and weaknesses of recent mainstream burnout research


Burisch (2002) summarizes the state of the art in burnout research as follows:
In 1986 (p. 637) Jackson, Schwab, and Schuler envisioned a bleak future for
burnout research, namely that twenty years from now we will have more data but
not much more knowledge. Although their forecast period has not yet elapsed,
there is a definite likelihood that they will turn out to be right. As one metaindicator, an excellent state-of-the-art summary of empirical studies, Schaufelis
and Enzmanns (1998) recent Burnout Companion to Study and Practice A
Critical Analysis, is forced to refute one popular belief about burnout after
another. Are idealistic workers more burnout-prone than others? Inconsistent
results. Social support buffers against burnout? Equivocal results. Workload and
time pressure lower feelings of personal accomplishment? Virtually unrelated.
Burnout is linked to emotionally taxing client contact? Refuted. Burnout
increases drug abuse? Very weak relationships with at best one burnout
component. Burnout tends to spill over to private life? No conclusive evidence.
Burnout causes absenteeism, turnover, and low performance? At best small
effects, when self-report measures are used, at worst inconsistent and
disappointing results; and so on.

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

Clear operational definition leads to good


comparability of research results.

Tautology problem: burnout is what the


MBI measures, the MBI measures what
burnout is.
Burnout research takes a distanced position
to the individual suffering from burnout. A
healthy worker effect is most probable,
because most investigations take only those
into account who are still working.
Moreover, burnout is measured with selfratings in form of paper-pencil-tests. The
individual attributions, thoughts, feelings,
and emotions in a particular situation
embedded in a greater context are not in
focus (Pedersen, 2002).

Burnout is a well-recognized problem in


modern society and is a serious problem
both for the individual suffering from
burnout and for work organizations.

39

Table 2.3 Strength and weaknesses of contemporary burnout research (continued)


There exists a tremendous body of work
(Schaufeli & Enzmann, 1998 name 5.500
publications) in burnout research.
Replications of research outcomes can be
referred to.
There is a general frame of reference in
burnout research, giving the possibility for
comparison and relation to the same reality.

More of the same leads to a boring,


monotonous and irrelevant research area
that is self-perpetuating but not at all
developing (Rsing, 2003).

There is a tremendous body of research one


can relate to when investigating burnout.

Most of the work is cross-sectional and


does not make causal inferences possible.
Single case investigations to look at the
phenomenon in depths are not existent.

The same frame of reference creates


blindness toward new developments and
other observations. The construction of
reality is done on the basis of established
knowledge. Scientific development grows
out of questioning the already known and
not out of common agreement.

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

burnout. Schaufeli & Enzmann (1998) report an interesting observation that


cross-sectional findings with respect to job-demands on burnout could not be
replicated in longitudinal studies. They assume that this might also be due to
methodological problems (using regression approaches instead of simple change
scores from time one to time two).
A general frame of reference is positive when relating to the same phenomenon.
However, especially with phenomena changing over time and situation it is also
regarded as important to discuss different approaches to burnout which do not
refer to a mainstream approach of burnout research.
Pedersen (2002) makes a pledge for a subject theoretical approach, investigating
forms of practice as historical, concrete, and situated by taking the first persons
perspective. In a subject theoretical approach relations between situational
conditions, a persons concrete actions, and the reasoning behind these actions is
investigated. Instead of questions of cause and effect of single characteristics in
relation to burnout (e.g., personality, work conditions, or subjective
expectations) complex, dynamic relations are in the center of attention. In doing
this, the researcher as person is involved in a different way then being involved
in sending out a burnout questionnaire to an unknown person. This is in fact one
fundamental difference between quantitative and qualitative research: the
researcher as person suddenly has a face and needs to be referred to. A subjecttheoretical approach always includes the relationship of societal conditions and
the concrete situation and action of the person investigated and the interpretation
and reasoning behind this action. In a subject theoretical approach the context
gives meaning to a phenomenon. Therefore, the context stands in the center of
investigation. In the case of burnout it is for example interesting to compare
different job groups in regard to their primary task, what kind of actions need to
be taken to fulfil the task and how does the person perceive the fulfilment of the
task. By comparing different jobs and contexts this way it becomes obvious
where the differences between jobs of the same categories are, e.g. human
service jobs. Pedersen is criticising burnout research as one example for research
41

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

perception of stress and diverse situational determinants. The authors summarize


that nomothetic methods are useful for thinking generally about occupational
health and stress whereas single case approaches help to detect parameters
important to understanding the phenomenon in this specific context.
In somewhat the same direction Sderfeldt (1997) argues in regard to
understanding burnout. She claims that burnout should not be understood as an
ideal concept but rather as a social construction, as a concept with reference in
real life. With regard to this Ph.D. thesis burnout as social construction points to
an understanding of the phenomenon as being bounded in a specific context
(here: the job practices of the midwives), understood with a certain connotation
(here: challenges and demands of the helping to give birth), and valued in a
specific way (here: the organizational and situational problems at the ward
which lead to frustrations and feelings of being burned out) (see discussion in
Chapter 8).
Definitively, the theoretical foundation of burnout needs to be developed further.
There is some agreement about the weak theoretical foundation of burnout
research (Schaufeli & Enzmann, 1998; Rsing, 2003; Pedersen, 2002). Schaufeli
& Enzmann (1998, p. 101) distinguish four sets of theoretical approaches to
burnout: individual, interpersonal, organisational, and societal. In conclusion,
they propose an integrative and descriptive model of burnout as a heuristic
model that schematically summarizes common issues that are included in the
previous approaches (ibid, p. 140). As three recurrent themes, Schaufeli and
Enzmann (1998) propose: (1) a strong initial motivation as a necessary
precondition for the development of burnout; (2) the relation of burnout to an
unfavourable job environment; and (3) burnout as self-perpetuating process
because of inadequate coping strategies. A heuristic model is one way to react to
the theoretical vacuum or fuzziness in burnout theory. An open framework of
burnout could be another way out of the dilemma. A complex but
comprehensive framework of burnout would help on a meta-theoretical level to
organize research as well as the observation and cure of burnout. On a
43

theoretical level it would help to re-think burnout by understanding burnout as a


phenomenon, which leaves space for idiosyncratic perceptions, subjective
interpretation and causal attributions.

2.2.2.5 Prevention and cure of burnout


Another important aspect neglected in burnout research so far is the question of
a cure for burnout. As blurry and fuzzy as the description of burnout is, the
recommendation of what to do to prevent or cure burnout is far reaching. The
catalogue reaches from meditation to medication, from activation to vacation,
from running to yoga, and so forth. As in many other forms of psychological
distress, cure is often accompanied by a long search for the right therapy. To test
the reality of burnout in practice, Sderfeldt (1997) left the ivory tower of
scientific research and went to the marketplace for burnout cures (e.g.,
convenience sample of acupuncturist, homeopaths, psychotherapists, and two
health stores). Her conclusion is that many people know what to do about
burnout and much is earned in curing it. If these approaches in practice are goal
directed or trial and error led is left to ones own appraisal. Kalimo et al. (2003)
investigated work characteristics and personal resources that are associated with
the burnout symptoms in the long term. They conclude that the paths to burnout
and to well-being are drastically different. According to them, the development
of burnout is furthered by weaknesses in the organizational climate and by
unrewarding work as well as in the persons lack of feelings of self-worth and
competence. Well-being, on the other hand, is based on strong internal personal
resources and challenging work. Therefore, the prevention of burnout should
include both enhancement of the possibilities for developing the employees
personal resources and improvement of the social processes at work (ibid, p.
120). Thinking about prevention and cure of burnout always brings the
question of complexity of the issue into sight. It should be kept in mind that a
complex phenomenon such as burnout is not curable with simple
recommendations. Rather, a thorough investigation of causes and resources in a

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

First, a functional approach to motivation (Kuhl, 2000) with roots in


McClellands concept of power, achievement, and attachment motivation
(1987), self-regulation theory and new developments in cognitive and
personality psychology is introduced. Second, commitment research is
introduced being defined as an applied form of cognitive choice models of
motivation. Third, the concept of flow is presented as proximal concept of
motivation. The concept of flow is regarded to be important because of the
emergent quality of the experience and the possibility of describing an
emotional experience in motivational terms.
Along with the three constructs of motivation, two recently developed models of
engagement from within burnout research are portrayed: the three dimensional
concept of engagement from Schaufeli et al. (2001, 2002) and the rephrasing of
burnout as an erosion of engagement with the job (Maslach & Leiter, 1997). To
conclude, not the most prominent but, from the authors point of view, the most
promising concepts are introduced, representing different paradigms in
motivation theory which can be related to concepts of health and well being at
work, and more specific burnout.

2.3.1 Implicit and explicit motivation


The first concept to be introduced relates back to the beginnings of motive
measurement in the early fifties of the last century. At that time, there was no
reliable measurement methodology for human motivation (Niitamo, 1999, p.
21). However, there was already a strong belief in two different motive
systems: an implicit and an explicit system. The basic idea behind this thought is
that personality is not totally accessible through consciousness but that to a
certain degree, our personality functions on a conscious as well as subconscious
(or nonconscious) level (here referred to as in depth). It was close at hand that
this in depth personality is not to be measured through self-report because it is
non-conscious and therefore not accessible through self-report measures. Two
different traditions of motive measurement started to flourish side by side. The

47

first concentrates on self-reports to assess human motivation and the second


relates to projective (fantasy) techniques in order to reach deeper levels of
personality (e.g. Murray, 1933, in Niitamo, 1999). Motives measured in fantasy
are called implicit motives and those measured through self-reports are called
self-attributed motives (McClelland, 1989). Implicit motives seem to be better
at predicting spontaneous, self-generated behaviors and behavioral trends over
time and behavior in field settings. Explicit motives seem better at predicting
specific responses in situations in which the incentives are explicit (Niitamo,
1999, p. 27). Implicit and explicit motives seem to function in different
motivational subsystems. Important in the context of the present work is the
consequence of this assumption. If, in fact, two different motivational
subsystems exist, they should be measured with different instruments.
McClelland, Koester & Weinberger (1989, p. 697) emphasize the importance of
measuring implicit motives with operant measures, because implicit motives
seem more likely to be built on affective experiences with natural incentives
early in life, before the development of language. Self-attributed motives are
developed later in life, after concepts of the self, others, and what is valuable
have been acquired.
In 2000, Kuhl introduced an integrative framework of cognition, motivation and
emotion; the personality systems interactions theory- PSI. This integrative
approach wants to step beyond the shortcomings of previous motivation theories
by merging personality trait approaches with motivation and action theoretical
constructs. On the basis of the belief that cognitive content is not sufficient to
explain volitional action, a functional-design approach to motivation and selfregulation is introduced (Kuhl, 2000). The rather complex theory shall not be
explained further and the introduction may stay on a surface level, because it
would exceed the frame of the present project to take it in depth.
Most important at this point is the understanding that the early trend in
motivational research to differentiate between the implicit and explicit
48

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

organization, commitment is assumed to lead to benefits ranging from better


performance to lower absence. However, evidence from research shows that the
picture is more complex. In a meta-analysis of 35 studies, Randall (1990, in Tan
& Akhtar, 1998) could show that higher levels of commitment had stronger
positive relationships with attendance, effort, and continuing employment with
the organization than with actual job-performance. Moreover, several
researchers started to question the overemphasis of positive consequences of
organizational commitment, formulating possible negative consequences of
commitment. Organizational commitment in these approaches is regarded as
possible source of psychological strain. Keenoy (1992, in Tan & Akhtar, 1998)
terms this dilemma a motivation-control equation, which asks for greater
autonomy and generous rewards for employees in order to reach greater
commitment. Another critical view of commitment as form of managerial
control is inspired by Hochschilds work (1983). She uses the term emotional
labour in order to describe employees who are trained to modify their
behaviours in accordance with organizational expectations of their emotional
responses to customers. This facet of organizational commitment, operating on
the affective domain, is meant to have negative consequences for the health and
well being of the employee.
The body of research work on commitment is complex and for the purpose of
this short theoretical introduction of the concept, it might be enough to conclude
that affective commitment has the strongest effect on an employees
performance. Findings on commitment and employee well-being summarized by
Meyer & Allen (1997) show that there is rather weak evidence that affective and
normative commitment enhance employee well-being. Nonetheless, there is
some evidence that affective commitment might have positive consequences
whereas continuance commitment has negative consequences for employee well
being. Thus, there is a need to investigate these relations in depth. It should also
be noted that positive and negative outcomes of commitment depend to a large
extent on the perspective from which commitment is looked at. An overly
committed employee might perform highly satisfactorily but at the same time
50

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,

52

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.

2.3.4 Motivational concepts developed from within burnout research


Just recently, the two internationally predominant research groups in burnout
research have started to show interest in the positive side of burnout. Christina
Maslach and her colleague Michael Leiter, as well as the group around Wilmar
Schaufeli, have developed an antipode to burnout, called engagement.

2.3.4.1 Engagement as antipode of burnout


Maslach & Leiter were the first to step beyond the pathological model of
burnout as a negative psychological state by enlarging the concept through the
positive antithesis of burnout; job engagement. Burnout is rephrased as an
erosion of engagement with the job (Maslach et al., 2001). This relation can be
described between the two poles of burnout and engagement. Burnout is, as
before, defined as the three-dimensional model of emotional exhaustion,
cynicism, and ineffectiveness. Engagement, on the other hand, is defined by
53

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.

2.3.4.2 Engagement as a persistent, positive affective-motivational state


The second, recent approach towards engagement from within burnout research
comes from the Netherlands. The research team around Wilmar Schaufeli
developed an instrument to measure engagement. The concept of engagement
grew out of a theoretical analysis (Schaufeli &Bakker, 2001) where two
underlying dimensions of work-related well-being could be identified: (1)
activation of the poles exhaustion and vigour, and (2) identification, ranging
from cynicism to dedication. The third concept, absorption, is included in
engagement; whereas reduced professional efficacy is enclosed in burnout.
Absorption and reduced professional efficacy are not poles of a continuum but
conceptually rather distinct from each other.
Engagement is understood as a positive antithesis of burnout but assessed in its
own rights. Engagement is defined as: a positive, fulfilling, work-related state
of mind that is characterized by vigour, dedication, and absorption. Rather than
a momentary and specific state, engagement refers to a more persistent and
pervasive affective-cognitive state that is not focused on a particular object,

54

event, individual, or behaviour. Vigour is characterized by high levels of


energy and mental resilience while working, the willingness to invest effort in
ones work, and persistence even in the face of difficulties. Dedication is
characterized by a sense of significance, enthusiasm, inspiration, pride, and
challenge. Different from involvement, which is also defined in terms of
psychological identification with ones work or ones job, dedication goes a step
beyond. In a quantitative sense, dedication refers to a particularly strong
involvement that goes one step further than the usual level of identification. In a
qualitative sense, dedication has a wider scope by not only referring to a
particular cognitive or belief state but including the affective dimension as well.
The final dimension of engagement, absorption, is characterized by being fully
concentrated and deeply engrossed in ones work, whereby time passes quickly
and one has difficulties detaching oneself from work (Schaufeli et al., 2002).
This recently developed concept of engagement seems to be a promising
approach to understanding positive aspects at work. The measurement of
engagement is done with the Utrecht Work Engagement Scale (UWES,
Schaufeli & Bakker, 2003). The UWES scale provides a well-defined and
thoroughly developed instrument to measure engagement. If this new path of
burnout research should lead to interesting, new developments in the field, it is
dependent on the creativity and openness with which the research community
will approach it. It will further be interesting how relations to other related
concepts (flow, job involvement, affective and passionate commitment) will be
drawn. Nevertheless, engagement as positive work related behaviour is defined
and clears the way for new insights on how to understand the relationship
between motivation and burnout.

55

2.3.5 Relationship and overlap between motivational concepts introduced


above
The two concepts of engagement developed from within burnout research try to
define this continuum from engagement to burnout. In doing this, they do not
explicitly refer to motivation research. Nonetheless, they both refer to the
aspects of intensity and persistence of motivation. Engagement is regarded as a
popular synonym for motivation. In fact, the Danish language prefers the term
engagement to describe motivational states. Motivation is perceived as a
scientific term, not used in every day language. Both concepts of engagement
use the term energy in order to describe the resilience and willingness to invest
effort. Energy as an antipode to exhaustion refers to the physical and cognitive
realm, not so much the emotional.
Being fully absorbed in ones work comes close to a state of flow. However,
typically, flow is a more complex concept that includes many aspects and refers
to a rather particular, short-term peak experience instead of a more pervasive
and persistent state of mind, as is the case with engagement. The five concepts
of motivation introduced above represent different streams in motivation
research and are regarded as relevant in the context of this case investigation.

2.3.6 The relationship between motivation and burnout


One of the core assumptions in burnout research is the notion that a strong initial
motivation is necessary in order to develop burnout (Freudenberger &
Richelson, 1980; Pines, 1993; Burisch, 1989; Bssing, 1992; Schaufeli &
Enzmann, 1998; Maslach et al. 2001). In a recent article, Friedman (2000)
explains the process of burning out in teaching with the professional efficacy
discrepancy approach. Thereafter, teachers entering the field with high levels of
idealism and commitment experience a discrepancy between expected and
observed sense of professional self-efficacy. This leads to a feeling of low
accomplishment and frustration, and developing exhaustion. The threat to self56

efficacy components, defined as tasks (teaching and school administrative


organization) and relations (with students and with administration and
colleagues) in a harsh reality of occupational life can lead to burnout.
Although the assumption of motivation being a necessary pre-condition for the
development of burnout is widely cited throughout the literature on burnout,
empirical proof of the assumption is rare. In the following, the existential model
of burnout (Pines, 1993), which describes the relationship between motivation
and burnout based on experiential data, is introduced. Further, a selection of
recent empirical studies is also introduced. All empirical work is recruited from
a larger database search using the search terms motivation and burnout and
commitment and burnout, and from cross-citations. The author selected those
studies which investigate explicitly the relationship between motivation and
burnout.

2.3.7 The existential model of burnout


Alaya Pines is the one who described the core assumption of burnout research in
rather powerful words (Pines, 1993, p. 41): in order to burn out, one has to
first be on fire. In the existential model of burnout, she formulates the
assumption that a high motivation to succeed in ones job is a necessary
precondition in order to experience burnout. Only highly motivated individuals
can burn out. Burnout is regarded to be a developmental process. This aspect is
also included in many of the burnout concepts known from the literature, as for
example, Golembiewskis state model (Golembiewski & Munzenrider, 1988) or
Maslachs idea of different phases of burnout (Maslach et al. 2001).
Pines (1993) argues that the loss of meaning in life causes burnout. She states
that nowadays meaning in life often is approached through work instead of
through religious beliefs as in the past. Work has become the religion of a
secularised world. The existential significance of a person is measured by the
meaning found in doing his/her job. The work we do ought to be significant,

57

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.

Figure 2.1 Existential model of burnout (Pines, 1993, p. 42).

Pines (1993) distinguishes three sets of motivations: universally shared work


motivations, profession-specific work motivations and personal work
motivations. The first are motivations like: having a significant impact, being
successful, and being appreciated. The second is described as profession58

specific work motivation which results in interrelated processes: selection and


professional socialization. The third are personal work motivations described as
a romantic image of the work modelled after certain experiences, important
persons, admired characters, etc.. A close relation to the three basic motives of
power, achievement and affiliation (McClelland, 1983) can be drawn. Pines
work is based on experience from some hundred burnout workshops. The
experiential data is used as the basis for well-described research processes. The
model is appealing in the sense that it is sound and easy to comprehend. The
model leaves space for many assumptions about burnout research. For example,
personality dispositions are not mentioned explicitly but can be thought of as
having an influence in the process of setting goals and forming expectations.
The recognition of subjective feelings and cognitions as being important for the
appraisal of the situation is regarded as important aspect by the author of the
present work. Another appealing aspect is seen in the clear assumption of an
initial state of being on fire as a necessary prerequisite for burnout. The logic
of the model works with the assumption that the environment has to be
supportive with a maximum of positive features that enable professionals to
reach their goals by providing the needed autonomy, resources and support
(Pines, 1993, p. 43). Yet at the same time, Pines states that the appraisal of what
is supportive or not is strongly dependent on the individuals estimation of the
situation.
It can be concluded that the assumption of motivation as a necessary prerequisite
for burnout has not been empirically proven by Pines work. Nevertheless, her
observations are valuable as a reference frame for further research on the
relationship between motivation and burnout.

2.4 Selected empirical studies on the relationship between motivation and


burnout
The following section comprehends short summaries of eight different empirical
studies. The studies focus on the investigation of the relationship between
59

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)

#Motivation and burnout#

57 (11)

191 (13)

#Commitment and burnout#

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.

60

(1) A Meta-Analytic Examination of the Correlates of the Three Dimensions of


Job Burnout (Lee & Ashforth, 1996)
In a comprehensive meta-analysis, Lee & Ashforth (1996) assessed the
associations between various correlates and the three burnout dimensions as
operationalized in the MBI. The conservation of resources theory (Hobfall,
1989; Hobfall & Freedy, 1993) is used as framework for understanding how
such correlates are related to the different dimensions of the burnout concept.
The conservation of resources theory (COR) assumes that burnout occurs when
certain valued resources are lost, fail to meet demands, or do not yield the
anticipated returns. It is further suggested that certain outcomes occur as a result
of resource loss and burnout, and one is the erosion of organizational
commitment. The results of the meta-analysis support this assumption.
Organizational commitment was negatively related to both emotional exhaustion
and depersonalisation.
(2) Brennt wirklich aus, wer entflammt war? (Is really burning out who was
enflamed?) (Schmitz, 1998)
Using a LISREL-analysis, Schmitz (1998) investigated the question Do people
really burn out who were once enflamed? in a sample of 207 people in human
service work. In reference to Hallsten (1993), burnout is thought to start with the
counteraction of three factors: a certain vulnerability of the person, problematic
conditions of the job, and specific expectations about the own role. The
following original states for the development of burnout are defined and their
roles in regard to burnout are investigated: basic beliefs and expectations
towards the job, unrealistic aspirations, commitment, enthusiasm and
involvement. Occupational disappointments are defined as mediating variables.
The structural model included demographic information as exogenous and the
original states of burnout (see above), the occupational disappointments
(mediating) and burnout (endpoint) as endogenous variables. Results show that
only the path from unrealistic aspirations towards the job through occupational
61

disappointments (mediating) is significant. The path from enthusiasm,


involvement and commitment to burnout actually shows a slightly negative
relation. The metaphor of only those who have burnt can burn out could not
be tested with the structural analysis. Enthusiasm, commitment and involvement
should not be defined as original states (Prodromalzustand, Prodromalmerkmal)
to develop burnout. The author replicated the finding in a second investigation
(Schmitz, 1999) using a sample of 103 teachers.
(3) Organizational commitment and experienced burnout: an exploratory study
from a Chinese cultural perspective (Tan & Akhtar, 1998)
Tan & Akhtar (1998) investigated organizational commitment and the burnout
experienced using a questionnaire survey of 147 employees of a Chinese-owned
bank in Hong Kong. The assumption of the overemphasized beneficial effects of
organizational commitment on health and well being of employees was
questioned and investigated in depth. Moreover, a Confucian-based Chinese
cultural perspective is included in the analysis. The authors refer to the threedimensional concept of commitment proposed by Meyer & Allen (1997),
differentiating normative, affective, and continuance commitment. Emotional
exhaustion is measured, representing experienced burnout and is assumed to be
the core constituent of burnout. Along with the commitment and burnout
measures, work perceptions were measured using the Job Descriptive Index
(Smith, Kendall & Hulin, 1969, in Tan & Akhtar, 1998). One proposition was
that higher levels of normative commitment would lead to higher levels of
emotional exhaustion. This proposition proved to be right, showing that
normative commitment contributed five percent variance to emotional
exhaustion in the predicted direction. Further, affective commitment showed no
significant effect on emotional exhaustion. Both results are discussed on the
background of cultural assumptions, differentiating between an Anglo-American
culture and a Confucian-based Chinese culture. In a Confucian-based society,
affective bonds are mainly tied to the family and not to the organization. Thus,
affective commitment does not play an important role as a source of emotional
62

exhaustion. On the other hand, a strong appeal to normative commitment is


reported. A normative orientation, expressed in loyalty towards the employer,
respect for authority, filial submission and devotion to service, is core in a
Confucian-based society.
(4) Job Stages of Entry, Mastery, and Disengagement Among Nurses (McNeeseSmith, 2000)
McNeese-Smith (2000) describes the relationship between different job stages
and organizational commitment. Job stages are defined, following Grahams
model of entry, mastery and disengagement (1970, 1973; in McNeese-Smith,
2000). The study shows a strong relationship between organizational
commitment, measured with The Organizational Commitment Scale (Porter et
al., 1974), and the phase of mastery and preventing disengagement. Her study
gives support to the notion that strong organizational commitment may prevent
burnout.
(5) The Measurement of Engagement and Burnout: A Two Sample Confirmatory
Factor Analytic Approach (Schaufeli et al, 2002)
Schaufeli et al. (2002) reformulated burnout as an erosion of engagement with
the job. They compared and tested a model which suggested two second-order
factors on which all three burnout scales load (exhaustion, cynicism, reduced
efficacy) and the three engagement scales (vigour, dedication, absorption), with
a model which suggested one general undifferentiated dimension of
engagement. A test of the factor structure of the two concepts (burnout and
engagement) yielded satisfactory results, proposing that the factor structure of
burnout and engagement is reliable. Nevertheless, professional efficacy (being
defined as a factor of burnout) loads onto the wrong factor, suggesting that the
component of professional efficacy appears to be an element of engagement.
This result is consistent with other findings (Leiter, 1993; Lee & Ashforth,
1996), suggesting that professional efficacy develops independently from
exhaustion and cynicism. Further, the results of the analysis give to understand
63

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.

64

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.

2.5 Work Family Conflict (WFC)


The introduced concepts of burnout and motivation research are short on
explanations about the importance of context for a working person. The crossover from work to family and the other way around is a focus in literature about
work family conflict; also called work-home interference (Geurts & Demerouti,
2003). Work family conflict is defined as an incompatibility of work and family
roles, leading to stress experienced by the individual (Geurts et all., 1999;
Jansen et al., 2003). In the literature, the problem of work family balance is
defined from two sides, work family conflict (WFC) and family-work conflict
(FWC). Interestingly enough, the issue has, up to now, mainly been investigated
65

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
66

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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2.6 Emotions at work


Emotions in the workplace first now are starting to get the same recognition that
cognitive and behavioural aspects in the workplace have gotten for the last 40
years (Ashkanasy, Hrtel & Zerbe, 2000). Fisher & Ashkanasy (2000)
summarize that very little is actually known about emotions in the workplace,
expressed in a special issue on the topic in the Journal of Organizational
Behaviour. Nevertheless, emotions in the workplace are regarded as being a hot
topic, as they are a fundamental part of human expression.
Even though emotional exhaustion is regarded as the core dimension of burnout,
emotional work demands have only rarely been considered as predictors of
burnout (Zapf, 1999, 2001; Brotheridge & Grandey, 2002). Therefore, the
observations and information gathered in the interviews are put in a broader
frame of reference of emotions in the workplace. On the theoretical forefront
stands Hochschilds groundbreaking work on emotional labour. Further,
Bruckss reflections about action- and affect-psychological base of work
psychology are introduced. Finally, Zapfs theoretical and empirical work on
emotion work and burnout is presented.
2.6.1 Concepts of emotion work
In 1983, Hochschild published The Managed Heart: Commercialization of
Human Feeling, a book describing her experiences and observations of flight
attendants who need to act in accordance to feeling rules of the corporation they
work for. Since publication of the book, the display of emotions and the acting
out of feelings demanded in order to be an excellent human service worker has
been investigated in different research contexts. Hochschild (1983, p. 7) defines
emotional labour as the requirement to induce or suppress feeling in order to
sustain the outward countenance that produces the proper state of mind in
others. Hochschild differentiates between surface and deep acting. In surface
acting, a person is pretending to feel something she/he is not feeling. Others are
deceived about how a person really feels but the person herself is not. In deep
acting, feigning is unnecessary; the person really feels how she acts. In active

68

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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a regulation problem. Emotional dissonance is defined as an external demand


according to display rules of an organisation or profession and not as a reaction;
a discrepant feeling. Zapf et al. (1999) found that emotional dissonance was
positively related to emotional exhaustion and depersonalization. The display of
positive emotions and sensitivity requirements were positively related to
personal accomplishment. These outcomes point to an understanding of emotion
work as having positive as well as negative implications. In accordance with the
theoretical work and the empirical findings, Zapf et al. (2001, p. 529)
differentiate five aspects of emotion work: (1) the requirement to display
positive emotions, (2) the requirement to display and handle negative emotions
and at the same time a high variety of emotions to handle and to display, (3) the
requirement to sense the emotion of the interaction partner, (4) the influence on
the social interaction, and (5) the dissonance between felt and displayed
emotions. Among many other findings Zapf et al. (2001) report that clientrelated stressors are important in the development of burnout. The qualitative
aspects of the service provider-client relationship had some predictive power for
the development of burnout. This seems to be of particular interest in regard to
the present case study in midwifery.
Referring to early research work from Dembo (1931, in Brucks, 1998) and
Menzies (1975) and more recent work from Richard and Bernice Lazarus
(1994), Brucks (1998) describes the emotion psychological triangle. The triangle
describes the interdependence of an instrumental action (e.g. the dramaturgical
plot of a work task); an emotion following from this action, and the significance
of the situation for a person and the action following from it in order to cope
with the situation. Both client and human service worker react in accordance
with their own dramaturgical plot. At this point, non-reciprocity of feeling is
experienced. Brucks (1998, p. 170) points to the two patterns of emotional
labour which have been described by Strauss et al. (1980), as sentimental and
emotional work. Emotional labour is described as work related to the handling
of meaning and feelings of non-reciprocity. Brucks (1998) discusses the
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importance of finding a way to better cope with non-reciprocity of feelings on


an organisational level, so that the intensity of these feelings declines at the level
of the single person.

Figure 2.2 Emotion psychological triangle (in reference to Brucks, 1998, p. 169).

Taking the emotion psychological triangle as a reference frame for the


interpretation of results from the present case investigation in midwifery is
especially interesting when looking at the professional role and the reported
feelings in regard to traumatic incidences and in regard to client demands. In
midwifery, non-reciprocity of feeling is task inherent. Part of the professional
work role of the midwife is what Strauss et al. (1980) describe as sentimental
work. To describe it in different words: the midwife holds the space for the
woman giving birth by taking action which supports the woman in labour: she
motivates, is empathetic, directs, decides, caresses, etc. The better the midwife is
in holding the space and taking the perspective of the woman in labour without
getting lost in the emotional turbulence of a birth, the better she can fulfil her
primary task. On the other hand, a midwife often has to handle and control her
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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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research focussing on isolated aspects of a persons psychosocial wellbeing at


work can be brought together into a broader perspective so that a more
thorough understanding of processes which lead to either motivation or burnout
in midwifery is possible, both on a collective as well as individual level.
The present project is regarded as a step in between two research traditions. A
strong reference to existing theory and research in the field is established with
the purpose of staying connected to what I call a mainstream position in
contemporary work psychological research which is dominated by a
quantitative research approach. In a way, this is a pragmatic choice of being
able to interconnect with colleagues, thinking, doing research, and writing
about it from a positivist stand. I personally share the propositions of a postmodern approach of doing research in believing in the value of investigating
the subjective lifeworld perspective as well as in the necessity of constantly
questioning the own fore-understanding in order to come to a better
understanding. Both traditions, the quantitative and the qualitative, seem to
have advantages and disadvantages and are not to be seen independently from
the epistemological paradigm they refer to. A quantitative approach inherits the
beauty of being able to make assumptions about the world as it is whereas a
qualitative approach is more hesitant and refers to a world as it seems to be.
In the next chapter, the qualitative paradigm of doing research as understood in
the present project is introduced in more depth. Further, the chosen research
approach, strategy, and design of the present project are outlined. Whereas the
previous chapter clearly represented knowledge gathered within the
quantitative paradigm, the forthcoming chapter describes a way of
understanding the relationship between motivation and burnout in midwifery
from a different epistemological stand.

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Chapter 3: Epistemological reference frame and method

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

75

complex phenomena on a different level than quantitative research (Gordon et


al., 2005).
The present project refers to the qualitative research paradigm. The qualitative
paradigm is characterized by different approaches to reach understanding about
a phenomenon. Qualitative research approaches are well documented (e.g.,
Lamnek, 2005; Creswell, 2003; Flick, 2002, 2000; Denzin & Lincoln, 2000;
Malterud, 1996, 2001; Strauss, 1998; Kvale, 1994; Moustakas, 1994; Lincoln &
Guba, 1985; Kleining, 1985).
Lamnek (2005, p. 33) summarizes the following attributes of qualitative
research:
Interpretative: Social reality is constructed through interpretation and
meaning, it is not objective.
Naturalistic: The field for research is the real world. Methods to
investigate the natural world are naturalistic.
Communicative: Rules for every day communication are also true for
methodological rules in qualitative research.
Reflexive: Qualitative research needs to be self-reflective in different
ways.
Qualitative: Qualitative research is different from standardized
quantitative approaches. Not standardized methods are used in order to
approach the field openly and adequately in regard to the research matter.
The interpretative nature of qualitative research is its strength and challenge at
the same time. It is strength as the understanding of meaning is looked upon
with imperturbability. Findings, results, knowledge interpretations and meaning
are dependent on the context and must be understood as interpretations of
reality. This does not imply that outcomes from qualitative investigations are
arbitrary; they are just not normative. The challenging part is to transform,
integrate and translate interpretive knowledge into new contexts. Concerning
the naturalistic nature of methodology and the investigation in the real world the
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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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refers to a corresponding methodology, which then is followed by exemplified


methods and techniques. The particular choice of procedure is greatly connected
to the research question and underlying assumptions about the phenomenon.
Throughout this following section, phenomenology as a research paradigm is
introduced. The phenomenological paradigm serves as the background for the
choice of method and the implementation of techniques for data analysis in the
present project.
Phenomenology has the goal of investigating a phenomenon as it is, independent
from pre-existing knowledge, prejudices, and theories (Lamnek, 2005). There is
a difference between the thing as it is and the experience of a phenomenon.
Intentionality is the central concept in Husserls transcendental phenomenology.
Intentionality refers to consciousness, to the internal experience of being
conscious of something; thus the act of consciousness and the object of
consciousness are intentionally related (Moustakas, 1994, p. 28). The object
exists (noetic) independent of the perception of the object (noema). The
appearance can differ from one situation to the other, which does not change the
essence of the phenomenon as such.
The phenomenological approach tries to

Box 3.1 Bracketing

describe the phenomenon as objectively as

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.

possible, independent of subjective,


theoretical and traditional elements. The
essence of the phenomenon is reached
through reduction. Lamnek (2005,p. 59)
describes the process of reduction in four
steps. First, all elements of the phenomenon
are gathered. Second, the relevance for the
research question is questioned. The irrelevant

aspects are set aside. In phenomenological terms this process is called


bracketing (Moustakas, 1994). Third, only those elements remain that are

78

necessary and invariant for the object of investigation. Fourth, the remaining
objects give a structure; they are the essence of the phenomenon.

3.2.1 The phenomenological method


In the present project, data from single interviews and the group interview are
analysed using the phenomenological method, a well-described, codified method
to analyse qualitative data in social and medical science (Giorgi, 1975, 1985;
Malterud, 1996). This form of data-analysis focuses on the condensation of
meaning.
The procedure is summarized in the following four steps of analysis (Malterud,
1996):
1. Reading all the material to get an overall impression and formulation
of general themes
2. Identifying meaning units and coding
3. Condensing and abstracting the meaning within each coded group
4. Summarizing the content of the analysis as a whole.
In the following sections, each of these steps is described in more depth.
Ad 1) Reading and formulation of general themes
The first out of four steps to analysing data, is, according to Giorgi (1975), the
determination of natural meaning units. This procedure furthers the
understanding on the interviewers side from one interview to the other and
gives the opportunity to listen more closely when new meaning is established.
This procedure makes the accumulation of knowledge more explicit. A period of
transcribing data and interpreting meaning on a first rough level follows each
interview. This stepwise acquisition of new information is treated as a growing
base from which further interviews are conducted. First of all, the whole
material is read in transcribed form to get a holistic impression of it. In this first

79

part of data analysis, it is important to put ones fore-understanding and


theoretical background aside and to try to be open for new insights and impulses
coming from the material. This is a challenging and risky process, because the
already existent theoretical background and knowledge is the foundation on
which security of judgement is experienced. Yet judgement and quick
interpretation is exactly what should be left aside at this point of the analysis.
The first step of analysis is dominated by pure observation, keeping all senses
open to perceive new insights. During this first step of analysis, the writing of
notes can be helpful. Interesting things can be marked but should not be
analysed in order to retain the impression of the whole. General themes 2, themes
grounded in the material, are the result of this first step of the analysis.
In the present project, the entire interview material is read in one piece to get an
impression of the whole before getting into a more thorough analysis of the
material. General themes are noted in a logbook throughout the reading of the
data material.
Ad 2) Description of natural meaning units
The second step is to code natural meaning unit. The material is analysed line
by line in order to find natural meaning units. Each general theme from the first
analysis step represents a preliminary idea, which is now systematized by
finding natural meaning units in the material. Van Maanen (1990) uses the term
theme to describe more closely what is meant by the description of meaning
unit. According to this, themes are like knots in the webs of our experiences,
around which certain lived experiences are spun and thus lived through as
meaningful wholes (van Maanen, 1990, p. 90). Themes are those aspects of a
phenomenon which stand out from the amount of observations made to
describe the phenomenon in depth.

Van Manen (1990) describes a theme as an experience in the process of phenomenological


reflection. In this sense it is described as an experience of focus, of meaning, of point, a
simplification, a form of capturing the phenomenon one tries to understand.

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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 3) Condensation into abstract meaning units


The third step in phenomenological data analysis is to find abstract categories
to condensate the meaning units. Only those parts of the text coded as a
meaning unit are further processed. Throughout this third step of data analysis,
all coded meaning units are checked for redundancies. Redundant meaning
units are either merged or deleted when not regarded as important for the
research question. The material (textbites) is re-written into more abstract
meaning using language different from the participants language. Codes with
only a very small amount of coded text-bites are excluded or summarized under
some other code.
This step includes the researchers own professional perspective, foreunderstanding, and experience. The process is both interpretative and
associative. The content of each subgroup is condensed and reformulated in a
more general form but it still contains the concrete content of the original
meaning unit. The leading question throughout this process is: How to
understand the content of the material on the background of existing theoretical
knowledge, ones own experience, and in relation to the research question.

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
83

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.

3.2.2 Context dependency


The present project refers to two phenomena in psychology which have been
widely studied: motivation and burnout. A tremendous amount of knowledge
exists about these phenomena, but still open questions remain (Schaufeli &
Enzmann, 1998; Burisch, 2002). The choice to use the phenomenological
paradigm is based upon the assumption that there is an essence to these
phenomena which needs some further explication. At the same time, it is
assumed that the phenomenon as it is is dependent on the context in which it
appears. The approach chosen in the context of this work tries to combine the
idea of being able to capture the essence of a phenomenon with the idea of
context. This second aspect is explained throughout the following section.
The experienced truth of a phenomenon is found in subjective theories about a
phenomenon of the lifeworld of an individual or group. Individuals develop,
similar to researchers, theories about the functioning of the world and their
actions. They use these theories when taking actions, they test them and if
necessary, they revise them (Flick, 2002, p. 37; according to Blumer, 1973).
The subjective theories inherit important knowledge about the investigated
phenomenon, as they are basis for approaching the world in a certain way, using
schemata and causal attributions to organize and find meaning in a complex
world. The investigation of subjective theories opens up for new meaning about
the phenomenon. Subjective theories can be based upon experience, culture,
traditions, values, feelings and emotions, as well as spiritual beliefs. They can
best be approached through proximal methods of investigation, such as field
research, participant observation, qualitative research interviews, and focus

84

groups. According to these assumptions, the lifeworld of the person plays a


fundamental role in understanding the phenomenon. Lifeworld refers to a
concept of Habermas (in Hyde & Roche-Reid, 2004) and can be described as
the world viewed from a participant perspective, and it is structured through
meaningful symbols, communicated through verbal action that is oriented
toward understanding.
Reflection of context in the present case investigation
Subjective theories can be both personal and collective. In the present case
study, individual midwives are interviewed about their personal understanding
of motivation and burnout. Each midwife has her own personal background
which is different from all the others. This personal background has importance
for the schemata, attributions, and subjective theories she uses to describe the
phenomena. At the same time, each midwife belongs to the job group
midwife. In the present project, shared subjective theories are in the
foreground. The phenomena under investigation are related to the context of
work, not private life. Even though personal experiences are shared throughout
the interviews, most of these experiences can be related back to the primary task
of a midwife, understood as helping to give birth. In conclusion, the work in
midwifery is regarded as the context in which the data of the present case study
need to be understood.

3.2.3 The use of theory throughout the monograph


A theory is a way of understanding the world in a
certain way. It is a description of the world that is
continuously revised, tested and reconstructed. In
the best sense, theory can be used as a tool for
thinking (Greif, 1993, 2004). Theory can be used
in different ways throughout a research process.

Far more interesting than the


testing of existing ideas ()
is the generation of new ideas
as they lead to more
appropriate theories.
(Hermanns et al., 1984, S.
149, in Lamnek, 2005, p. 318,
translated by A. Garleff).

Depending on the research question, theory is used top-down or bottom-up. The

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).

86

Critical reflection of using theory in the present case study


In the present project, the relationship between motivation and burnout is reinvestigated using a qualitative, in-depth approach. Using an abductive approach
of reasoning (Reichertz, 2000a in Lamnek, 2005; Kirkeby, 1994) the
participants were asked to give descriptions of the phenomena of motivation and
burnout in their own language, referring to narratives from their life world.
Theory is used in two different ways. First, theory is used as a reference frame.
The reference frame explains the state of the art of research in the field. It is the
theoretical knowledge base a researcher refers to (Lamnek, 2005). It should be
noted that the reference frame is not an objective entity but, to a certain degree,
a product of choice. The reference frame consists of the most prominent and
most promising theoretical issues in the fields of burnout and motivation.
Second, theory is used as a lens or perspective in order to interpret the
observations made in the field. A bottom-up approach to investigating the
phenomenon with open-ended questions is meant to lead to further insights
concerning the research question. This led to affirmation of already existent
knowledge in the field and to new descriptions of the investigated phenomena.
Motivation as well as burnout is reflected in the light of new themes which
emerged in the research process and that are meant to have impact on the
relationship between motivation and burnout.

3.2.4 Dialogue as a guideline for research


In a qualitative approach, communication with another person (the field, the
research participant) leads to a growing understanding. It is the other through
whom we see the world as it is (Buber, 1965, in Moustakas, 1994).
Communication is the path to reach a negotiated understanding of the world.
Communication is context-bound and therefore understanding is something
established in context, referring to a specific setting, a specific time and place.
Within these communications, meaning is constructed. The construction of
meaning is understood as an ongoing process. One necessary pre-condition for
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understanding is putting ones fore-understanding, mindsets, and beliefs aside


and taking the risk of reformulation into account.
During the process of understanding, the quality of the dialogue between the
researcher and the participant is crucial. The researcher faces a lot of challenges.
She has to be open enough to be perceptive on different levels. She needs to be
focussed in order not to be overwhelmed by the amount of information she gets
in the course of her investigation. She needs to be rational in order not to be
swept away in sympathy for the person she is talking to. She has to be able to
take someone elses perspective in order to react in a responsible manner.
Further, she needs to be reflective enough to give favourite assumptions up and
look for new meanings. To fulfil these challenges, meta-positions (see Section
3.4.6) are used.
In qualitative interview research, flexibility of the dialogue is another key issue.
Fog (1994) stresses the point that the interview questions to be asked should be
known by heart to be able to concentrate fully during the phase of contact to the
participant (e.g., interview). Instead of working through a checklist of questions,
answers are found on the way through talking about the phenomenon under
investigation. This procedure of guided construction of meaning is an open but
guided search for understanding the phenomenon in context. Kleining (1986, p.
734, in Lamnek, 2005) describes the dialogical process as follows: A
qualitative dialogue is not authoritarian-critical but rather egalitarian. As a rule,
an answer creates a new question (and probably a new approach); and this in
turn a new answer and so on, until the structure of the object is explained. 3
Another aspect of understanding is how to handle conflicting information and
awkward interview partners. To really understand what an interview partner is
talking about takes time and patience and the courage to reconfirm and ask again
3

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).

88

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.

3.3.1 Formal basis of the Ph.D. project


The Ph.D.-project started on the first of July, 2000 after the formal application
for a scholarship at the National Institute of Occupational Health in Copenhagen
was successful. The flow of the Ph.D. work was interrupted at two points, being
on maternity leave for a year each time.
In the announcement, the following description of the research focus was given
(translation by the author, sen).
Work motivation
The goal of the Ph.D.-project is to analyse motivation in relation to
work, understood as flow at work, engagement, joy at work or other
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factors, which can both be inhibitory as well as supporting in regard


to the preservation of work motivation throughout a whole work
lifecycle.
The project is both practical as well as theoretical. The theoretical
part of the project contains a clarification and discussion of different
work motivational theories. The empirical part can contain a
combination of: qualitative analysis of motivation on an individual
or workplace-level, and an analysis of motivation in regard to work
climate and health-effects.
In the first proposal, a combination of qualitative as well as quantitative research
methods was outlined. The main focus was work motivation and in a second
step, the impact upon health and well being. An underlying goal of the project
was the usage of relatively new methods to assess motivation (Experience
Sampling Method to measure flow, Ciskszentmihalyi, 1987; Operanter Motiv
Test to measure implicit motivation, Scheffer & Kuhl, 2000) as well as the
qualitative approach to investigate the relationship between motivation and
health.
Some paths planned in a first step proved irrelevant, impractical or did not fit
into the research scope of the National Institute of Occupational Health,
Copenhagen (NIOH) and therefore were excluded. Altogether the first proposal
was very far reaching and beyond the scope of a three-year Ph.D.-project. What
remained is a coherent, consequent qualitative case study in the field of
midwifery, investigating the question of how to understand the relationship
between motivation and burnout in human service work. The research process
throughout the project has been a great opportunity to learn and to develop my
own research profile.

3.3.2 Description of the PUMA investigation


The present study of the case on motivation and burnout in human service work
was initiated as reaction to the partly devastating results of a comprehensive,

90

prospective study of burnout and psychosocial well-being at work in different


job groups in Denmark (PUMA). The three main goals for the PUMA
investigation were formulated as following: (1) to write a critical appraisal of
international research on burnout with the focus on the conceptualization and
measurement of burnout as well as intervention research in the field (Kristensen
& Borritz, 1998; Thomsen, 2002); (2) to translate and validate the relevant
instruments to measure burnout to the Danish language; (3) to carry out a
prospective investigation in the field in order to be able to make assumptions
about the extent, causes, and consequences of burnout in different job groups on
the Danish labour market.
Over a period of six years, 1,914 participants from the field of human service
work are asked at three different points in time (baseline: 1999-2000, first
follow-up 2002-2003; second follow-up 2005) to answer a questionnaire
containing questions from the Copenhagen Psycho Social Questionnaire
(COPSOQ, Kristensen et al., 2005b) and the Copenhagen Burnout Inventory
(CBI, Kristensen et al., 2005; see Appendix A). The following seven
organisations, representing different parts of the human service sector in
Denmark participated in the PUMA investigation: home care services
(countryside and capital), a somatic hospital, a state psychiatric prison,
institutions for severely disabled adults in a county, and a social security service
in the urban area. PUMA is designed as an intervention study with interventions
not under control of the research team but to decide in the different workplaces.
Interventions at the different workplaces can take place but do not necessarily
take place. Through follow-up meetings with group delegates from the
participating groups, the process of interventions at the sites is reflected on.
Hence, the knowledge about interventions is not formally assessed. In the first
round (and also in the follow-up investigation) of PUMA midwives showed the
most severe levels of burnout in comparison to the other job groups and
compared to an average through the Danish working population. This settled

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matters for an in depth investigation of the relation between motivation and


burnout in Danish midwifery.

3.3.2.1 Selected results from PUMA


Interesting in the context of the present project are the PUMA results regarding
burnout. In Table 3.1, average scores on the CBI scales of 15 main jobs in the
PUMA baseline study (n=1,914) are shown. There is considerable variation
between job groups.
Table 3.1. The average scores on the CBI burnout scales of the jobs in the PUMA baseline
study (Kristensen et al., 2005a)
Personal Burnout

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

Home helpers (Cap.) 43.1

2.

Home helpers (Cap.)

41.8

2.

Midwives

38.4

3.

Hosp. secretaries

39.4

3.

Hospital doctors

39.8

3.

Home helpers (Cap.)

35.9

4.

Social workers

38.8

4.

Hospital secretaries

37.8

4.

Social care workers

34.1

5.

Social care workers

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.

Social care workers

34.6

8.

Supervisors

26.8

9.

Hospital doctors

36.6

9.

Prison wards

32.6

9.

Hospital doctors

26.7

10. Adm. Staff

35.0

10. District nurses

31.4

10. Adm. staff

26.2

11. Prison wards

33.0

11. Adm. Workers

29.8

11. Home helpers (Pr.)

26.3

12. Home helpers (Pr.)

32.6

12. Chief doctors

29.2

12. Chief doctors

25.8

13. Chief doctors

31.3

13. Head nurses

28.8

13. District nurses

25.3

14. Supervisors

30.8

14. Supervisors

27.9

14. Hospital secretaries

21.4

15. Head nurses

29.5

15. Home helpers (Pr.)

26.4

15. Head nurses

19.7

Average

35.9

Average

33.0

Average

30.9

N=20-264 for the individual jobs

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).
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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.

3.3.2.2 Role of PUMA within the present project


The PUMA investigation is the starting point as well as the frame of reference
for the present case study. Chronologically, the present Ph.D. project started at
the point where the first round of investigation was finished and the results were
already given back to the sites. The high degree of burnout in midwifery was an
alarming result and was met with high interest from the midwives who had
participated. From a research perspective the results from the first round in
PUMA suggested a qualitative approach to get more insight into causes and
consequences of burnout in this job group which is otherwise known for high
engagement at the job. Qualitative investigations (interviews) to help in the
process of developing and validating an instrument to measure burnout and to
find out about developmental processes of burnout had been planed for PUMA
(Kristensen & Borritz, 1998) but had not taken place before the start of the
quantitative investigation. Besides the present case study on the relationship
between motivation and burnout in human service work in midwifery, two other
job groups were chosen for further in-depth investigation: home care services in
both the Danish capital and countryside (Thomsen, 2002) as well as in one
countys institutions for severely disabled adults (Christensen, 2003).

3.3.3 The role of the researcher


In psychological research referring to the quantitative paradigm, the importance
of the researcher was long neglected. Moreover, the researcher has been defined
as an objective agent whose influence needs to be controlled to a possible
93

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.

3.3.3.1 The researcher as catalyst for knowledge production


All throughout the research process, the person of the researcher has influence
on the emergent result. Malterud (1996) draws attention to the impossibility of
defining the observer as an objective agent. The observer can have different
forms of involvement (e.g., from sending out a survey to fieldwork over a longer
period of time). Yet in the end, any observation is, to a certain degree, connected
to the observer (Flick, 2002). The way of formulating the research question, the
mode of data collection, the analysis and the communication of results is
characteristic for the researcher as a person and mirrors her mindset and belief
system. According to this, it is not a question whether the researcher has
influence but rather how the researcher has influence on the production of
knowledge (Malterud, 1996). To know ones own role throughout the research
process as well as ones cultural background, explicated mindset and tradition is
an important part of the investigation. Also of prominent importance is the
explication of the authors fore-understanding as well as the theoretical
reference frame chosen as basis for further analysis. Fore-understanding
(German: Vormeinung, Gadamer, 1990/1960) indicates the existence of a form

94

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.

3.3.3.2 Researcher as traveller


The researcher as traveller is a metaphor used by Kvale (1994) in order to
explain one approach to conducting a qualitative research interview. In contrast
to a miner, whose prominent goal is to find buried treasure, the traveller
wanders along, asks questions that lead the subjects to tell their own stories of
their lived world, and converses with them in the original Latin meaning of
conversation as wandering together with them (Kvale, 1994, p. 18). The

95

researcher looks for the best possible form of understanding. Moreover,


understanding is negotiated. It is a circular process changing both the observer
as well as the observed. This is not only true for qualitative research approaches.
Kristensen (2005a) mentions one important aspect when investigating health
issues in practice: as soon as a person pays attention to a phenomenon, not
known by name before, she will be even more attentive to it and her nave
perception about this phenomenon is gone forever. Her perception, her attitude,
even her emotional relation to the phenomenon is different from before; her
innocence in regard to the phenomenon is lost. The researchers role within a
qualitative research paradigm is to lead through this explorative process without
imprinting pre-formulated meaning about the phenomenon. The researcher has
to be open to reformulate her understanding about the phenomenon at any time
and risk a well-defined understanding about a phenomenon in order to reach to
the essence of a phenomenon. Then again, this essence of the phenomenon is
open for change, negotiable in context and defined in dialogue with the other.

3.3.3.3 The researcher as observer and constructor of meaning


The researcher sits with the expectation of constructing meaning on her own
using the information provided by the participant and putting it into a new
context (reconstructing or reframing). This process demands best knowledge
about the field of investigation (theory, assumptions), good interpretative skills
with high sensitivity for the data, the informant, and the context. Any
phenomenon can be interpreted, put into another context, or seen from a
different perspective, dependent from the observer, the creator of meaning. The
description of any observation leads us back to the observer. It is her referential
frame that is the ground for the observation described. The observed is so to say
dependent on the observational skill of the observer. In qualitative research, the
process of observation is reflected in-depth. The self-reflection is important in
order to differentiate between the phenomenon as it is and the phenomenon as
seen and described through the eyes of an observer. The influence of the

96

researcher as observer is taken into account and is a vital part of qualitative


research. On the other hand, this does not imply that an observation is arbitrary
(Fog, 1994). The observation is always bound up in context. Moreover, the
observer has an obligation to stay connected to the context within which the
observation is made. Meaning is created on the ground of the documented
communication between the researcher and the field. Qualitative investigation is
about finding a path or pattern of meaning in the chaos of perspectives on the
phenomenon. The helping aid is active listening (understanding through asking
and answering questions), thorough observing, and an open mind. The
researchers body and mind is the lens through which the information is
condensed. The characteristics of the lens are defined by the cultural and
situational context the researcher is living and working in. The more experience
she has gathered and deliberately integrated into her heart and mind, the more
differentiated her interpretative skill.
Especially with proximal methods of qualitative inquiry, it should be kept in
mind that any interpretation of the information given can be threatening and
hurtful for the participant. It can open new perspectives, which have been hidden
behind a sound argumentative context for good reason. One important skill for
any researcher engaged in qualitative research is the ability to look at the world
from a different perspective. With any interpretation grounded on the data
gathered, there is the responsibility to reflect on the respondents perspective
(worldview) in the best way. Last but not least, there is no definite truth about
social phenomena, because they are embedded in and grow out of the context,
which is in flow. It can never be the same again; never be seen with the same
pair of eyes, heard with the same ears, nor felt through the same body. The
observer of the observed is unique and so is the observation, but this does not
make the observation less relevant.
Any qualitative research setting demands a direct contact to the participants in
the field. Staying at the edge and observing from the outside will not lead to
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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.

3.3.3.4 Explicated fore-understanding and self-reflexivity


The explication of ones fore-understanding and self-reflexivity are regarded as
vital and important parts in a qualitative research approach. Therefore, different
ways and methods of acknowledging this were used throughout the present
project.
An interview about the authors fore-understanding was conducted: A
colleague at the National Institute of Occupational Health (NIOH,
Copenhagen) interviewed the author of the present monograph. The
preparation for the interview was a written text, given to the interviewer
before the interview took place. The informal paper served as first
impression and focus throughout the interview. The interview was
recorded to use as reminder. One important outcome of this reflection in
dialogue was the cultural perspective onto the field of midwifery (see
Chapter 8).
Since October 2002, a logbook was used for documentation of the
research process. All through the process of data analysis memos (Strauss,
1998) were written in this logbook. The logbook in the present study
served different purposes. It had the purpose of documentation of the
research process as a whole. It is a way of documenting choices and the
influence of new insights during the process. More concrete in regards to
the case study, the logbook serves the function of a diary. Present

98

thoughts, insights, feelings,


surprising events, etc. were
documented in an unstructured
way. It kept the memory being an
observer fresh during the course of
the investigation. In the phase of
participant observation, the journal
was used to document the
impressions and observations
during and right after the
observation period. Throughout
the interviews, the logbook was
used in a more structured way,

Box 3.2 Memo writing


Memos contain different aspects. They
can be descriptions of categories used
while coding certain passages of an
interview. Memos are written about
rules used throughout the coding
process. They can be thoughts and
ideas which come to the analysists
mind while coding and/or which do not
directly refer to the data analysis at the
moment. It could be a question about
the material which is not answered by
the recent interview but might have
some relevance in the further process
of analysis. Memos also include
comparisons or relations between
people, situations, or single codes
(Strauss, 1998).

documenting the course of each interview, recording important


observation, awkward feelings and specific observations which were not
communicated throughout the interview. Throughout the overall process
of the project, the logbook serves as form of diary, in order to keep
important thoughts alive. The unstructured documentation is not
published as such, but serves as a way to ground interpreted meaning.
Throughout the entire research process, the project was presented and
discussed in different groups at different times: at the research meeting of
the psycho-social department of NIOH, Copenhagen; at the
Kvalinetvrket of NIOH, Copenhagen; at the Doktorandenkolloquim at
the University of Hamburg, led by Ursula Brucks; at the research meeting
of the department production og ledelse of the DTU, Copenhagen.
Further, project presentation at the following Ph.D.-courses:
Fokusgrupper og gruppeinterview i almen medicinisk forskning (Kirsti
Malterud, 2002); The meeting between the researcher and the field
(Margaretha Jrvinen, Nanna Mik-Meyer, 2002) Artikelskrivning fra
kvalitative studier I almen medicinisk forskning (Kirsti Malterud, 2003).
All these different locations, people, and situations have had more or less
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influence throughout the process. Some of these situations were


experienced as highly inspiring others as rather destructive. Nonetheless,
taken together, all of them had influence on the development of the
project as they added new perspectives onto the process of investigating
the case.
The cultural background of the author was a valuable platform for
observation and reflection. Being brought up and being educated in
Germany endows the author with a certain perspective onto the field
which is meant to open up for further insights. 4 Throughout the empirical
phase, it gave a lot of freedom to ask questions, relating the participants
narratives to the authors cultural background. This was not done for the
purpose of comparing Danish and German midwives but rather for
stimulating thought. One specific example was the felt responsibility of
Danish midwives; also in cases where they had already given the
responsibility over to a doctor. Other observations were reflected in a
rather informal manner, throughout collegial communication and with
interested others (e.g., fellow Ph.D. students). The different cultural
background also plays a role in choice of reference frame.
During the course of the Ph.D. project, I went on maternity leave twice.
This is of course a significant aspect to consider when investigating in the
field of midwifery at the same time. In my diary (logbook), I reflected on
my personal experience during the two pregnancies in regard to the focus
and outcome of the case study. Twice, the need to consciously set the
frame for observation beyond my personal experience made me change
track. The first sequence was a planned period of participant observation
during my first pregnancy. I was seven months pregnant and had a period
of very scary dreams about birth. I decided that this period was not very
good to expose myself to being witness of somebody elses delivery. Not
4

One example is to be sensitive to differences between health care systems. Having a


different frame of reference (German health care system) makes it easier to see particularities
in the Danish health care system (e.g., less technological check-ups such as ultrasound under
pregnancy but higher workmanlike understanding of midwives (embodied knowledge).

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.

3.3.4 Ethical considerations


The qualitative research approach chosen in the present project is characterized
by a proximal approach towards the participants. The single in-depth interviews
conducted in the course of the project are an intimate approach into the
understanding and perception of the lifeworld of a midwifes work. There are
several things to consider when investigating with such an open approach. The
most important thing from the authors perspective is the rapport with the
interviewee and the establishing of an atmosphere of trust. In any case, the
interviewee needs to be informed about the use and further analysis of
information given in the interview. In the present case investigation, the
anonymity of the individual is guaranteed by the author. Interviewees were
given those parts of the interviews which were used to illustrate the findings for
permission. Agreement was asked for regarding the general use of a statement
but not for the understanding of the content of the interview.

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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.
102

3.3.5 Case study as research approach


The case study is defined as research approach, an in-between of methodological
paradigms and concrete techniques of data collection (Lamnek, 2005, p. 298).
Throughout a case investigation, relatively few people are investigated in depth.
The single person is regarded as an important knowledge agent for the
interpretation of the life world. Case study approaches are open for the usage of
very different techniques and methods. Case studies can refer to the qualitative
as well as to the quantitative paradigm. Common is the combination of different
methods in the sense of triangulation of methods (Denzin, 1989, in Flick 2002).
The triangulation of methods furthers to the validity of the outcome of the case
investigation (Lamnek, 2005), because bias of single methods is reduced.

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

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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

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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.

3.3.6 Entering the field


The access to the field; the opening up for the researcher; the step into the field all are different descriptions of entering into the research field. To open up for a
research investigation means taking time, investing effort, being willing to give
answers, to risk losing control, etc. (Wolff, 2000). These aspects can also be
described as costs or investments of the participant in a research project. In most
cases, the initial contact to the group of participants is of core importance for the
success of getting access to the field. Before being able to get in (physical
entrance to the field) and to get on (social entrance to the participants), an initial
contact has to be established.
The decision to focus onto the field of midwifery was made after the author was
asked by a research colleague at the National Institute of Occupational Health to
use the research focus (relation between motivation and burnout) in order to
shed some light on the devastating results from the investigation of burnout in
different job groups in Denmark (see description of the PUMA investigation in
section 3.3.2). Even though one underlying assumption of the PUMA study was
the relationship between motivation and burnout, this relationship was not
investigated in depth. For this reason it was decided to choose the scope of the
case study of human motivation and burnout in human service work
accordingly. The focus was defined as doing a case study within midwifery in
Denmark, using one specific ward as case. The author decided to ask those
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midwives who had already participated in the PUMA investigation to participate


in an in-depth approach to investigate the relationship between motivation and
burnout.

The research colleague responsible for PUMA at the National Institute of


Occupational Health (NIOH) in Copenhagen made an initial contact introducing
the author to the leading midwife at the ward. A first meeting took place in order
to talk about the conditions and the procedure in the course of the research
project. At that point the first round of the PUMA investigation had been
published and first steps towards intervention had been started from the
hospitals side. The leading midwife has the role of a gatekeeper (Bortz &
Dring, 1995, in Masberg, 2004), deciding about the access to a closed field.
She signalled clear interest in getting to know causes for the relatively high
levels of self-reported burnout at her ward. Besides this interest from the leading
midwifes side, it seemed to be of initial importance to get compliance from the
group of midwives, being known as a rather active and critical job group.
Therefore a short presentation of the projects intention and scope was given to a
group of midwives at one of their monthly central meetings. At this meeting, the
project was introduced and outlined. Information included the methodological
approach, confidential aspects, and how participants for interviews are to be
selected for single interviews. In the course of the meeting, agreement for
participation was asked from the participants. The midwives being present at the
meeting (approximately 50% of the staff) decided positively about taking part in
the case study.

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
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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
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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.

3.4 Research methods


Following the principle of triangulation of methods, different methods were
used to investigate the research question. In the following section, the research
field is described in a first step. The description of the field is based upon
insights into midwifery in Denmark through reading. This reading is defined as
method rather than as acquisition of theoretical knowledge, because it focuses
on one specific job group in a specific work setting in a defined cultural
background. It is thought to give the interested reader an impression of the
historical and practical developments in midwifery throughout the last years.
Further, the reading serves as source for validation and reflection of outcomes
from participant observation, qualitative research interviews and group
interviews in the result section (Chapter 4-7).
The description of the research field is followed by the description of the
qualitative methods used to investigate the field:
Participant observation, as means to understand the particularities of
midwifery in situ.
Single interviews, as core method to investigate the research question.
Group interview, used as member check (see Box 3.5).

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3.4.1 Description of the research field


Midwifery in Denmark was first legally recognized in 1537. In 1902, the Danish
Midwife Organisation (Den Almindelige Danske Jordemoderforening) was
founded. Throughout the last century, a lot has changed regarding the work
situation of midwives in Denmark. On an organisational level midwifery
changed from one-woman-businesses (private practice) into employee status
(being employee at a midwife center and later hospital) in 1984 with the
introduction of the midwife centers. Up until 2004 is maternity care in Denmark
provided in 33 hospitals with a birth frequency ranging from 15 births per year
on a small island up to 5.533 births per year in one of the large maternity centers
in Copenhagen. Today, most of the midwives in Denmark are employed at a
midwife center connected to a hospital, however, a small but growing number
work in private practice. But still, 98,8 % of births in 2004 and 2005 took place
in a hospital (Sundhedsstyrelsen, 2006).
In recent years, economical press in the health sector increased and does not stop
at the doors of the maternity wards. This has also serious consequences for the
work in midwifery. These consequences are discussed in the result section in
regard to the role of allocated resources.
In the following, some of the historically important developments of midwifery
in Denmark throughout the last 20-30 years are described. These latest
developments in the field and the planned developments in the near future are
those that have the greatest impact on the recent midwife generation. The job
conditions in the public sector are also dependent on political developments in
the Danish social welfare society. The following aspects of modern midwifery in
Denmark are described in order to give some insight into the outer conditions of
Danish midwifery today: (1) Midwifery as human service profession (2) From
pay per birth to regular monthly payment, challenges of becoming part of
public human service (3) Job description for midwives in Denmark (4) Midwife
education in modern Denmark (5) Working conditions of midwives in Denmark.
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The section closes with a summary of selected results of a survey amongst


active and passive members of the Danish Midwife Union
(Jordemoderforeningens medlemundersgelse, Resonans ApS, 2003).

3.4.1.1 Midwifery as a human service profession


Midwifery is a particular profession within human services. In reference to
Hasenfeld (1983), human service work is classified by their goal (people
processing, people sustaining, or people changing) as well as by the type of
people they serve (customers, clients, patients, students, etc.). It is a challenge to
classify midwifery according to this description. Midwifery is a little bit of all:
people are processed, sustained, and changed. Women giving birth are today
understood as clients but some midwives refer to them as customers.
Hasenfelds classification is not distinctive enough to describe human service in
midwifery. Another interesting approach pointing at the logic used to classify
jobs is outlined by Kaross & Spindler (1994, in Brucks, 1998, p. 19). It was
investigated if scientific categories of job classifications correspond to lay
categories classifying the jobs. They asked medical doctors to classify five job
groups in the human service sector in regard to different categories. The
similarities they found between job groups were not based on the reputation of
the job. Rather, a factor analysis showed that an inner relationship between the
jobs exists that is thought to be grounded on content and functional criteria. This
approach is regarded as interesting model of thought. Midwifery has, from the
perspective of the author, certain characteristics which can also be found in
other sectors, e.g. air traffic control. Although relationships are found between
different job groups, it is important to recognize that human service work is
characterized by specific demands. This is more than relevant today where the
human service sector is the growing sector of labour in modern society with at
the same time declining resources to pay for the services.

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3.4.1.2. From pay per birth to regular monthly payment


The greatest change of working conditions in midwifery in Denmark throughout
the last 30 years has been the change from free to public employment of
midwives. Until 1984, most midwives worked in private practice, being in
competition with other midwives in the same district. In 1984, the so-called
center organization with public employment of midwives was introduced.
Midwife centers are smaller or larger places where a group of midwife
cooperates in the service provided to pregnant and birthing women. The
midwives working in a center are public employees with regular pay. Today,
midwife centers are most often connected to a hospital and resemble other wards
in a hospital organization and have up to 30-40 midwives working together
(Larsen, in Cliff, 2002). One of the biggest challenges was a change in
perspective, not being competitors in helping to give birth any longer, but being
colleagues with the responsibility of working together and cooperating. Another
challenge related to the integration into public service was the change of the
financial situation of midwives. There was some fear that the financial situation
would change dramatically, because the midwives would change from pay per
birth to a regular monthly pay. This change had, in fact, negative consequences
for those midwives who had many births per year. Yet for many others it
brought a regular monthly payment, security for times of illness and absence
from work. Regarding work content, the center organization resulted in severe
changes of the organization of work. Until then, midwives always had had their
own pregnant women, consulting them through pregnancy and helping to give
birth when the time had come, independent of where (at the hospital or at home)
the woman in labour chose to give birth. With the organization of work in eighthour shifts, this was no longer possible. Suddenly, midwives could not finish the
work they had begun when the shift had ended. The holistic work experience
simply vanished with the center organisation in midwifery. Today only a
handful midwives work in private practice but with a growing tendency.

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3.4.1.3. Job description


The primary task of a midwife is defined as helping to give birth. This is the
case in any situation where the birth has started and is taking a normal course
without complications. A midwife can give her helping hand at home, in a
public hospital or a private clinic. Beyond that, a midwife is usually engaged in
consultation of pregnant women one day per week. She checks if the pregnancy
is taking a normal course, she does the preventive check ups during pregnancy,
and consults the pregnant women according to demand. Some midwives lead
group-consultations in the evenings. The midwife might also be responsible for
observation of a pregnant woman who is hospitalised because of health reasons.
Many of the midwives teach maternity classes in the evening as a supplement to
their regular job. After birth, the midwife can visit the new mother at home to
consult her about questions of breast-feeding, and child caring
(http://www.dadj.dk, 28.01.2004). This last aspect is not necessarily the recent
practice for midwives who work in hospital settings.
In 2002, 1,183 midwives are registered as active in Denmark (Statistic register
of the Ministry of Education, Denmark). Within midwifery, different job
categories and according to those different job types exist.
Table 3.2. Job classifications in midwifery in Denmark (extended on the basis of Dyhr, 1999)
Category

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

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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.

3.4.1.4. Midwife education and resources in modern Denmark


The education to become a midwife nowadays lasts three and a half years.
Theory and practice each take 50% of the educational time. The midwife
education is recognized as academic study, qualifying the students to do
research and quality development at the worksite. The new professional
bachelor degree enables the newly educated midwives to continue with further
education. After having finished their education, midwives can apply for jobs at
centers for midwifery, hospitals and at the midwife school. The conditions for
entrance to the education are commonly recognized as high. It is not uncommon
that those who are feel a call to become midwife but need to wait in order to get
in.
Resources in midwifery in Denmark always have been a problem. At the point
of organizing midwifery in midwife-centers, there were not enough midwives to
do the work. At the beginning of the 80s, birth rates went down dramatically so
that the number of places in midwife education had to be reduced to 40 per year.
Nonetheless, already in the 90s birth rates in Denmark went up and another
dramatic shortage of midwives was experienced. At the end of 2003, there were
50 positions vacant throughout the country, which resulted in a lot of overwork
for the remaining midwives. Therefore, the Danish ministry for education

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decided to create more places to educate midwives. Throughout the coming


years, 90 midwives per year will be educated in Denmark.

3.4.1.5 Working conditions of midwives in Denmark


Midwifery is a specific form of human service work, characterized by rather
unique work demands and job characteristics. Dyhr (1999) summarizes some
factors of the psychosocial work environment of midwives that might be
relevant for work related health and well being:
A midwife
usually works in shifts,
is regularly on 24 hour emergency call,
works always with acute cases,
works mostly alone,
works with people in a crisis, and
works in a field, in which a mistake can have serious or even fatal
consequences.
Interesting with midwifery is that the core work task can be understood as
universal. Yet at the same time there are cultural differences in this area of great
importance. There are many differences in the perception of pregnancy, birth,
and motherhood across different cultures. The role of and the way midwifery is
organized differ from one country to the other. The job of a midwife in Denmark
is characterized by low payment with at the same time high responsibility,
dreadful ergonomic positions, challenging work hours (weekend work, work at
times of holidays and vacation, work at night, working in short shifts with high
qualitative and quantitative demand), and a high threat of stress related illness,
e.g. burnout (Cliff, 2002).
Working conditions of the midwives in the present project can be described by
using the description of the psychosocial work environment of Dyhr above. The
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participating midwives work in a three-shift-schedule (day, evening, night). The


day shift lasts from 8.00 a.m. to 4.00.p.m.. Evening shift is from 4.00 p.m. to
12.00 p.m.. Night shift is accordingly from 12.00 p.m. to 8.00 a.m.. There are
three midwives in each shift, supported by two nurses. There is one medical
doctor responsible for each shift. All of them are present at shift change. Cases
are shared at the beginning of each shift, when the leaving shift reports about the
actual situation. The midwives work mostly alone with the women giving
labour. In cases of insecurity or emergency other midwives are asked for support
and professional help. The doctor is called in severe cases, e.g. sudden caesarean
section and critical situation of mother or child. Some of the midwives at the
ward work only day shift and evening shift. Others work only day shift being
assigned to special duties not serving the primary task any longer.

3.4.1.6 Organisation of maternity care, desires of women and obstetrical


figures
The organization of maternity care in Denmark is in my opinion best described
as being pragmatic. The Danish health care system gives women access to a
predetermined number of check-ups during pregnancy covered by the general
practitioner and a midwife working in the hospital (maternity center) that the
woman is assigned to give birth at. In case of complications during pregnancy, a
woman has access to special treatment (ultrasound scanning, check ups done by
a gynaecologist, acupuncture for pain relief, etc.). Pregnancy in Denmark is
handled as a healthy state as long as everything is without complications. Danish
midwives share the attitude of natural birth being the best option to vote for.
Nevertheless, with further development of modern technologies, there is a
growing tendency towards caesarean section, a good part of them being
caesarean sections on maternal request. The rate of caesarean sections went from
12,4% of all deliveries in 1991 to 19,5% in 2003 (Sundhedsstyrelsen, 2005).
Reasons for this growing number of caesarean sections have not yet been
investigated in depth, but indicate that mainly multiparae (women who have

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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.

3.4.1.7 Summary of member survey of the Danish Midwife Union


A recent questionnaire investigation amongst members of the Danish Midwife
Union (Jordemoderforeningens medlemsundersgelse, Resonans ApS, 2003)
gives interesting background information for the present case study. In the late
summer 2002, all active and passive members of the union were asked to answer
a questionnaire. The main question of the investigation was about how the union
should develop in the years to come. 1,142 members returned the questionnaire,
which corresponds to a return rate of 57% (71% active members, 43% passive
members, 44% students). Amongst other themes, 75% of the study participants
wish that working conditions (psychological as well as physiological) got a
higher recognition in the work of the union. Moreover, the participating
midwives stress the fact that work organization is especially a problem in larger
organizations. Especially the conditions of helping to give birth in a responsible
manner were named. The investigation was not focused on psychological

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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.

3.4.2 Participant observation


One of the core methods in qualitative research is observation. Lamnek (2005, p.
564) summarizes those poles of observation which differentiate the various
forms of observation as described in the Table 3.3.
Table 3.3. Types of observation (Lamnek, 2005; translated by A. Garleff)
Dimensions of
Differentiation
Scientific rigor

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.

German: Aneignung des dem beobachteten sozialen System angemessenen Sinnverstndnis.

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3.4.2.2 Procedure for participant observation


To offset the investigation and in between times, participant observation was
planned during one of three shifts (morning, day and night shift). The days were
chosen at random and were not communicated to the midwives on duty in
advance. The decision whom to follow during the whole shift was made at the
change of shifts. The three midwives being on duty during the shift decided
amongst themselves who the researcher should follow during the shift. One
midwife was followed for the whole course of a shift. Being the midwifes
shadow throughout the shift made a very smooth and silent observation possible,
where not much talking was afforded while running from one room to the
other. It was the most appropriate solution because it is very common that
midwives are so busy delivering babies that they disappear for a longer period
of time in the labour ward. Different from the original plan, the observation was
done during two different shifts instead of three. (1) During a day shift in
October 2002, 8.00 a.m. 4.00 p.m., and (2) during an evening shift in
November 2002, 4.00 p.m.-12.00 p.m.. Observations were documented in free
form in the logbook during the observation period and were complemented right
after returning from the observation. The rather unstructured observation was
meant to further unexpected insights and to expand the tacit and explicit
knowledge of the observer. A list with knowledge-based and experience-based
questions was formulated before starting the observation to be used as red thread
throughout the observation period.
Daily organization of work
How many shifts per day?
How many people per shift (midwives and other staff at the ward)?
Who does what (work roles)?
What kind of shared routines are there (e.g., meetings)?
Content of work
What particular tasks has a midwife?
Are there obvious work routines?
What kind of decision criteria can be observed?

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Climate at the ward


How do the midwives communicate with each other, with patients,
and with people from other job groups (both, personal and
professional)?
How can the overall climate/atmosphere at the ward be described?
The list of criteria above is understood as a list of observational categories,
helping to understand the work life of a midwife in this particular hospital.
Insights from observation are used as basis to get a better understanding of the
research field and in the sense of method triangulation. It is regarded as
necessary to have some insights into the research field in order to be able to ask
significant questions. In a second loop, observational insights are used to
validate insights from interviews. The single interviews constitute the core
method of investigating the relationship between motivation and burnout in
human service work. The subjective nature of in-depth interviews is
advantageous and challenging at the same time. By using insights from
observation as validation, subjective information is tested against a second
perspective onto the subject.
Reflection of participant observation in the present project
The way observation was done in the present study has the following limitations
and shortcomings: (1) Two points of observation do not give a complete picture
of the work situation of midwives. In regard to validation of insights of
outcomes from the single interviews, a second observation period could have
been helpful. This was not done because of organizational reasons. The
organizational structure of the ward was changed throughout the research
process and at the time the empirical phase came to an end, the process of
restructuring was still in a revolutionary phase. This revolutionary phase was
not regarded as particularly good point in time for observation of the regular
work flow in midwifery. (2) As described in the foregoing section, observation
was done by being the shadow of a single midwife. At the same time, it was not
planned beforehand whom to shadow, it happened by chance. Those being
present at the ward could volunteer to be shadowed. It should be noted that there

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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.

3.4.3 Qualitative research interview (single interviews)


The core method throughout the case study is a set of in-depth, single,
qualitative research interviews with approximately 10-12 midwives from the
particular ward. A stepwise procedure of gathering, transcribing and analyzing
information in regard to the research question gives the possibility of keeping
the amount of interviews to be conducted open. As cut-off point of when to stop,
the criterion of saturation of information and knowledge is formulated. In the
following, the purpose and procedure of the phase of single interviews is
described.

3.4.3.1 Purpose and methodological frame of the single interviews


The main purpose is to get a deeper understanding of the relationship between
motivation and burnout in human service work based upon subjective
interpretations of it. The acquisition of subjective definitions, cognitions,
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emotions and feelings, and interpretations about the relationship between


motivation and burnout is the focus throughout the interviews. Subjective,
personal wording and description of the field is highly desirable wanted. It is
assumed that the access to subjective understanding of the relationship between
motivation and burnout brings about new perspectives. The particular, everyday
understanding of scientific terms, which is determined by everyday experience,
belief, and feelings are of interest.
Understanding in the context of a
qualitative interview is established
through the process of professional
interviewing. The research interview is
different from a normal conversation of
one-sided interest. The researcher
approaches the interviewee in order to
get information about the research topic.
In fact, it is a rather uneven process,
where the researcher is in a powerful
position in relation to the interview
person (Kvale, 2002; Hauge, 2005). The

Box 3.3 Post-modern understanding


Post-modern thought can be traced
back to Kuhn (1970) and Feyerabend
(1976) who both questioned the modern
understanding of explaining the world
through systematic study (Gergen,
1992). Instead, truth is thought to be a
matter of perspective. In a post-modern
understanding the scientist is no longer
the superior knower but understood as
traveller negotiating meaning on the
way. Historical roots, cultural patterns,
preferred discourse, and situational
circumstances are accounted for in
post-modern inquiry. The ability of
critical self-reflection is essential for
the post-modern scholar.

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
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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

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of work group outcomes, focussing on change (e.g., making recommendations


of how to plan shifts).
15 midwives were pre-selected after the principles of purposeful sampling
(Denzin & Lincoln, 2000; Malterud, 2001). Purposeful sampling is done by preselecting settings, groups, and individual participants according to the most
relevant criteria for the case to be studied. All possible participants (every
midwife at the ward) of the interview investigation were asked to fill out a form
with demographical questions (age, marital
status, number of children, seniority,
education, and job position, see Appendix B).
Participants were selected according to the
greatest possible diversity in regard to their
demographical background, because it is
assumed that such participants can contribute
additional aspects to the research question.
Interviews are done in stages. After each
interview, the material is analysed before

Box 3.4 Saturation of meaning


Saturation is the criterion used to
decide when data acquisition has
reached a point of sufficiency in
the sense that no more
meaningful knowledge can be
added to the already gathered
material. Kvale (1994) mentions
the rule that interviewing can be
stopped at a point where further
interviews do not add new
insights.

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.

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Table 3.4. Age profile of midwives working at the ward


Age group in years

Number of midwives

25-30

31-35

36-40

11

41-45

46-50

12

51-55

56-60

61-65

Total of all age groups

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

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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.

3.4.3.3 Description of procedure


The interview itself is supposed to follow the natural flow of a dialogue. A
preformulated interview guide (see next page) is used as a guideline for asking
questions. Variations in order of questions in the course of a qualitative research
interview are natural (Kvale, 1994; Fog, 1994). It is regarded as important to
distinguish between research questions and interview questions, because a good
research question must not necessarily be a good interview question (Kvale,
1994).
A complete version of the interview guide (including introductory and closing
questions) can be found in Appendix C. The opening question is kept the same
in each interview. It is a warm-up question about the history of the personal
career development (beginning at the point of leaving school). It is thought of as
an introduction into the interview situation as such and is meant to be a good

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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

How are motivation and


burnout used in colloquial
language?

What do people say about


themselves when they are
burned out?

What does the word burnout mean to you?


Have you ever felt burned out? If yes, can you
describe the experience?

What motivates people to


go to work?
What motivates a person?
What is the source of
motivation and job
satisfaction?

If you think of an ordinary day, what motivates


you to go to work?
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?

How do people interpret the


various reasons for being
motivated or demotivated?

How would you describe a person who is


motivated/involved in his/her work?
How would you describe a person who is
burned out?

Do you remember a situation were you were


very motivated?
How would you describe the emotional
experience in that situation?
Do you remember a situation where you lost
you involvement in the work? Can you
describe the situation and your behaviour?
Exactly, what happened when you lost your
motivation?
How would you describe the emotional
experience in that situation?
Who/what helped you in that situation?

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3.4.3.4 Data processing


Interviews were recorded on a memory stick, a data device able to record sound
files and transform them into the computer. From these files, a research assistant
transcribed all interviews into full text. It was regarded as important to have
some personal continuity throughout the transcription process. The transcription
of the interviews was done after formulated rules for transcription (see
Appendix D).
For data analysis, the word document containing the full text of the interview
was transformed into rich text format and coded with NVivo (Bazeley &
Richards, 2000). NVivo is a data analysis program especially designed to code
data from qualitative research projects. It is based on the principles of grounded
theory (Glaser & Strauss, 1967) and is used in the present project as a help to
organize data in the logic of phenomenological data analysis (Giorgi, 1985;
Malterud, 1996; see description in Section 3.2.1). The program was used as
structuring help and managing system for interview data (transcribed text).
Reflection of the procedure of single research interviews
Altogether, the interviews went well and brought various insights about the
relationship between burnout and motivation in midwifery. Good contact
(rapport) with the interview partners was established. A trusting atmosphere was
established leading to openness in regard to the research question. In two
interviews, the author had the impression that job position (leader) and union
membership was responsible for a different perspective brought into the
dialogue about the relationship between motivation and burnout. This is not
understood as bias but rather as supplementing position. This observation makes
obvious that role membership seems to have an important impact on the
perspective to look upon the phenomena under investigation. All interviews had
an explicitly subjective perspective regarding experiences, meanings, feelings,
thoughts, and narratives were inquired about. The step-wise procedure of

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interviewing made reflection throughout the whole empirical process possible


and led to enriched data in the course of the interviews.

3.4.4 Group interview


The third and last empirical part of the project was the group interview. The
discussion during the group interview was recorded, transcribed, analysed, and
reflected according to the same phenomenological procedure used for the single
interviews. In Chapters 4-7, the results from the group interviews are used to
validate findings from the single interviews.

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.

Box 3.5 Member check


For member check data, analytic
categories, interpretations, and
conclusions are played back to the
stake holding group from whom the
data was collected. Member check is
seen as the most crucial technique to
establish credibility (Lincoln &
Guba, 1985). Member check is also
known as form of communicative
validation of the material (Steinke,
2000).

3.4.4.2. Description of procedure


All midwives at the ward were invited to take part in a group interview to
discuss and interpret the findings from the single interviews. Aim of the group
interview was to get affirmation or rejection of themes extracted from the single
interviews was meant to play a role in explaining the relationship between
motivation and burnout in midwifery. Further, new themes could be shared
reaching beyond the aspects already mentioned in the single interviews.

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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?

Is there anything above the following


attributes of an engaged midwife: being
professional, having an interest in ones own
development, being aware of other people,
having work spirit and sharing it with others,
that should be mentioned?

Resources and
safety

Can lacking resources


affect the involvement?
How is the process
described?

What happens emotionally when resources


are lacking?
When does lack of resources make you lose
your involvement?
What is a critical threat to safety

Emotional
demands and
feelings at work

What does a difficult


process mean emotionally
and in relation to your
involvement in the work?
Does emotional
responsibility mean
anything to the
development of burnout?
What is good and effective
coping in relation to
traumatic events?

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What role does emotional responsibility play


in relation to being involved in the work?
What happens when it all becomes too
much?
What is important after a difficult delivery?
What do you think helps the most?

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.

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Description of the sample


The interest in participating in a group discussion was disappointing. Eleven
midwives showed interest in participating in a group interview. Five midwives
could be scheduled on one of the two dates. Three of them had already
participated in a single interview, two others had not. All came with a personal
interest. The age range was between 41 and 51 years of age.
It is assumed that the low interest in participating in the group interview was due
to a restructuring at the ward at the time when the group discussion was
scheduled. Those who participated said that the motivation to participate was
low, because many midwives felt that they were not being taken seriously
enough throughout the re-structuring process at the ward and had given up being
involved in extracurricular activities. They described themselves as being too
tired to invest more time and effort into something not related to their daily
work.

3.4.5.4 Data analysis


The group interview was read and analysed line by line using the programme
NVivo. Interview parts were coded as free nodes. The third step of data analysis
(condensation into abstract meaning units) was done on paper. Unlike the single
interviews, the research questions formulated for the group interview were used
as a filter for analysis. Free nodes were checked for redundancy and usability to
answer the research question.
Reflection on the group interview
The goal of the group interview was fulfilled. Participants confirmed to a great
extent the observations and greater meaning units extracted from the single
interviews. The actual situation of organizational change (re-structuring of the
ward) made it a challenge to keep focus throughout the interview. The midwives
were thankful for a forum to exchange their opinions about these changes.
Motivation and burnout were discussed again on the background of this
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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.

3.5.1 Proximity to the object of study


An essential difference between quantitative and qualitative methodology is the
distance to the research participant. Qualitative methods are proximal methods,
investigating a phenomenon in the natural setting. The aim is a relative high
proximity to the object of study; here a midwife at work, fulfilling her primary
task. It is taken into account that controllability in the natural setting is rather
low. Instead, it is important to establish trustworthiness (Law et al., 1998) in
order to ensure better quality of the study findings.
In the present case investigation, proximity to the subject matter was realized
through participant observation at the ward as well as in-depth interviews with
both single midwives and a group of midwives. The proximity was furthered
through an open interview format, letting the midwives guide the conversation
within the framework given by the author. In regard to establishing
trustworthiness, this is valued as essential and important. In fact, one of the

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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

codified methods in order to make the methodological choice more transparent


and comparable to other investigations.
In the present case study, different approaches to achieve reflexivity are chosen.
First of all, the authors fore-understanding was reflected on before entering the
field and at different points in the process using a personal logbook. The
logbook serves both as a diary where personal experience and unexpected issues
are documented as well as in the real sense of a logbook, which is to document
any step throughout the research process.
Metapositions were established through discussion of study outcomes in three
different research settings 6 as well as in collegial exchange 7.

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.

135

in stages, starting with observation and followed by single interviews, which


were member checked in a group interview as a last step.
Triangulation of perspectives onto the research field was reached through
discussion with colleagues, continuous literature work, and finally through
writing. These different modes of reflection forced the author to adjust the frame
of the present project at different points. Both forms of triangulation are meant
to lead to a higher credibility of outcomes from the case study.

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

136

to use purposeful or theoretical sampling. By taking this path, it is possible to


further transferability.
In the present study, one case (a maternity ward of a community hospital on
Zealand, Denmark) was investigated in depth, using various methodological
approaches. The results gathered by investigating the described case can be
transferred to midwifery in general. In a personal conversation with a German
midwife, it became clear to the author to what degree outcomes of the present
case study are relevant for midwives with a culturally different background.
Parts of the results are bound in context and as such specific, e.g. structure of the
ward as a midwife center, role of the midwife (differences between countries).
Other outcomes, e.g. primary task, demands from modern parents, security and
uncontrollability and the role of traumatic birth incidences, can be transferred to
other groups of midwives. The procedure of purposeful sampling led to
heterogeneity within the group of participants. Nevertheless, the investigated
group showed a small range of biological and job age. Altogether, transferability
is valued as being high for all of the findings of the case study.

137

Part II: Introduction of the result chapters (4-7)


The aim of the present case study investigating the research question of How to
understand the relationship between motivation and burnout in human service
work - midwifery as case was (1) to reach an understanding of the high score of
burnout amongst midwives in the PUMA study, and (2) to gain insights into the
relationship between motivation and burnout in midwifery in Denmark.
The pre-structured but open format of the interviews led to a web of knowledge
spun around the research question. The explorative approach yielded valuable
insights into the relationship between motivation and burnout in midwifery. In
the course of data analysis using the phenomenological method as described in
Chapter 3 different themes emerged. The following four chapters cover the
presentation of findings referring to these themes. The information gathered
stays foremost on a descriptive level. Original citations from the interviews are
used to illustrate the insights found throughout the interviews. For better
legibility the original citations were translated into English by two Danish
colleagues and double checked by the author of this thesis.
Four different themes represent the main findings from the single interviews and
the group interview and are regarded as being of peculiar interest for
understanding the relationship between motivation and burnout in human
service work. The findings are separately outlined in the following four chapters
(Chapters 4-7) of the result section. Chapter 4 summarizes the subjective
definitions of motivation and burnout in midwifery in order to set up the frame
of how the concepts of motivation and burnout and their relationship are
understood by the participating midwives. In chapter 5 person-related and workrelated factors named by the participating midwives as being important for the
relationship between motivation and burnout are summarized. Chapter 6
discusses the role of resources in an insecure setting. The discussion about
resources was given particular emphasis from the participating midwives side.
138

Finally, chapter 7 is outlining the reflections of the participating midwives about


the role of emotional demands and feelings in midwifery. An integration of
these findings with pre-existing knowledge and theory referred to as explicated
fore-understanding of the author (see Chapter 2) follows in Chapter 8.

139

Chapter 4: Engagement and burnout in midwifery

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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introduced at the ward. The introduction of the electronic journal was


accompanied with a number of problems such as computer systems that did not
run which led to some frustration among the midwives. Following along with
these structural changes, the ward was affected by some serious long term
sickness absences. Altogether the work morale at the time the baseline
investigation took place was rather low.
As another aspect, bad working conditions were named which were made
responsible for the high burnout score.
Interview 1: 38 years old, 14 years work experience as midwife
Well, I think the same. I believe I think the same. But it does not surprise me. It
does not surprise me. This is of course because I do the job every day and I
think it is an unbelievably demanding job for unbelievably low pay under
unbelievably bad working conditions.
Interview 3: 43 years old, 6 years work experience as midwife
And then I thought it was a shame if many people thought it was a phenomenon
in our field. But then I turned it around and said that it is a trade where you give
much. You give yourself all the time. You can not come to work and say you
have a bad day.
Interview 8: 50 years old, 24 years work experience as midwife
But I think the PUMA report must be published as we have some managerial
problems.

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.

The reaction of this particular midwife can be interpreted as methodological


critique from a lay perspective. From her understanding of the cause, the
questions asked in PUMA and the interpretation drawn from these questions do
not stand in any relation to each other. She also points out the fact that all the
positive aspects of job engagement and motivation to do the hard work of a
midwife are not shown in the PUMA study.

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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 devastating outcome of PUMA was discussed in the media. In this


discussion, midwives were accused of being self-centred in the sense of
following a job ideology which is not beneficial for the ones giving birth. The
public reputation of midwives emerged as having a negative connotation. From
the midwives perspective, this discussion was experienced as not fair and also
unexpected. Such a picture stands in deep contrast to the common vision of ideal
practice (Hunter, 2005) shared by the midwives themselves.
Two comments referred to the activities and initiatives started after the PUMA
baseline study to improve the situation. There was, for example, an externally
moderated meeting with all midwives to discuss the implications of the PUMA
investigation. Workgroups were established to make plans for improvement, e.g.
the shift planning.
Interview 6: 58 years old, 33 years work experience as midwife
We have the results and we have discussed them, right. But we have also held
many meetings about the psychological work environment, what we can do
better etc. And . no , it has not become better.
Interview 8: 50 years old, 24 years work experience as midwife
We have spent so much money on this PUMA project and got no results.

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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4.3. Subjective descriptions of burnout


Participants were asked about their personal understanding and meaning of
burnout and if they could report any personal experience of burnout. The
participants, describing states of physical, emotional and behavioural
indisposition, use the expression burnout in a rather broad sense. Most of the
descriptions refer to examples of everyday behaviour, like complaining a lot,
choosing the easy work tasks, and being slow in reacting to clients needs.
Burnout is often used as everyday description of being fed up. There are
hardly any descriptions about own experiences with burnout which might be
interpreted as a sign for either high social desirability or a healthy worker effect
again. It is plausible that those midwives committed to take part in an interview
are not at the edge to burnout but alert about and interested in it.
In the following three sections, the results of the responses to subjective
understanding of burnout are structured along the following themes found in the
interviews: work related burnout, emotions related to burnout, and behavioural
aspects of burnout.

4.3.1 Work-related burnout


Work-related burnout is understood as burnout caused by the work related
conditions as for example high demands and low resources. Work-related
burnout is referred to when an imbalance occurs between resources, work
demands, reward and responsibility.
Interview 4: 45 years old, 20 years work experience as midwife
That it what makes the work so great, you cant get it any better. We work too
many hours, the wage is poor, our families suffer but it is still a great job. I think
it is these three things which are the reasons for the negative evaluation. You
slog away; you totally involve yourself every day, 8 hours, 10 hours, 24 hours
per day. You work Christmas Eve, you work during the Easter holiday and you
work during the summer holiday. Maybe you have two weeks holiday with your
children even though they have 8 weeks and you get lousy pay. Many of the
young midwives wont put up with it. They find other jobs.

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Interview 5: 49 years old, 8 years work experience as midwife


If you ask me. No Im not burned out, but I know the reason why. Working 8
hours per day and getting a good nights sleep are extremely important. I
remember how it was to be on a night shift. Just the thought of it makes me sick,
really.

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).

Recognition from the leadership is expressed as being important. The


responsibility of the leaders is seen in taking care of the problems and daily
hassles of the job. In the case of missing care for the personnel, burnout is
named as possible outcome. Reward is referred to as financial reward; as getting
adequate pay for the responsibility taken when doing the core job. The
participating midwives experience an imbalance between their own effort put
into fulfilling the task and the reward they get out of it.
Reward and recognition, resources, job demands, and responsibility are
understood as being connected with each other. Keeping equilibrium between

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them is regarded as important for staying motivated while doing the demanding
job of a midwife.

4.3.2 Emotions related to burnout


In the following section, emotions which are related to burnout are described by
the participating midwives: loss of work spirit, loss of volitional control over
emotions, and fear as reaction to traumatic birth incidences.
Interview 6: 58 years old, 33 years work experience as midwife
But if you have trouble getting dressed and going to work, meeting your
colleagues, meeting the women you assisted during delivery the day before, then
you are burned out. When you dont feel like going to work.
Interview 1: 38 years old, 13 years work experience as midwife
Maybe you have lost interest in providing service, which in this case, is helping
women during delivery.

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.

In regard to volitional control over emotions, overly high emotional sensitivity


and instability is described as signs of burnout. When the borderline to
emotional overcharge is lower than it used to be and emotional expressions
(especially tears) are no longer under control, emotional burnout is seen by the
midwives to be close at hand. Being able to react to job demands flexibly is
described as declining alongside diminishing job stress tolerance because of
ebbing resources. As soon as a state of overstrain is reached, extra demands
cannot be accomplished as they once had been before.
Losing the control over ones own emotionality is seen as a sign of weakness. It
is not seen as normal to break down because the work situation is busy. The
usual readiness to go on with the work that needs to be done first is described as
having disappeared. The ability to handle a busy job situation has changed into a
more restricted behaviour pattern, which is no longer flexible.
A last aspect described which might be a reason for emotional burnout is the
inevitable condition of being confronted with uncontrollable exposure to
traumatic incidences.
Interview 7: 48 years old, 12 years work experience as midwife to the question
of reactions to traumatic incidences
And I can see that some of my colleagues are tired out because of such
processes where they have really been there and felt so sorry afterwards that
they have reported sick. It is difficult to get on with other deliveries, being
scared. Clearly afraid that it could happen again and what could then happen.

An emotionally demanding job situation is described as being a possible reason


for absence from work. Not being able to cope with the emotionally straining
situation is thought to lead to job related fear and further to the inability to carry
out the primary task. Fear is described as the emotion related to traumatic
incidences which could not be handled in a different way.

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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.

4.3.3 Behavioural aspects of burnout


As mentioned above, burnout is used as a broad reference category for different
descriptions of work behaviour. Low client service, risk avoidance, and constant
complaints are referred to by the midwives as behavioural aspects of burnout.
Interview 1: 38 years old, 14 years work experience as midwife
I was tired and not very easy to get on with. Yes, you are not really easy to get
on with, neither the one place nor the other. And you also partly lose your
feeling of responsibility to be part of a greater system, and that things shall work
together, dont you?!

you distance yourself from everything and you dont care to participate.

you serve on a minimal level.

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.

In the citation above, risk avoidance behaviour as sign of burnout is described.


Colleagues, who show signs of burnout, are described as having the tendency to
avoid any risk related to the core job. They always choose the easy tasks. At any
possible time, excuses are found for not being able to take one of the more
complicated cases. Another similar behaviour is the tendency to close the door
to the delivery room and stay there no matter how busy everybody else at the
ward is. Colleagues who behave like that are not much appreciated at the ward.
The strong focus on the self describes the opposite of one reported aspect of
engagement: the care for others (see Section 4.4.3).
The following citation refers to constant complaints as sign for burnout.
Interview 3: 43 years old, 6 years work experience as midwife
I would say that it is a colleague who comes in and is a bit sad and isnt
motivated, and while we sit and patients are handed over at shift change, so it is
her to always complain about how exhausted she is. Some complain more than
others. Some always complain. There are always some who complain. Then
there is something wrong with the planning of who is on duty, and then they
havent done enough to please us. Do you know the type, who must complain all
the time?

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Further, constant complaints were named as another behavioural sign of


burnout. Colleagues contaminating the atmosphere by complaining about
everything and everybody without taking the initiative to change things are
experienced as irritating by the remaining midwives. Colleagues who constantly
complain build a negative atmosphere and this kind of behaviour is experienced
as being destructive for a good and equal relationship.
An exaggerated feeling of responsibility is described as cause for burnout. Here
it is assumed that a person who is overly committed at work will end up in an
overly exaggerated work behaviour which later will end in a feeling of
exhaustion.
Interview 2: 46 years old, 20 years work experience as midwife
My experience is that those who break down easily are often those who feel a
high degree of responsibility. They take on more than they should. They
sometimes take on the responsibility for what others have done in the delivery
room. Like if I had done something different my colleagues would also have
done it differently. It is the colleagues with the highest sense of responsibility
who break down.

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.

Further, the participating midwives discussed work behaviour described as only


taking the easy things. Colleagues who do not take on their share at the ward
are not accepted. As soon as a client has to bear the negative consequences of a
midwife not being engaged enough to do her job in a responsible manner, the
remaining group expresses displeasure about that kind of behaviour.
4.4 Subjective descriptions of engagement at work
Participants in the present case study were first asked to describe a colleague
who is highly engaged. Second, they were asked to describe a job situation
where they remember having been engaged in a particular way. At this point it is
interesting to note when participants refer to being engaged in the job, they refer
to engagement which is not related to the primary task but to activities to
organize work (e.g. union activities, education of young colleagues). The
descriptions of work-related engagement are summarized in a triad of:
professional self, work spirit, and care for others.

4.4.1 Professional self as sign of engagement


The first aspect of engagement, called professional self, describes the
professional knowledge and the professional role a person brings to the field and

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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.

She is interested in all kinds of developmental activities in order to learn more


about best practice in the job. She invests time and effort into extracurricular
activities in order to stay updated in her profession. An engaged midwife is
described as proactive in seeking new information.

4.4.2 Work spirit as a sign of engagement


Work spirit is the second aspect named as part of a persons engagement. Work
spirit refers to the climate experienced which is created by a person.
Interview 5: 49 years old, 8 years work experience as midwife
She is positive, she is dynamic and she radiates energy. She never complains
(laughs). Well yes, she can do that. No, well it depends. No she never
complains, she gives constructive criticism and a lot of criticism but it is
different from complaining.

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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.

4.4.3 Care for others and ones self as a sign of engagement


The third aspect of engagement relates to proactive work behaviour and a form
of intrinsic motivation. The descriptions of an engaged person in regard to
especially this aspect are read as painting an ideal picture of a colleague.
Interview 9: 44 years old, 18 years work experience as midwife
But engaged in a way which means to be happy also; so you do something for
the good fellowship. At 4 am you say we need a quarters break, make some
coffee or tea and toast so we can relax. Then you get new energy to think about
other people.

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.

She is service-minded and client-oriented in her work, which can be noticed in


her quick, calm and patient reaction towards clients. Last but not least, she is
seen as one who brings her things to a close. Nothing is left to others to clean up
after her. In summary, a midwife who is engaged is sensitive to the needs of
others and herself.
Interview 8: 50 years old, 24 years work experience as midwife
She is not the one to remain seated for the report. She is the one who says: shell
take that one and who will you take. She is very aware of the woman in labour.
She doesnt necessarily spend all her time in the delivery room as such a
colleague who closes the door and only cares for the woman while the rest of us
run around - can be a problem. It is a person who finds the golden middle, who
helps you with the paper work, replaces you if you havent had time for lunch or
asks if she should fill in if you have a woman in labour to be with.

Further, an engaged midwife is described as being fast, standing up from the


chair when a client is at the door. The opposite behaviour not getting off the
chair - was addressed when describing a person with signs of burnout. The
immediacy of reaction to client demands is reflected as a sign of engagement
and the absence of it as sign of burnout. In relation to the aspect of to what
extent a person is service-minded; burnout and engagement are described by the
midwives to be the ends of the same continuum. In the case of burnout, servicemindedness is meant to be secondary to self-centred focus of attention (e.g.
complaining about low resources, only caring about the most necessary things).
The person being burned out is busy with dealing with the condition of being in
a bad mood and has not much energy left to take care for others. Engagement,
on the other end of the continuum, is described as the immediate reaction to
client demands.
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In the group interview, the aspect of professional self was mentioned in


particular:
Group interview, IP 2
A midwife is not engaged unless she enjoys working with childbirths. So it lies
implicitly in her job that her engagement is the primary thing in the job. It is
obvious that the clients are welcome and nice to work with and of course she
enjoys working with them if she is engaged in her job. The first to feel if she is
engaged is the customer. If she is not engaged, then she cant work with
childbirths. She cant do the work if she doesnt enjoy being with people in the
delivery room. It is the prospect of a successful delivery that motivates her. To
use some talents and get a good result.

Engagement was defined as a necessary precondition of the profession. Without


being engaged it would not be possible to bear the hassles of the job and be a
good help to the pregnant women throughout giving birth. The citation from the
group interview, above, is a good example of the understanding midwives have
of their defining engagement as an external demand in order to be able to fulfil
the job sufficiently. In the context of the present project, engagement is also
defined as part of the professional work ethic of this particular job group. The
core task of helping to give birth is described as the source of being engaged.
From a midwifes perspective, the invariable conditions of the work are seen as
part of the core job and experienced as a positive challenge and are seen as
reasons for burnout at the same time. How these two aspects are seen to be
related to each other is discussed in the next section.
4.5 The relationship between engagement and burnout
In this last section of the chapter, the question of at what point engagement at
work is lost is reflected on the background of selected statements from both the
single interviews and the group interview. In the single interviews, the
participants were asked about incidents and experiences of losing engagement at
work. Out of the many comments on this question, two longer statements have
been selected. These two statements illustrate in a comprehensive way the
variety of reasons which purportedly cause declining engagement and support
the development of burnout. The statements are regarded as being representative

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of how the relationship between engagement and burnout is interpreted by the


participating midwives.
Interview 2: 46 years old, 20 years work experience as midwife
. It could be something job-related that makes you lose the motivation. But it
can also be personal. It could be something at home. We have seen colleagues in
menopause, where the body changes, become a different person from what she
usually is. The children leave home and what you usually lived and breathed for
is suddenly gone. That also means something when you go to work. Too much
and too hard work for some time; the fact that the clients have different
characters. When I became a midwife everybody thought that I was only there
for their good. That is not how the clients are today. I can enter a delivery room
and the clients shows distrust even before I have said hello. If I meet many such
clients I feel unsure of myself, what is it I do that make them feel I dont want
their good when I enter the room. If you are used to be the one who takes on
everything, even the most difficult things, and then have had too many difficult
things for a time then you can feel drained of energy. Then we must be aware of
it and give such a person some of the easy tasks. You should have maternity
rooms where things go easily and where people remember that you are there for
doing something good. You must not compare your working life with the
women who scream or women who have a bad birth experience or those who
always end in something problematic as it has been a difficult process. It has
nothing to do with me entering the maternity room. It has something to do with
me choosing them, things which are difficult and that I think I can usually
handle it so why not today. But that makes it hard.

In the foregoing interview statement, different reasons for burnout and


diminishing engagement are named: job related, client related and person related
(private) reasons. Declining engagement is described as losing the pleasure of
doing the work of a midwife. Main theme in the interview quote above is the
relation between engagement at work and quality of client contact. The
participating midwives not only differentiated between easy and hard birth
processes but also easy and hard clients. Complicated and unrighteous client
behaviour is regarded as a reason for losing engagement to do the work of a
midwife. The combination of high work demands and missing reward from the
client and her family is thought as destructive for the feeling of being engaged.
A good contact between client and midwife is regarded as important. The degree
of trust and security a client has and feels in the relationship to her midwife is
thought to give energy back to the midwife to do her job in a balanced way. If

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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

A leading theme throughout the second comment about losing engagement to do


the job is the feeling of being let down by the management. The feeling of being
let down is experienced in regard to very different aspects of the job, reaching
from help with the physical demanding job situation, to individual solutions
regarding shift planning, to professional help with the coping with traumatic
birth experiences. It is assumed that it is the incident as such combined with the
missing support from leadership that causes a loss in job engagement. Especially
the handling of traumatic incidences, causing stress and feelings of guilt on the
midwifes side is named as one example for need of support from leadership in
the form of an institutionalized support system.
Further the aspect of taking on (shouldering something) as midwife is named as
a critical factor by the participating midwives. This aspect is named in the
following statement as being responsible for the sudden turn of well-being at
work:
Interview 2: 46 years old, 20 years work experience as midwife
Something happens with midwives. Midwives are generally good at coping with
many things. We receive live-born as well as stillborn children and many of us
think that we must cope with it all alone. And suddenly you break down and end
up being on long-term sick leave. As I see it, you havent been good at taking
care of yourself, or too good at handling too much.

Part of the professional understanding of a midwife is the demand towards ones


self to be able to take on and on, no matter how hard the situation has been. This
demand can hinder a healthy appreciation of ones self, borders, and limitations.
Engagement, formerly regarded as a positive work attitude and behaviour, turns
into having a negative impact. The presumed positive effect turns into a serious
impairment of health and well-being of the helping midwife.

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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.

It was discussed that engagement is maintained by doing a good and successful


job at fulfilling the core task, helping to give birth. A birth of a child reestablishes the broken belief of doing something important.
4.6 Summary of findings on engagement and burnout in midwifery
In the foregoing chapter, four different fields of findings from the single
interviews and the group interview were presented. First, reactions to the results
from the PUMA baseline study were investigated. The variety of reactions was
broad. One group of midwives expressed undivided understanding and
supported the outcome of the PUMA baseline study with their own estimations
about burnout relevant aspects in midwifery. They named a variety of reasons
for the high level of burnout in midwifery, reaching from low reward and
recognition from clients and leaders to emotional demand to ergonomically
challenging job conditions. Another group of midwives expressed astonishment
about the results and gave explanations how this high burnout score came about,
e.g., the PUMA baseline investigation took place at the same time as major
organizational change, the implementation of the electronic journal. One
midwife simply stated her disbelief in the results of the PUMA investigation.
For her, the high burnout score came about because the questions asked hit some
important points in midwifery but should not be interpreted as burnout. It can be
concluded that comprehension of the results from PUMA is far from being
unequivocal.

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In order to investigate the relationship between motivation and burnout, the


participants were asked to describe their understanding of each of these
phenomena. With regard to burnout, three main themes were found: workrelated burnout, emotions related to burnout and behavioural aspects of burnout.
Work-related burnout is referred to when outer conditions of the job were felt to
be the reasons for the development of burnout. The aspects named by the
participating midwives refer to established categories of work psychological
research. High job demands paired with low reward and low recognition and at
the same time low resources are thought to cause burnout. The positive energy
connected with the primary task is spoiled by bad working conditions.
Moreover, an imbalance is felt between the individual effort put into the
fulfilment of the primary task and the reward gotten out of it.
As emotions related to burnout, the following three were named: a feeling of
being dispirited and having lost the core drive to carry out the primary task, high
emotional sensitivity and instability leading to uncontrollable emotional
outbreaks (especially tears), and fear as reaction to emotionally demanding
situations (e.g., traumatic birth incidences). A feeling of being dispirited is,
according to the midwives, seen in a low energy to serve clients. A consequence
described in the context of losing control over ones own emotional expression
is a lower flexibility to react to high work demands and a higher rigidity in
holding on to single tasks. Not being able to cope with the emotionally straining
situation such as traumatic birth incidences is thought to lead to job-related fear
and further, to the inability to carry out the primary task. As such, emotions
related to burnout are described as having far reaching consequences for the
fulfilment of the primary task.
As behavioural signs for burnout, low client service, risk avoidance, constant
complaints, and an exaggerated feeling of responsibility are named. The
described signs of behavioural burnout give expression for the loss of readiness
to carry out the primary task, which is understood as the core drive in
midwifery. Low client service is described as finding expression in being tired,
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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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mentioned in particular. Furthermore engagement was defined as the necessary


precondition to do the job.
The last and fourth area discussed in this chapter summarizes the comments
made by the participating midwives about the relationship between engagement
and burnout. The way the participating midwives interpret it incorporates many
of the other findings of the subjective description of the single phenomena. Jobrelated, client-related and person-related aspects are named as possible reasons
for declining engagement. Midwifery is described as a highly demanding job in
terms of work time, responsibility, clients demands, physical demands with at
the same time low reward and low recognition from the management. It is
assumed that facing a traumatic incident combined with missing support from
leadership can lead to loss of engagement and even burnout. Further, midwifery
is described as a field of work which incorporates many of the commonly
known disadvantageous working conditions (e.g., high demand, low control,
high effort, low reward etc.). Being overcommitted in terms of responsibility
and demand towards ones self and the exposure to too many negative birth
experiences with a low recognition of ones own limitations and borders are
named as further reasons for losing engagement and being on the route to
burnout. In contrast, positive birth experiences where everything goes well are
described as highly rewarding situations. These positive experiences are seen as
being the motor for the midwives engagement. The acute and significant nature
of the primary task is described as being specific for this field of work.

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Chapter 5: Person-related and work-related factors

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.

5.2.1 Biological age


All midwives who volunteered to take part in the single interview part of the
study are above 35 years of age. This is a reflection of the general age profile at
the ward and in Danish midwifery in general (Danmarks Statistik, Indenrigs- og
Socialministeriet, 2002) with a peak in the middle age group (35-45 years). 44
out of 49 midwives employed at the ward are 35 years old and above (see Table
3.5). For those who are 35 years old and above, the number of years on the job is
at least eight years. The group of midwives investigated in this case study can be
described as experienced.
One midwife described differences between younger and older midwives in
regard to recovery time and special needs for different age groups (e.g., seniority
agreements).

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Interview 7: 48 years old, 12 years work experience.


It is primarily the older midwives who have a problem embracing the situation. I
can feel that the younger midwives can embrace it more. The busy shifts
become tough on you and it takes more time to recover.

The participating midwives described biological age as being important in


regard to recovering from demanding shifts. Higher age is seen as being
responsible for a longer recovery time after work-related stress (e.g. very busy
shift). Also ergonomically challenging positions leading to backaches and
problems of body posture over time (with higher job age) were mentioned in the
interviews.
Interview 8: 50 years old, 24 years work experience.
We have no seniority agreements have no . As they go into labour at night
and that is their right. We cant make such an arrangement as if you make senior
arrangements a group of other midwives must cover the extra night shifts and
the extra 24-hour shifts. They will then burn out much earlier. Midwives who
are 30 today and have the energy also have children, and they will also burnout
at the age of 50, right. It is a vicious circle. We should have more work which
includes fewer night shifts, among other things.

There are no seniority agreements at this ward. Such agreements would be


difficult to realize because of the rather homogenous age profile of midwives at
the ward. Biological age, job demands, and age-related stresses (e.g. having
small children at home, longer recovery time for older midwives) are described
as problems that are not easy to solve.
Interview 8: 50 years old, 24 years work experience.
Yes, it can set you into a state of worrying, that you do it good enough, it is a
high responsibility you face; and I could see some of us, maybe it was like that
. There is not only one example, I have this particular example now, but I
have also seen this before, that this insecurity comes at last. I have experienced
this a lot during the eighties and at the beginning of the nineties where we really
developed the monitoring of the unborn child. The step from working with the
wooden pipe (Danish: trrr) to the electronic monitoring, it such things, you
know. At the point you have a certain age, it gets back on you; thereafter you
have to say to yourself: I may find out about this also. It was the same thing
when we implemented the electronic patient journal. There we could see many
different types; we had two who took their hat because of the electronic journal.

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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.

5.2.2 Generation membership


The participating midwives described a change in work attitudes and
expectations between different generations of midwives. There seems to be an
older generation of midwives who got their education 20 or more years ago
and a younger generation of midwives who were educated more recently.
Interview 2: 46 years old, 20 years work experience as midwife
They are different than those who come now. They want something different.
They will not work fulltime. They find out that the wage is too low compared to
what want to be offered. It doesnt add up and they want to be rewarded in
another way. I feel that Im rewarded by all the happy pregnant women I have
met and the joy I have seen, but also by the families who come back and say
they are expecting their fourth child and then ask me if I will help them again.
That is an experience they will be without when they come to such an enormous
hospital like this. They never become a part of their I work in my
immediate environment. They see me on the street and the children say hello.
They will not experience that as they are not in the system long enough as I have
been.

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.

The younger generation (understood as more recently educated) is more used to


working in teams and is actually looking for possibilities to do so. Working in
teams is valued as positive, because of the aspect of learning and widening of
horizon. For the older generation of midwives, teamwork is often experienced as
challenging and threatening. To share knowledge and let somebody else take a
look at ones professional self is experienced as risky.
According to one midwife, the focus of education seems to have shifted
somewhat between the different generations of midwives.
Interview 8: 50 years old, 24 years work experience.
I think that midwives who have ended their education recently and it is clear
among our midwife students . I wont say that the basic studies programme
is different but they concentrate on other things. They are good at researching

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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.

5.3 Structure of working time


One core issue in the single interviews was the structure of working time. Work
time issues are a constant point of discussion even though the outer conditions
of the primary task, which lead to these work time demands, are accepted as
given. Different facets of work time are discussed: working shifts and shift
planning, night work, part time work, the balance between work, family, and
personal time, and job routine.

5.3.1 Working in shifts and shift planning


Due to the nature of giving birth, midwives need to be available at all times. For
most midwives, this means that their work is organized in a rotating shift work
system including day, evening, and night shifts. Under certain conditions,
however, for example health impairments or other personal reason (e.g. family
demands), midwives can be assigned to day work (day- and evening-shifts)
only. Three of the participating midwives had such specific job assignments and
work a normal eight hour day work schedule. Another three complained
particularly about work at night and the related strain. The weekly change of
schedule was not mentioned as either a positive or negative aspect of the job.
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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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Interview 5: 49 years old, 8 years work experience as midwife


But we can try to make smaller units. We have talked about it. Smaller units
where we have influence on how the shifts are planned. I think it is right that the
feeling of having no influence leads to burnout. I really think that.

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.

5.3.2 Work at night


Among the different shifts most midwives have to cover, working at night is by
far the most demanding. Work at night is described as being different in regard
to the quality of service given to a client. In midwifery, the demands from
clients being in labour during the day and at night are not different from each
other. Children are born 24 hours a day and the same service a midwife gives to
a client at daytime ought to be given to a woman in labour at night.
Nevertheless, the participating midwives describe a difference in service they
are able to give at day and at night. They are very frank and at the same time
uncomfortable about their inability to serve during the night. They state that
there is a difference in service readiness between night and day shift. At the
same time, there is agreement about the necessity to cover the hours during the
night, because childbirth cannot and should not be planned according to the
working hours at the ward.
Interview 1: 38 years old, 14 years work experience as midwife
I have to admit I am not good at working at night. I cannot at all provide the
same quality of service as during the day.

I am simply too tired. I dont function well.


Interview 3: 43 years old, 6 years work experience as midwife
Sometimes I think about what the women in labour well you are
different, Im another person when Im on night shift than if I have a day shift.
But they dont know. Then they would have to come a second time and see that
there is a difference (laughs)
Interview 7: 48 years old, 12 years work experience as midwife
Sitting in a delivery room makes me very sleepy and I have trouble not falling
asleep. Sometimes I dont dare to sit down as Im afraid of falling asleep. And I
dont think Im being nice, Im not as patient as I usually am in the daytime. A
midwife must be patient and Im not at five oclock in the morning, then Im not
patient anymore. I feel that Im not good enough and I feel that Im not a good
midwife during the last hours of a night shift. Im really not.

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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.

The consultation days (consulting women during pregnancy) are described as


time to relax from the primary task of serving when helping to give birth.
Unforeseeability, uncontrollability, and time pressure being present during a
regular work day at the ward are not present when consulting pregnant woman.
Instead, consulting days can be described as structured, planned ahead, and with

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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).

5.3.3 Part time work


About one third of the midwives in this ward work part time. For some
midwives, part time work is regarded as the only solution to be able to
coordinate a family, a home and the demanding job of a midwife. In their view,
working part time gives some extra flexibility to recover between shifts. This is
time which is not available as a full-time midwife.
Interview 1: 38 years old, 14 years work experience as midwife
No. I believe that I instead would My working hours have been reduced since
I took this job. And maybe I want to work half-time later on. I believe that a
half-time job which includes shift work means that you are not very much away
from home and you have better time to recover between duties thus allowing
you to spend more time with your family. To work full-time as a midwife would
be impossible for me. I have never worked as a full-time midwife but only
been employed 32 hours per week.
Interview 7: 48 years old, 12 years work experience.
I worked full time the first years, but it was tough. It was very tough as you have
a tight schedule.

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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shortage of full time workers. One participant mentioned a feeling of injustice


because part time work is used to cover the uncomfortable shifts. In doing so,
the advantage of part time work fades away. Short work weeks stand in
competition with inconvenient working hours, often to the disadvantage of the
part time worker.

5.3.4 Work-family balance


Interview 2: 46 years old, 20 years work experience as midwife
When I applied for the job, my family was quite happy about it as it was nice
that I was home all the time. That is how they see it if you are home at dinner
time and when you tuck them in and so on. Then you are always home if you ask
a child. After some years, I had to find out if I wanted to stay in this job. We
talked about it at home . It was only our youngest who lived at home, he
turned 15 . And I went home and talked with him . He must have been
about 12 years old. I told him I could go back to the shifts as I think I am more at
work in this function than in the other I had before. Then he asked if I had to
work in the evening and on weekends. And yes that would be the consequence of
that, but there would then be other positive things about it. He and my husband
then said it would be nice if I could work day-time.

The foregoing interview quote illustrates the consequences of shift work at a


maternity ward from the perspective of a midwife with special duties, working
day shift only. The statement is an illustration of the ambivalence behind the
effect that working hours have on work-family-balance in midwifery. For the
family, the day shift is experienced as a tremendous relief. Even if the mother
actually spends less day time at home, the perception is that the mother is
spending much more time at home than before, because she is at home at the
same time as the rest of the family. Shift work takes time away from the family,
which cannot be paid back by time spent at home during hours of the day where
the rest of the family is absent.
Interview 7: 48 years old, 12 years work experience as midwife
Because it is so hard on our everyday lives, and it taxes our family once in a while, you work
when the rest of the family has time off, sometimes you go to work at inconvenient hours,
mother comes home and is a bit grumpy, and oh something is wrong again, right. And you cant
take a three-week holiday with your children. That is hard, I think.

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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

5.3.5 Job routine


At first sight, midwifery seems to be a field of work without any kind of work
routine. Instead, high unforeseeability and uncontrollability of events seem to be
the key characteristics of this job. However, during participant observation, it
became obvious that even here some routine task exist.
Interview 4: 45 years old, 20 years work experience as midwife
I have consultation hours as a midwife; One day every second week; I share
them with a colleague, she has the other part. That is a lot, I think. Then, when it
is only every second week, it doesnt become as intensive as if it was once or
even twice a week. But it makes up a large part of being a midwife .. working
with pregnant women. I wish I could do more. I would like to have consultation
hours every week. Of course it takes a lot of time. And there are so many other
things to do on a maternity ward. Not only births. Check-ups and observations
and

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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5.4 Summary of findings


The foregoing chapter reported person and work related factors found in the
interviews, which are meant to have relevance for the understanding of the
relationship between motivation and burnout in midwifery.
Biological age was interpreted as having an impact on the way stressful work
episodes are handled by the single midwives. Older midwives are described as
needing a longer time to recover from stressful work episodes. Moreover,
biological age was put in contrast to flexibility to adjust to technical changes
(e.g., new techniques, computerization). Differing occupational ideologies and
identities are described for different midwife generations, leading to a difference
in fulfilment of the primary task. In conclusion, younger generation midwives
(understood as more recently educated) are described as being less committed to
the primary task but more interested in developing other skills (e.g. doing
research, look for different job opportunities) and less willing to accept high
work demands with low recognition (financially, etc.). Younger midwives are
described as being less competent in acute situations and at the same time more
willing to learn from each other and more eager to work in teams.
The organization of work time and time at the ward was reflected as a sensitive
issue in regard to work motivation. Some midwives regard the system of shift
planning as insufficient and dissatisfactory, because the central planning does
not give them enough influence. However, at least one other midwife does not
regard the missing influence in planning the shifts as the most important reason
for work-related strain.
Working at night is described as being very demanding and is thought to be a
reason for burnout. The term burnout as defined and used by the participating
midwives refers to an acute state of exhaustion which can be overcome if
followed by an adequate recovery period typically known from minor states of
physical exhaustion. Consultation days, which are more clearly structured and
more foreseeable, are experienced as a welcomed break in the otherwise
demanding work routine.
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Part-time work is described as being common at the ward (approximately one


third of the midwives work part time). An advantage of working part time is
seen in a higher flexibility in the personal work schedule. A disadvantage is seen
in getting fit into the schedule after shifts have been given to full timers, leading
to unattractive shifts for those working part time.
Work-family balance is also named as an important issue for the midwives. The
acute nature of the work often leads to not being able to balance work and
family sufficiently, family often standing in second line. This leads to strain for
the family, especially for full timers. On the other hand, some disadvantages of
day work were named by those three midwives on a day schedule. One
interesting aspect they report is that time at home alone during the day used to
recover from the demanding work is no longer available.
Finally, job routine was discussed. Even though the job of a midwife is
characterized by a high degree of unforeseeability, there are also aspects of a
daily job routine. Job routine in this sense is described as recurrent tasks in the
course of a work day (e.g., journaling after a birth has taken place) and in the
course of helping to give birth (regular check ups).

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Chapter 6: The significance of resources in midwifery

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.

Besides the problems of comparing midwifery in terms of economical factors,


midwifery is defined as special case in the public health care system because
midwives work with people in a crisis. Although, fortunately, in most cases it is
not a negative crisis, but one with a happy end, it is nevertheless a period were
everyone involved is very anxious until the child is born and it is clear that
mother and child are well off. The birth of a child, which is at the same time the

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birth of a (larger) family, is in any case a form of fundamental experience, a


significant life event.
6.3 Balance between resources and job demands
The fit between resources and demands is rather sensitive, as it touches on a
variety of issues. In the following, occupational standards and the ideology of
serving 100% are discussed in the resource context. Moreover, the resource
question is reflected on with regard to feelings of security while fulfilling the
primary task. The meaning of resources for health and well-being is also
discussed, as is the importance of resources for client education.

6.3.1 Balance of resources and demand to serve 100 percent


In the course of the interviews, it became clear to the author that midwifery is
different from other occupations in regard to two aspects: first, service in
midwifery often cannot be delayed. Second, there is no middle ground in regard
to service, quality and commitment to the single birth process. Midwives need to
be able to provide 100% service when fulfilling the primary task.
Interview 6: 58 years old, 33 years work experience as midwife
At some point during a delivery you have to focus on the woman. And in our
plans we say that a woman in the last phases of the delivery has a right to have a
midwife present. However, the county doesnt fully accept that. It still defines a
delivery as something that at least takes 6-7 hours, so you have plenty of time to
see other patients in between. But life is not always like that.

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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of birth, some flexibility is needed in order to be able to secure 100% service in


the critical phase of birth. The gap between official evaluation of standards and
practical experience leads to an allocation practice which is far from being
optimal seen with the eyes of a midwife.
Interview 3: 43 years old, 6 years work experience as midwife
then you risk having to go from one room to another without being able to
be there 100%. Then you feel you are on only 50% present in the two rooms.
That is very frustrating.

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.

Another aspect standing against the professional understanding of giving 100%


service to the women in labour is the organisation of shifts in a centrally
structured organization. The original meaning of midwife goes back to the Old
English word med wife which, translated, means being with wife (Molnar, 2004).
In the original sense, this is a description of the function a midwife is meant to
serve while assisting to give birth. In the interview, the midwife mentioned that
this original understanding of midwifery is not met in modern, large hospital
organizations. Large organizations need to have a functional structure to
organize work. On the contrary, natural birth, which still is the preferred birthing
practice in modern midwifery, follows the rules of natural time. The eight-hour
shift introduced with the centre organization of the maternity wards in Denmark
led to a fragmentation of midwifery. This fragmentation is experienced as the
second best way to work as a midwife. The work of the midwives nowadays is
organized according to economical figures and not so much according to the
natural birth process, which would, for example, require staying with the woman
giving birth until the child is born. Instead, time and effort needs to be invested
in order to build up confidence and rapport with the women coming to the ward
and again throughout a birth process when shifts change. This effort costs
resources (time and emotion), both for the midwife and the woman in labour.
Therefore, this practice is not regarded as optimal birthing practice because it
also leads to insecurity in the woman in labour. The organization of birth
according to 8-hour shifts leads to a higher anonymity between midwife and

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client. This is seen as a tremendous difference between small places to give birth
and larger hospital organisations.

6.3.2 Expertise, resources and security


The aspect of job routine, understood as acquired expertise to do the job of a
midwife with a feeling of high security about ones own decisions, seems to be
of importance in regard to resources and security. During the observation, one
midwife said that it takes at least seven years to reach a feeling of
professionalism on the job, which the other midwives confirmed. These first
years on the job are like gathering invaluable experience and collecting precious
and important moments and incidents.
Interview 6: 58 years old, 33 years work experience as midwife
When you have worked here for so many years, things just happen. Things dont
become total routine, but you work up some kind of routine. And there are no
two similar births, Ms. Hansen and Pedersen etc. How shall I put it you can be
more relaxed about it, in a positive way.

Each birth process is regarded as a new challenge not to be compared to


previous birth processes. Expertise is associated with a greater security to make
clear decisions in a highly uncontrollable setting.
Uncontrollability is common in midwifery because of unforeseeable birth
processes and emergencies of different kinds (e.g. premature contractions,
bleeding, no signs of life, nausea, etc.) which can happen at any time. This kind
of uncontrollability is taken into account and is also regarded as part of the
challenge of midwifery. One point where this positive challenge can turn into a
feeling of insecurity and even anxiety is when resources are low. The relation
between feelings of security and resource availability was one aspect which
emerged as important in the course of the single interviews. In the group
interview, the issue was discussed in more depth. Findings from the single
interviews were confirmed and emphasized.

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Interview 6: 58 years old, 33 years work experience as midwife


The limit is reached when you are forced to provide poor service as you have
two of them. It becomes too much when you have to provide poor service.

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..

A feeling of security is named as being essential in the course of helping to give


birth. A critical incidence starts at the point where the midwife is starting to feel
insecure because she is not able to monitor what is going on in each birthing
room. It is regarded as natural that death can happen in the course of birth, but it
is stated as unacceptable if this happens because of low resources. One strategy
to avoid this uncomfortable feeling of insecurity is described as staying
voluntarily at the ward at busy times to help those colleagues on duty.
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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.

Another threatening aspect is described as the imagination of being alone at the


ward (which corresponds to the actual situation at the ward at the time of the
group interview) without knowing what to expect. The possibility that
something overwhelming and maybe uncontrollable will happen is stressful and
described as lurking. Being alone with the possible situation of too much work
and not knowing where to run to first is described as a real threat to established
work routines.
Group interview
IP 2: I feel that I would end up in a situation where I faced a catastrophe. In a
state of total preparedness, with a rapid pulse, and extremely focused on all the
things that can go wrong and what to react on. It can be compared with an
animal ready to attack. It is a situation where the adrenaline is pumping. It is a
rather stressing situation. And the thought of such shifts with regular intervals
and that it can happen on my shift. It is not as it is planned but it can happen in
the future. And in the phase before, where I know that I have a shift where I will
be alone. Well, I really think about the situation and try to decide if I can handle
it. In such a situation, I can easily imagine that if you feel just a little bit ill you
could come up with an excuse for not taking that shift. The pain develops into a
real headache. I think we could all be tempted to think like that.

The bodily reaction to such a situation is described as fight or flight and as a


situation no one wishes to experience again soon. Trying to avoid this feeling
can lead to absenteeism; here described as faking or the imagination of illness.
To be forced to regularly work under conditions where the feeling of security is
threatened because of short resources is experienced as stressful and frustrating.

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6.3.3 Resources for client education


Client education was valued as an important field of work, which is increasingly
reduced because of declining resources. Some of the midwives see client
education as an important part of actively preparing women for the birth
experience or to inform parents about the health impairments for the child
connected to smoking, drug abuse, and alcohol during pregnancy and while
breast feeding.
Interview 8: 50 years old, 24 years work experience as midwife
And we think we do a good job, and we think we have much to offer within the
health promotion area as we meet the women and their families at a perfect time
in their lives. We meet them when they are young, when they a going to have a
baby, when they are motivated and maybe then it is possible to change some
habits etc. We can present health promotion to them but resources are cut down.

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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fulfilling the primary task successfully; in terms of bringing healthy babies to


Earth. Low resources and the connected consequences are seen as leading to
serious health impairments.

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Chapter 7: The role of emotional demands and feelings in


midwifery

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.

7.2.1 Reactions to rising demands from clients


In the interviews, the midwives report about rising demands and expectations
from their clients in recent years. There are more women now who express their
own ideas about how the birth process should be arranged. There is a higher
demand for techniques and medicine to avoid pain in the birth process and

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especially planned caesarean sections are requested more frequently by the


younger generation.
Interview 2: 46 years old, 20 years work experience as midwife
Another factor which has appeared in the past years is the medical aspect where
the clients are becoming very demanding with respect to how they approach
birthing. Take someone like me, who has always felt convinced that women are
born to give birth to children and that it is a natural process which they need
help and support to go through however, they do not need all kinds of
technicalities. But if you ask me today, I think it is all right to ease their pain
when they are in labor, though I still find it difficult to see completely healthy,
pregnant women telling me that they are so scared of giving birth that they want
a caesarean section. They prefer an operation which I know will have a serious
impact on their body instead of the completely normal and natural process a
birth is, and which their body is made to go through. It causes some
complications which make us and our clients confused. They often come from
homes where they have learned that if there is anything you need from the
health service - you should just insist on having it! And if the authorities are not
willing to give you what you want, you have the right to complain. Nobody
would have complained about me 20 years ago because I did my very best.
However, to do your very best today just isnt enough anymore!

The quote above is an example of the self-image the participating midwives


refer to when they talk about their clients. This image is as being a facilitator
and pacemaker throughout the birth process, guiding the woman in labour and
her family. This self-image stands in contrast to the clients demands
experienced by the midwives. The midwives describe the recent birthing
generation as a generation with high demands, being less willing to go through
pain and discomfort during the birth process. Women giving birth are described
as being well informed, often knowing exactly what they want, and who
confront the midwives with their wishes and demands. The fact that women are
informed is not seen as critical but the decline of recognition of the professional
knowledge of a midwife is experienced as problematic, especially in
combination with the accelerating demands towards the midwife. Modern
women are seen as expecting to receive best service according to their own
conditions. The opinion of the midwife is heard but not necessarily accepted as
the last word. The participants of the case study describe a feeling of being
bewildered, especially when a pregnant woman is making choices against the
good knowledge, experience, and advice of the midwife. Moreover, a midwife
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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.

There is a gap between the self-understanding of a midwife and the appreciation


from the womens side. The birthing generation is often described as selfcentred and commanding. In contrast to former times, the respect and
appreciation brought to a midwife seem to have diminished. The comment
above goes as far as to speak of imbalance of the present situation whereas to
look down on the woman is described as the opposite of the situation today.
Interview 9: 44 years old, 18 years work experience as midwife
To the question: What is it that is so difficult about doing the work of a midwife
nowadays?
What has become difficult or more difficult is that we are not only there helping
to give birth but in some situation even if you can not generalize this they expect
us to deliver the child, and this I think is a little tough. Well, I have delivered my
children and I really want to help others to deliver theirs but I cannot deliver for
them. Especially in situations which are a little bit difficult, where the process is
maybe a little tiring and slow and quiet, she does of course get tired and her
husband cannot bear to look at his wife in such a condition where she is in pain,
and still it is not happening much; in these situations you can experience that
they turn their frustrations against us. And this I think is a little difficult to
handle; you are there to help them but each time you try to say something about
what the woman shall try to get some relief you get the eyes of the partner on
you as if he says, hello!, dont you understand, have you not understood
anything?; and than you might think ah, I do not say this to make it worse, I say
this because I try to help.

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Interview 1: 38 years old, 14 years work experience as midwife


And if they make demands which are in opposition to the rules ... you can say
that normal practice means wide limits. But sometimes they can make
impossible demands, e.g. they want an epidural or a caesarean because they
dont want to be in labor anymore or and suddenly you see a whole family
blow themselves out at the birth where nothing indicates that things are meant
to turn out that way.

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.

In positive birth processes - and even more so in difficult situations - the


midwives need to give their full attention, empathy, and make use of their
professional knowledge as well as intuition. In each birth process, midwives
need to get physically and emotionally involved as well as be alert and highly
concentrated. These high demands are experienced as tiring, especially when
there are no possibilities for recovery. Moreover, facing family demands upon
coming home and not being able to satisfy them in a sufficient way because the
job has been too demanding is experienced as frustrating.

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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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7.3 Emotional reactions to traumatic birth incidences


Traumatic birth incidences are a natural part of the job of a midwife. Giving
birth is a natural process with a certain chance of failure. Even though modern
times demand the control of nature in the best possible way, giving birth is
maybe one of the archaic incidences to which there is no access to total control.
In the interviews, it became obvious that traumatic birth incidences lead to
emotional reactions (entanglements) which might have influence on the
relationship between motivation and burnout. In the following three sections, the
different challenges a midwife faces in regard to traumatic birth incidences are
discussed. First, how the midwives experience the handling of traumatic
incidences is presented. Second, the feeling of being responsible is described.
Third, the aspect of healing and support after traumatic birth incidences is
discussed.

7.3.1 Experience with the handling of traumatic birth processes


In the course of the interviews, the experience of and the dealing with traumatic
birth incidences was reflected.
Interview 6: 58 years old, 33 years work experience as midwife
I believe that pregnant women today really demand that nothing must fail or
happen to them or their child. Moreover, they want the best service they can get.
They want full security through the whole process.

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.

7.3.2 Feeling of responsibility and guilt


Responsibility is often the immediate feeling described in connection to difficult
or even fatal birth processes. Especially in unforeseen fatal incidences, feelings
of responsibility or even guilt can arise. The midwives also report feeling
responsible even without having the formal responsibility. Finally, there is the
feeling of being responsible for supervising clients and their families who have
experienced a traumatic birth process.
Interview 4: 45 years old, 20 years work experience as midwife
Of course you experience traumatic birth incidences where either the child is
dead or the mother almost dies, and the whole birth process becomes so terrible
that it affects you mentally afterwards and sometimes makes you feel guilty
though it isnt necessarily your fault, Midwives are like that we feel guilty!
We want everything to be perfect and correct it is living human beings we are
dealing with. Nothing must go wrong. I have also felt terribly sad sometimes.

Healthy is here used in the sense of being emotionally in one piece.

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The citation above reflects in a comprehensive way the emotional entanglement


when thinking about responsibility in traumatic birth situations. Emotionally, the
midwife goes through a variety of feelings, which reach from being puzzled to
feeling guilty. Traumatic birth situations are often not clear in respect to who is
to be made responsible. The feeling of being responsible or even guilty is
described as the immediate and most consistent feeling connected to an
incomprehensible birth process with a negative outcome. Midwives are
described as taking this responsibility upon themselves, also with the
consequence of emotional strain.
Interview 3: 43 years old, 6 years work experience as midwife
Another thing is when I have assisted women in delivering a stillborn child
where they already knew the child was dead. In a situation like that you must act
professionally. You feel terribly sorry for the parents and you must of course
it is so terrible, particularly when the child is perfect and it is dead. However,
you cant walk around with this sense of guilt that you have done something
wrong. You feel guilty when you are carrying a dead child in your arms and
have to tell its parents or the father (who sometimes hasnt participated in the
birth) that their child is dead.
Interview 9: 44 years old, 18 years work experience as midwife
It is extremely difficult to assist a woman in delivering a stillborn child. The
worst situation for a midwife is when a pregnant woman is carrying a live child
in her stomach when she arrives and delivers a stillborn child. It is the worst
thing that can happen to me!

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.

7.3.3 Support and healing after traumatic incidences


In the following, different ways of handling and coping with traumatic
incidences and the related consequences, as referred to by the midwives, are
presented.
Interview 1: 38 years old, 12 years work experience as midwife
Maybe it is something that makes you feel burned out after a certain number of
years. You have been involved in so many traumatic incidences and you have
never had a chance to discuss them with anyone. Sometimes you discuss it with
someone in your private life or with your colleagues after work but it never
really get paid much attention to; and it is expected that you keep on working
just as if nothing has happened. Of course they feel sorry for you for about three
days but then you have to move on. We have all tried that. It is expected to be
like that.

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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after a traumatic incident has happened and the organizational expectation of


how to react to it. There is actually not much time given to cope with traumatic
incidences because of busy shifts and changing personnel working together.
There is an expectation from the working environment to be back on track after
a relatively short period if time. The emotional body, on the other hand, is
described as being slow in getting over a severe incident. In consequence,
traumatic incidences are banned to stay unresolved. This can in accord to the
participating midwives lead to serious problems as more and more such
incidences need to be stored in a subconscious state. In the end, in this
midwifes view, these unresolved experiences can lead to burnout.
Interview 7: 48 years old, 12 years work experience as midwife
It takes up a lot of your time, and you keep asking yourself whether it is right or
wrong. It is nice, but I also understand those colleagues who break down
because you are so much involved, and you cant just walk home and say - well,
that was that!

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!

It is described as important to work things through, talk about the traumatic


incident and take the time to recover. This is not always possible and the overall
structure of a persons life can be supporting, challenging, or hindering in this
respect. Midwives react very differently to such incidences. One group is
described as thinking that it is a sad part of the job, which has to be taken into
account with some professionalism. Others are described as getting deliberately
personally involved in the history of parents and families who had to go through
a traumatic birth event. A third position is described as acquiring a strong
professionalism in order to be able to handle these traumatic incidences in a
more distanced way. Altogether, it is regarded as a job demand to be able to
handle traumatic incidences and to develop the capacity to digest them.
The form of social support on the job is described as being existent in the
moment. The midwives try to support each other when having been through a
traumatic incident. Yet there is some implicit expectation to be back on track
after a short period of time. The support is described as physical, as being
there, as supportive in the sense of short term relief from questioning ones
own professionalism. However, as soon as the shift is over, it is hard to keep
track on those who have had a traumatic experience. The formation of teams
changes from shift to shift and it is not easy to maintain continuity. There exists
a form of peer debriefing after a traumatic incident, but there is no formal offer
of professional psychological help yet. However, during the study period, a
psychologist was employed at the ward for a limited period of time in order to
give quick professional support to those who have been impacted by a traumatic
birth incident. The midwives were positive about the psychologists work and

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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

Supervision as a step in between social support and professional psychological


help has, until recently, not been used as a form of support in the case of
traumatic incidences. After the first round of the PUMA investigation, two
colleagues were professionally trained to give collegial supervision. This form
of supervision is thought to be first help at hand after a traumatic incident has
happened. However, experience so far has shown that this form of collegial
support is not asked for. This is frustrating for those who went through the
education to become a supervisor. At the same time, it is interpreted as a sign
that collegial support is not the right way to approach the issue.
Interview 1: 38 years old, 12 years work experience as midwife
Debriefing in connection with traumatic birth processes, specifically traumatic
birth processes, is new. But they dont use psychological help, which I believe is
missing. You are missing in relation to the fact that you feel a heavy
responsibility being a midwife? And you do. Though a doctor comes in and
performs an operation, you still feel more or less responsible for what he or she
is doing. You need some kind of follow-up in a difficult situation like that.

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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.

In the group interview, the midwives describe themselves as being good at


giving support to each other because giving support and holding onto somebody
in a crisis is the core action when fulfilling the primary task as midwife.
Group interview:
IP: What is it what we do every single day, 8, 10, 12, 14, 24 hours in a row? We
stand at the labour ward and we bear, and we lift up and we support and we hold
onto. This is what we do, this is our job. And this is also what we do as soon as
we get home from work, maybe not directly at home because home is the place
where you have the space to break down sobbing. But in all other contexts you

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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.

The collegial support is reflected by the midwife on the background of the


competencies connected to the fulfilment of the primary task.
Besides the capacity to give support to each other, it was confirmed in the group
interview that emotional trauma is common in midwifery even if it is not an
issue to be talk about. The aspect of healing was brought up as being important
in case of emotional trauma. Healing can happen in different ways. The most
direct and cleansing way to heal from the inside is described as crying.
Group interview
IP 2: We cry. Well, I feel to really cry through something is a real cleansing
process. It does not happen that often, but when you have been totally down and
out and have cried through the whole process, than you are washed from the
inside, almost, and than you are ready again. So, I think, this is really good when
it is too much. In any case for me it is a good thing to cry through these phases.
And I also think there is the aspect of time, and than you also have a lot of
security nets you can establish for your own sake, so that the probability to come
into a traumatic situation another time is low. In these situations you check over
and over again with all kinds of technical devices, and the doctor is called 117
times you establish all kinds of security checks in order to heighten the
security you can at all establish.

Being able to shed tears about a disturbing emotional experience is described as


relief and a healing path. Beyond that, it is important to have time to get some
distance from work at the ward, find time for meditation, and time for healing in
order to built up new confidence in ones own competence and knowledge
again.
Group interview
IP 2: If you have been involved in a traumatic incident, you need time to
recover. You feel deeply involved in the crises, and you need time for healing
and find your confidence, competence and professional way to tackle problems
again. You believe that you can do things in a safe and competent way. You
need time to find out if the help you offered the pregnant woman (and her
husband) really was the best help she (they) could get. You need time to find out
how they are getting along with their lives after a traumatic incident. And you
need time to return to your workplace and talk with your colleagues and find
your own self again, and slowly get back to work. A traumatic incident is a
major drawback for your career where you dont feel certain about many things.

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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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emotional competencies as part of this professional role and therefore


emotionally distance themselves from the immediate experience.
In summary, emotion work showed to be a core theme in the single interviews
and this finding was supported in the group interview. Implications of the
different emotional demands and feelings related to the primary task in
midwifery are discussed in Chapter 8.

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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.

8.2.1 Essential characteristics of the primary task


The primary task in midwifery is specific in comparison to other tasks in the
human service work. The list of aspects in midwives psychosocial work
environment as proposed by Dyhr (1999, see Chapter 3) are used as a guideline
to describe the relevance of the primary task. The acute nature of birthing might
be comparable to cases in an emergency ward. The same is true for the necessity
of working in shifts, 24-hours, and all days of the year. Clients in midwifery are
in a life crisis. This crisis is different from an accident crisis as it is basically a
positive crisis with a rather small probability of a negative outcome. At the same
time, the possibility of a negative outcome is a constant threat, and has an
impact on the way midwives establish nets of security. Those partaking in birth
processes (most often the husband, partner, and family) are involved just as in
other acute life situations. In the case of birth, the involvement happens to be
planned, as today most men explicitly want to take part in the birth process. In
contrast to other settings, the involvement is proximate. This both supports as
well as hinders the work of the midwife in the sense that she needs to
communicate not only with the woman in labour in this acute situation but also
with the surrounding network present at the ward. Midwifery traditionally is also
characterized as work done alone. On the other hand, it was observed in the
present case investigation that midwives use their colleagues for discussion
about birth processes when meeting in the staff room. There is a constant

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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.

8.2.2 Demands and resources related to the primary task


The nature of the primary task leads to the following unchangeable work
demands reported by the midwives: constant, 100% attention when on duty,
shift work which includes nights and emergencies, the need to utilize the own
body as an instrument while helping to give birth, giving something of ones self
as one form of emotional demand, the ability to handle traumatic birth
incidences, and the skills to balance uncertainty and security. Demands related
to the primary task in midwifery are specific to the way birth is recently
organized in Denmark. The present case investigation made explicit that the

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work demands which are thought to cause burnout need to be discussed in


relation to the resources inherent in the primary task. Resources named in the
present case are the meaningfulness of the primary task and the positive energy
drawn from good birth experiences. Recognition from clients was named as a
further resource. Resources interpreted in this sense, are the source of
motivation to stay present and serve 100% even under demanding work
conditions. For the well-being of the participating midwives the balance
between resources and demands shows to be of particular importance.
Imbalance occurs when resources are diminished.
Two widely known theoretical models of work place stress are the demandcontrol model (Karasek, 1979; Karasek & Theorell, 1990) and the effort-rewardimbalance model (Siegrist, 1996). Both models are used in the following to
exemplify the demands and resources related to the primary task in midwifery as
found in the present case study. The demand-control model (ibid) identifies the
relation between job demands and job control as the main aspects causing work
related stress with negative effects on health. High work demands and at the
same time low control (so called high-strain jobs), is thought to have negative
consequences for health and well-being. Dyhr (1999) used the demand-control
model as a research frame to investigate the psycho-social demands in
midwifery in Denmark. The investigated midwives showed to be in the highstrain quartile. In the present investigation, high demands with corresponding
high as well as low resources were reported by the participating midwives. In
accordance with the demand-control model, this leads to the conclusion that
being a midwife as described by the participating midwives is a high strain,
active job, being both stressful and a positive challenge at the same time.
Negative as well as positive aspects are described as essential characteristics of
the primary task. Besides the description of the demanding aspects of
midwifery, the findings of the present case study point to the importance of the
positive aspects of the primary task which give energy back to the midwife.

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The importance of these kinds of work resources is formulated in the job


demands-resources-model introduced by Demerouti et al. (2001), enlarging the
perspective of the demand-control model. Demerouti et al. (2001) could show
that the development of burnout is determined by a specific constellation of
working conditions. According to the model, exhaustion increases when job
demands are high, whereas disengagement is higher with low resources. At the
same time, disengagement is not an outcome of exhaustion but is related to the
shortage of resources. Taking the job-demands resources model as a perspective
from which to interpret the findings of the present study, it can be stated that the
model fits the subjective descriptions that the midwives gave in both the single
interviews and the group interview. Exhaustion was referred to when specific
job demands were discussed. It was described as a short-term state of low
energy, which can be regained through sufficient time to unwind from stress at
work. The primary task was described as the main source of positive energy in a
highly demanding work environment. Low resources are experienced as
threatening to this positive work experience, because service quality, which is
highly valued by the participating midwives, becomes the buffer between low
resources and high demands. In other words, midwifery practice in Denmark is
characterized by high demands with at the same time task inherent resources
being present. Some of the task inherent demands can be interpreted as
resources and resources can also turn into demands. Most important resource in
midwifery is with no doubt the meaning of work done by a midwife when
fulfilling the primary task.
A further point in regard to resources is the intimate contact to the client and the
gratitude the midwife gets as reward for her engagement. Especially for the
older generation of midwives interviewed here, recognition from clients is seen
as a valuable resource. However, this resource is diminished by the attitude
towards giving birth shown by the recent birthing generation (see further
discussion in Section 8.4). As another job related resource, secondary tasks in
midwifery were named. Consultations with pregnant women, teaching maternity
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classes, and even otherwise disliked administrative duties were described as


welcomed time-out from the need to be constantly present while helping to give
birth. The importance of the secondary tasks reported by the midwives
emphasizes the necessity to unwind from stress at work. The importance of
unwinding in order to be able to cope with job-related stress is found elsewhere
in the literature (Hobfall, 1989; Frankenhaeuser, 1991; Mejman & Mulder,
1998; Sonnentag, 2001).
Finally, some of the characteristics known from flow experiences (see Chapter
2, Section 2.3.3) are described as resource inherent in the primary task in
midwifery. Yet in contrast to other activities which elicit flow states, midwifery
is also characterized by the structure and organization of the primary task: the
high workload and related to this the need to be present at different places at the
same time as well as the presence of a partner in dialogue. These two conditions
are seen as hindering for states defined as flow experience. High workload leads
to short intervals of task fulfilment before rushing to the next client. Moreover,
the intensity of client contact is different from tasks which can be done in
meditative contemplation. At the one side can client contact evoke states of
feeling high, comparable to flow states when a feeling of reciprocity between
client and midwife is present and the rapport to the client is good. On the other
side hinders the presence of the client a state of deep concentration because the
midwife needs to react to signals of her client. Furthermore, helping to give birth
is described as an engaging task with clear goals and a high focus of attention.
The effort-reward imbalance model (Siegrist, 1996, 2004) describes humans
strive for balance between demands (efforts) and rewards. Siegrist defines three
different types of reward which together form the reward category of the model:
income, job security and rewards from colleagues and supervisors. A prolonged
imbalance between high efforts and low rewards is thought to lead to negative
health consequences. Important in the relation to the present case seems to be
that midwifery is a highly demanding job with at the same time seemingly low
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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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A different explanation is that high quality of leadership and a meaningful work


task keeps a group who has shown to be overly dedicated and to have an
exaggerated feeling of responsibility longer in the job because of a feeling of
owing good performance. Both assumptions must stay on surface as the
present case investigation did not investigate the theme leadership in depth.
In conclusion, an imbalance between demands and resources has a negative
impact on health and well-being. From the findings of the present study, it
seems safe to assume that the recent changes in midwifery have impact on the
balance between demands and resources. These include: reduced professional
and personal recognition of the midwife helping to give birth as well as mothers
increasing dependency on external help while giving birth, such as epidurals
(described by the midwives as Prinsesse Alexandra-Effect because the rate of
epidurals went up after the princess had given birth to her first son with the help
of an epidural) or caesarean sections (see section 3.4.1.6). One demand in
particular which should be mentioned is the increased demand for security and
controllability of the birth process from the birthing womens side. The recent
birthing generation was described as a generation who is less willing to accept
any insecurity or pain while birthing. This development is recently discussed in
public and governmental circles under the headline Caesarean section on
maternal request (Sundhedsstyrelsen, 2005, 7(4)). This demand has two
consequences for the midwife: she has to spend more time in preparing and
convincing the woman of natural childbirth, which is in her opinion still the best
way to birth a child. This is time she does not have because of resource
reduction in all parts of the hospital sector. Further, she has to train herself in the
use of new technical devices against her own convictions. This aspect was
probably very meaningful for those midwives participating in the case
investigation. All of them had been in the job for more than five years, most of
them much longer. They had have experience with other conditions in
midwifery than the ones they work under now. Actually, there was a slight
tendency to glorify the good old days, when helping to give birth was a holistic
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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).

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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
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is charismatic, dynamic, inexhaustible, and super-competent" (Schaufeli &


Enzmann, 1998, p. 102). In the course of the interviews, signs of overdedication, an exaggerated feeling of responsibility and high demands towards
one-self were named by the midwives as being somewhat typical for an engaged
midwife. Hockey (1993) describes in the control model of demand management
how individuals use a performance protection strategy und the influence of
stressors in the environment. Through mobilization of sympathetic activation
(autonomic and endocrine), performance protection is achieved. As a long-term
effect of greater activation and effort, the draining of an individuals energy and
a state of breakdown or exhaustion are named. In midwifery, performance
protection is a sensitive issue. The participating midwives were very clear about
the importance of providing outstanding service when helping to give birth.
With the decline of resources, extra effort has to be put in, in order to make sure
that a high level of performance can be assured. In a positive sense, this work
behaviour can be described as engaged. However, it can also lead to overdedication and exaggerated demands towards oneself: This form of extreme
engagement can lead to serious health impairments for the midwife
(Engelbrecht, 2001). Over-dedication is also expressed in the fact that the formal
job-role is not accepted as ideal practice but rather high demands are thought to
be the ideal, which are at the same time not explicitly formulated by the work
environment but implicitly agreed upon by the midwives as part of their
occupational ideology. These findings from the present case support
Freudenberger & Richeslons concept of idealised self-image (1980) as a reason
for burnout.
Age is one of the demographic factors assessed in the present study which is
meant to have influence on the relationship between motivation and burnout. As
can be seen in the age profile of the midwives employed at the ward (see Table
3.5, Chapter 3), the middle age group (35-50 years old) is the largest group at
the ward (31 out of 49 midwives belong to that group). Biological age is thought
to be responsible for playing a significant role in the development of burnout in
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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
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adaptive coping behaviour. Younger generation midwives were described as not


willing to accept high demands and at the same time low recognition of the work
they do. Research on effort-reward-imbalance has shown that short term
imbalances between effort put into the job and reward from it might be
acceptable to the individual and do not have negative consequences for health
and well-being (Siegrist et al., 2004). However, midwifery in this study was
characterized as being a high strain job with high effort-reward-imbalance. For a
younger generation midwife, it can be regarded as highly adaptive and at the
same time protective to not put too much effort into the fulfilment of the primary
task but rather prioritize parts of the job where personal effort might lead to
adequate reward, e.g. research work.
In the context of the present case investigation, the difference in age and attitude
towards the job is not stated as a problem by the midwives themselves. The
reason might be the small number of younger generation midwives at the ward.
Yet the more critical attitude of the younger, upcoming generation of midwives
might influence traditional job beliefs in the future. In fact, a recent study by
Hunter (2004) has shown that not only client contact can be a reason for emotion
work but instead, conflicting ideologies of midwifery practice amongst
midwives. The first ideology mostly found in hospital settings functions by
necessity, and was termed with institution. The other ideology found in
community-based midwifery favoured a so called with-women ideology,
standing for an individualised, natural model of childbirth. Particularly evident
were these conflicting ideologies in the accounts of novice midwives and
integrated team midwives in a hospital setting, both committed to a with
women ideology (Hunter, 2004). Midwifery in Denmark today is mostly taking
place in growing birthing units which are most of the times part of the
gynaecological ward of a hospital. This fact has influence on the education and
socialization of younger generation midwives. In the present case study,
midwives gave expression to favouring a with-women ideology but named the
structure and organization of work as a hindrance in this respect. The
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professional identity of midwives is under constant redefinition dependant from


the setting in which education, socialization and work of the midwives takes
place (Benoit et al., 2001). In the future, the generational differences discussed
above might therefore be followed by a change in ideology in regard to
midwifery practice. A different scenario could be the reestablishment of smaller
birthing units or a growing tendency towards private practice in midwifery. A
comparison of the developmental history of midwifery practice in different
countries (deVries et al., 2001) has shown that changes in midwifery practice
often times were brought about by the dissatisfaction of the midwives
themselves either opposed by or supported by organisational structure, political
initiative, as well as the clients themselves. Sandall et al. (2001) recommend
three questions to be asked while creating new models of care:
1. Does the new way of organizing care empower my profession?
2. Does it allow me to live a fulfilling professional and personal life?
3. Does it provide the best service to my clients?
The three questions above reflect the three life-spheres the midwives in the case
study mentioned to be important for a balanced work-life: the profession, private
life, and the relation to her client. Imbalance in one life-sphere will after some
time cause problems in tone of the other.
8.4 Assumptions about client-related factors of relevance to the research
question
In the center of the fulfilment of the primary task stands the relationship
between the midwife and her client. This relationship is described as intimate,
intense, and yet of short duration. In the present case study, expectations and
demands from clients as well as the recent generations attitude towards birthing
were discussed. The participating midwives reported incongruence felt between
their own professional image of service given to the clients and the appreciation
of service from the clients side. Brucks (1998) describes emotional labour as
the work related handling of meaning and feelings of non-reciprocity. Midwives
in the present case described precisely this non-reciprocity in regard to
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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

from traumatic birth incidences. Midwives stated very clearly client-related


stress as being related to feelings of being burned out.
In regard to these conflicting demands and beliefs between client and midwife,
the aspect of emotional dissonance as the requirement to display emotions which
are not felt, needs to be discussed. Emotional dissonance has been shown as the
most stressful aspect of emotion work (Zapf et al., 2001). The primary task in
midwifery demands a clear position of ones own work role, a high feeling of
responsibility, and high sensitivity towards the clients needs. At the same time,
the midwife is confronted with unrealistic wishes and beliefs from the clients.
Whereas midwives in former times had both the necessary reputation but also
respect from clients to decide in the birth process what needs to be decided, the
modern with-women attitude in midwifery has led to emancipated clients who
demand what they think is right. In principle, this is valued as positive by the
midwives of the present case investigation, but at the same time, they reported
greater friction between them and the recent birthing generation in the case of
non-reciprocity of belief about what needs to be done. Finally, it should be
mentioned that there was a rather high consistency when the participating
midwives referred to friction with clients. The recent birthing generations
attitude and behaviour was repeatedly described as being in conflict with the
experience and belief of the participating midwives. This leads to two
contradictive assumptions: Either the clients are really very different from
former birthing generations or the midwives are short tempered because of the
high workload they face and a blaming the victim attitude is a first sign of
depersonalisation.
8.5 Structural and situational demands and conditions of work in
midwifery
The vertical axis of the descriptive model (Figure 8.1) illustrates structural as
well as situational demands in midwifery which are variable and therefore ought
to be named in regard to their recent influence on the fulfilment of the primary
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task and the potential to change it in addition to the influence on the relationship
between motivation and burnout.

8.5.1 Impact of political decisions in the health care system


The assessment of structural and organisational particularities in midwifery was
not done in the sense of a document analysis but happened on the way of
investigating the case using participant observation, single interviews, and the
group interview. Even if this kind of data is not structured in the same way as
the rest of the data is, the following assumptions are drawn: Resources and
resource allocation practice are influenced by the mindset and ideology of the
present health care system. This mindset and ideology can be described most
briefly as following market principles in the sense of applying cost-benefitanalyses to human factors. In the case of midwifery this leads to a resource
allocation practice which is far from optimal in the eyes of the midwives and to
the segmentation of the primary task contradicting the effort to provide
continuity of care.
Resources in midwifery are described as being a core issue. This is due first of
all to the importance of sufficient resources to fulfil the primary task in a
responsible manner. In the present case study, resources were described by the
participating midwives as being a significant aspect regarding the relationship
between motivation and burnout. The delivery of 100% service is described as
being of great importance for the participating midwives. Low resources lead to
a decline in service quality in fulfilling the primary task. Related to this,
negative feelings such as frustration, fear, anxiety, and the need to be alert are
experienced by the midwife. On the contrary, the primary task was described as
the main source of positive energy in a highly demanding work environment.
Low resources are experienced as threatening to this positive work experience,
because service quality, which is highly valued by the participating midwives,
becomes the buffer between low resources and high demands. A stress theory

232

focussing on the meaning of resource protection and enhancement is introduced


by Hobfall (1989). In the conservation of resources theory, resources are defined
as those objects and personal characteristics, conditions, or energies that are
valued by the individual or that serve as a means for attainment of these objects,
personal characteristics, conditions, or energies" (Hobfall, 1998, in Sonnentag,
2001, p. 197). According to the theory, stress is caused by a threat of resource
loss. In midwifery, one energy resource is the successful fulfilment of the
primary task, described as getting healthy children to earth. If this is perceived
as being threatened to an extent where a midwife gets uncomfortable with the
service she is able to give, the capacity threshold for work related demands is
lowered to a point of imbalance, leading to negative consequences of health and
well-being, here described as burnout. This phenomenon is also described in
capacity theories as an overflow when multiple stressors develop a joint effect
and then exceed certain capacity thresholds (Schnpflug, 1982, WielandEckelmann, 1992; in Zapf et al. 2001). The idea of a capacity threshold is
appealing and explains why a persons breakdown often comes rather
unexpectedly as was also described in the present case investigation. The
following basic theoretical assumption from PUMA confirms this finding:
exposure to adverse psychosocial work characteristics lead to unfavourable
psychophysiological arousal (distress), which in the long run will lead to a state
of exhaustion, which we label burnout (Borritz et al, 2005, p. 1016).
The demand to guarantee highest security while helping to give birth was also
discussed in connection with resource availability. It was described by the
participating midwives that midwifery is a field where resources are not easy to
calculate because unforeseeability of events is high. Not being able to deliver
high security because of low resources is experienced as stressful and not
acceptable. Reactions of flight, fight and freeze, commonly known as stress
reactions, were described by the participating midwives. It is interesting to note
that there is a parallel in regard to the security issue between midwifery and air
traffic control mentioned by the midwives themselves. In the group interview
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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

Lower quality of service


followed by threat
of security

Felt imbalance between


demand towards own service

Figure 8.2 Vicious cycle of declining resources.

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8.5.2 Organisation of working time


Working time issues were discussed by the participating midwives as work
related factors which cause burnout. In regard to work time issues, work family
balance is a constant point of discussion. Time at work, time for the family, and
time to be alone are competing issues, needing to be balanced in one way or the
other. The midwife is often not able to satisfy her personal needs to recover and
relax, stepping from one active and demanding environment into the other. This
might not be an uncommon experience for working women but it might be
particularly tough when doing a job which demands a lot of physical, mental,
and emotional availability, as is the case in midwifery.
Furthermore, the planning of shifts was mentioned as critical factor. Given the
fact that midwives spent a lot of time (regular working hours plus overtime) at
the ward, the influence they have on planning the shift is seen as too low.
Particularly part timers mentioned a feeling of injustice when talking about shift
planning. They feel neglected in the allocation of desired shifts (day shift during
the normal work week). Part time work is described as one possibility to balance
work and family demands. At the same time, part timers feel they are fit into the
schedule at unattractive points in time. No matter if this is the subjective
perception or a fact, it leads to a feeling of injustice and finally to frustration.
Kivimki et al. (2003) investigated the potential impact of organisational justice
on employee health in a longitudinal study in the Finnish hospital sector.
Organisational justice is defined as the extent to which employees are treated
with justice at their workplace" (ibid, p. 27). They found that the extent to which
employees are treated with justice has predictive power on health outcomes.
Especially the discussion in the group interview pointed to a feeling of injustice
in the group of midwives regarding work time and the recent re-structuring.
Tausig & Fenwick (2001) investigated the time-bind known as the inability to
combine work time and family time in a manner which causes less work-life

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imbalance by looking at the relationship between different work time schedules


and perceived work-life balance. The result of most interest in this body of work
is that alternate schedules do not unbind time, although perceived balance was
increased with higher control over ones schedule. Work family balance was
named as a serious problem by the participating midwives. Many midwives
work reduced hours in order to be able to follow commitments in the family and
at work. According to results from Tausig & Fenwick (2001), low control over
the work schedule was named as a source of frustration and burnout. Sandall
(1997) also reports a relationship between occupational autonomy expressed in
control over worktime and midwives burnout (see p. 63). The anticipated
positive impact of reduced work hours is absent when work schedules do not
take the individual needs into account. Consequently, giving control over work
schedules back to the midwives is assumed to have the most direct impact on
perceived work-family balance and in second line on the motivation of the
midwife.
One further aspect discussed by the participating midwives is the issue of
working at night. This also is an unchangeable condition in midwifery. Yet it is
not only an inconvenience but a real physical and psychological strain. The
participating midwives reported not being able to give the same quality of
service at night as during the day. From the perspective of professional belief
and the high expectation midwives have towards themselves, this reduced
service is not seen as being good enough. Besides the physical strain, it is the
psychological side of having a bad conscience when not being able to serve
optimally during the night. In connection with work at night, extreme exhaustion
is mentioned, which midwives feel after having been on a night shift. This
phenomenon is widely investigated and negative aspects of shift work are
known. A recent study on job-related stress and shift work in a three-shift
system revealed an increase of job-related stress and low control for workers in
a three-shift system (Harada et al. 2005). The problems reported by the
midwives in the case study are sleeping problems, exhaustion, circadian rhythm
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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.

8.5.3 Midwifery as a master piece of the female work role


In the present study, one aspect of engagement was described as the care for
others. The care for others is traditionally a primarily female role in society
(Brucks, 1998). Ostner and Beck-Gernsheim (1979, in Brucks, 1998)

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investigated the female work capability (German: weibliches Arbeitsvermgen)


as being characterized by three arguments: (1) the female work capability refers
to skills and competencies already present before entering the job as being part
of the female family role; (2) work within the dilemma of content orientation
and exchange orientation, two faces of work (Ulich, 1991; Schmale, 1995, in
Brucks, 1998, p. 40). Professional work forces different from house-work into a
dilemma between setting the priority in favour of the subject matter (content
orientation) or in favour of getting adequate gratification and recognitions
(exchange orientation). Women tend to prioritizing content and not exchange
and (3) the care for others is not easy to fit into the description of a modern job
role as described by Parsons (1952, in Brucks, 1998, p. 37) in the following
citation: The role of the medical practitioner belongs to the general class of
professional roles, a sub-class of the larger group of occupational rolesIn
common with the predominant patterns of occupational roles generally in our
society it is therefore in addition to its incorporation of achievement values,
universalistic, functionally specific, and affectively neutral. Unlike the role of
the business man however, it is collectivity-oriented, not self-oriented. The
three aspects of the work capability are partly represented in the midwifes role.
Traditionally, midwifery is a mainly female work environment relating to some
degree (communicative skills, emotional ability) to the female family role. The
form of engagement described by the participating midwives as to give
something of ones self, to show empathy, to take responsibility at points where
it is not ones own responsibility are characteristics of the female family role
and not so much in accordance with the work role described by Parsons. The
relatedness of female work role in midwifery and female family role can be
challenging, especially in the case of high work demands. Borders between
work and home are less clear and make an unwinding after a busy day at the
ward difficult. The participating midwives working on a day schedule reported
the disadvantage of working during the day as having less time on their own at
home. Their families enjoy having them at home yet at the same time they
sometimes miss the quietness to have a day alone. Engagement as the care for
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others therefore is regarded as to be especially vulnerable to work related stress.


Caring for the other as central component of the primary task is demanding in
the same way as is the care for members in the family. Because of this
similarity, unwinding from stress at work when being at home is not easy to
achieve for a midwife and is dependent on the family situation. Capacity
thresholds might be further strained when being at home instead it being a place
where batteries can be filled up.
In regard to the second aspect of the female work capability, the difference
between content- and exchange-orientation, the high importance of recognition
from the client needs to be discussed. As mentioned by the midwives, the recent
birthing generation does not express gratitude for the midwifes service to the
same extent as former generations. For the older generation midwives, exchange
of personal recognition seems to be more important then the exchange of
financial value. This attitude is close to the housewifes attitude of hoping for
recognition of the work she has done for the family and might not be a good
estimate of reward for professional service given to a client.

8.5.4 Relevance of implicit knowledge


The instrumental (or professional) knowledge needed to do the job of a midwife
can be discussed from two perspectives: the knowledge acquired in the course of
primary and further education and experiential knowledge, often stored as tacit
or implicit knowledge 10. The midwives referred to the latter as important in
regard to felt security on the job. Professional knowledge is, like in many other
fields of work, under constant development. New developments first are
approached explicitly. Explicit knowledge can become implicit through job
routine. The acute nature of the primary task sets the hurdle of accepting new
10

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).

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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
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dimension has, because of its pre-lingual nature, a tendency to remain in a state


which may no longer be adaptive with a representation of knowledge which is
inflexible to change (Herbig, 2001). One participating midwife described that
the acceptance of using implicit knowledge grows with the years of experience
in the job and the reputation the midwife has at the ward. The more a midwife is
recognized as highly professional, the more it is accepted that she refers to the
implicit knowledge base. This might not always be justified. Unfortunately, it is
inherent in the implicit dimension that change is not easy to establish.
Functional approaches have shown that the implicit and explicit dimensions
work with different memory systems (Kuhl, 2000; Rothschild, 2000). Explicit
memory is also called declarative memory as it stores facts, concepts, and ideas.
Language is a necessary mean to store explicit memory. Yet, explicit memory
also contains complex step-by-step operations like baking a cake that can be
recalled in a cohesive narrative. The counterpart, implicit memory, involves
procedures and internal states that are automatic. Here learned routines and
behaviours are stored and can be recalled. Implicit memory therefore is also
called procedural or nondeclarative memory. It is laborious and sometimes even
impossible to transform implicit memory back into language. In the present case
one midwife shared the experience of not being able to put her embodied
knowledge (as being stored in implicit memory) down on paper when wanting to
write an article about the competencies in midwifery. Part of the female work
mystique might be exactly based on this form of tacit knowledge stored as
implicit memory used with an instinct of knowing what needs to be done.
Among other interesting outcomes to the meaning of implicit and explicit
knowledge in nursery Herbig (2001) could show that implicit knowledge
embraces the emotional exchange of a person with her environment to a greater
extent than the explicit knowledge base does. This would be an explanation for
the frequent use of tacit embodied knowledge in midwifery, which is regarded
as highly emotional work sphere. The methodology applied to investigate the
research question is not valued as being the right approach to investigate implicit
processes. Implicit processes cannot simply be explicated through language.
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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.

8.5.5 The significance and impact of traumatic birth incidences


One aspect of emotions in midwifery was described as feelings in reaction to
traumatic birth incidences. The first point to discuss in this regard is the different
comprehension of traumatic incidences from a midwifes perspective and from

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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
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reported to be massive. The participating midwives reported a feeling of being


left alone with the burden of coping with traumatic birth incidences. Trauma
experienced at work is a singular issue. As in other medical fields, trauma can
happen to the provider of service as part of the primary task. However,
midwifery is regarded as particular case because death is on one side close at
hand but on the other side fortunately not the most probable thing to expect. In
contrast to an intensive care unit, the probability of clients deaths is rather low
in midwifery. It can and does, however, happen to each midwife in the course of
her professional career. Therefore, all kinds of check ups are implemented in the
process. During participant observation, it became obvious that there is a form
of rumination about outcomes, a constant discussion about cases, often with
detailed descriptions about what was done and what is planned to do. There is a
paradoxical feeling connected to traumatic incidences described by the
midwives. The possible exposure to traumatic incidences is on the one hand
seen as an inevitable part of the primary task; furthermore, responsibilities are
clear cut on paper. Nevertheless, midwives described the feeling of having been
exposed to a traumatic incident as highly negative, leading to feelings of guilt
and low confidence in the own professional competence. When a traumatic
incident happens, midwives in the present case study reported reacting to it on
the basis of intuition, because midwifery training does not include the
preparation for the worst case. According to them, the reaction to traumatic
incidences becomes more skilled after the first couple of years in the job. Yet,
each time a traumatic incident happens to a midwife or one of her colleagues is
described as being appalling.
The reported burnout as a reaction to traumatic incidents has a more severe
character than the work related burnout based on high work demands and low
resources. From the perspective of trauma research, this is not at all surprising.
Traumatic incidences find their manifestation in bodily reactions which again
have influence on the way to react to the next incident of the same nature
(Rothschild, 2000). If trauma is not sufficiently dealt with, it could happen that
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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
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discuss in regard to the impact of traumatic incidences in midwifery. The


probability of fatal outcome in Air Traffic Control is comparable to birth
processes, as fortunately having a rather low probability. Yet, a fatal or even just
critical outcome in both fields is experienced as highly traumatic for everybody
involved. The CISM program has two aims: (1) to reduce the impact of the
stressful event by facilitating an employees return to work and (2) by educating
the employees about signs and symptoms of traumatic stress and mechanisms to
manage stress. Moreover, additional support or professional referrals to recover
fully are established. The effects of CISM were estimated as successful. Those
who took part in a CISM program mentioned the enlargement of communication
possibilities after critical incidents in the form of supervision, whereas peers
emphasized the avoidance of long-term emotional consequences with substantial
losses of performance capability. The impact of traumatic incidences in
midwifery is, from the authors perspective, largely underestimated. Critical
incidences in air traffic control have a higher impact because more people are
involved and the loss is greater than losing a single child under birth. However,
the impact on the employee stays the same regardless if one person is lost or
many. Vogts study points to the importance of establishing formal support
systems for traumatic incidences in order to support the employee instantly and
professionally. The economical evaluation of the CISM program showed a
financial gain for the company. The same is estimated by the author to be true
for formal support programs in midwifery once fully established. Yet, in
midwifery it is on the background of what was said about the importance of
implicit knowledge in the natural process of giving birth regarded as important
to establish support in regaining trust and confidence in implicit knowledge
processes proposing something beyond a cognitive stress management
technique.
8.6 Summary and conclusion of the explorative case investigation
The findings of the present investigation point to the importance of the primary
task as a source of positive work experiences, which in turn balance the negative
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influences. In this sense, positive work experiences - being frequent in


midwifery - are regarded as an important resource and a buffer against high
demands and otherwise low resources (financial reward, recognition from
supervisors, colleagues and clients, etc.). This resource is threatened by
segmentation of the task and by growing demands of clients in regard to security
and controllability of the birthing process. A midwifes core competency is
helping to give birth the natural way. However, there is a trend in birthing to
rely more and more on technical devices and other medical support when
birthing a child. Furthermore, modern hospital organisation is modelled after
economical market principles. In the field of midwifery, it becomes obvious that
this approach has definite disadvantages, leading, for example, to a form of
resource allocation practice which does not take the task specific demands into
account. In the present investigation, it was shown that structural conditions
surrounding the organization of the primary task have an influence on the vigour
and well-being with which the task is and can be accomplished. Personal factors
were not investigated in depth though it was found that the group of midwives is
characterised by an idealistic self-image which is hard to live up to. Nonreciprocity of idealized-self and real-self, combined with the structural
limitations (low resources), leads to frustration about the conditions at work
(Freudenberger & Richelson, 1980).
The present study has further shown the impact of emotional demands and
feelings in midwifery. On the whole, emotions in contemporary work settings
receive higher recognition as being important for health and well-being than
even ten years ago (Ashkanasy et al., 2000). Zapf (1999) pointed to the necessity
of including emotional demands in burnout research in the field of human
service work. However, until now, emotional labour has not been a defined part
of the primary task of a midwife. Hence, emotional labour is done in ad hoc
action by a single person (in best case supported by her supervisor) and not as an
explicit strategy implemented at the workplace. Of particular interest is that
emotional labour in a field of work which obviously deals with the whole range
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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.

8.6.1 Strengths and limitations


As reported at the beginning of this Ph.D. thesis, most research on the
relationship between motivation and burnout is of quantitative nature, neglecting
the importance of defining the phenomena of motivation and burnout in context.
The investigation of midwifery as being a singular case in human service work
has shown that the interpretation of outcome is, to a high degree, dependent on
context variables. The understanding of burnout and engagement as a practice
concept of disease/motivation, taking conditional factors in midwifery into
account, emerged as being of high importance for the discussion of the
relationship of motivation and burnout.
A comparison between data from PUMA and data from the present case is
helpful in order to highlight one positive aspect of the explorative in-depth
investigation of the relationship between motivation and burnout. In PUMA, a
newly established questionnaire to measure forms of emotional exhaustion in
regard to clients, to work, and personal exhaustion was applied to measure
burnout (Kristensen et al., 2005). The open nature of the interviews in the
present case investigation encouraged interpretations beyond the variables used
in the PUMA study. Further, the findings from the interviews indicate that
research results do not necessarily get communicative validation by those who
were investigated. Some of the participating midwives mentioned doubt and
even disbelief in the findings of the PUMA study (see Chapter 4). This is
interpreted by the author as being an outcome of the research method used in
PUMA. This is further regarded as a serious but accepted shortcoming of distal
methods of investigation in applied research. Participants who volunteer to take
part in a research study invest time and effort to answer questions. At the same
time, they expect to get something back. If this expectation is not met, the

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
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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

8.6.2 Transferability of findings and reach of the study


The primary task in midwifery, due to the natural process of giving birth, is
universal. However, differences can be found in the structure, organisation and
even appreciation of giving birth in different cultures. Being pregnant and giving
birth is the most natural and yet also culturally defined process. Differences
between the way midwives work in urban and rural areas are close at hand. As
other parts of the health care system, midwifery is dependent on the values,
mindsets, and not least financial possibilities of the participating actors on the
local level. However, the strong emphasis on the primary task, the changing
demands of modern clients (recent birthing generation), the possibility of
experiencing trauma in relation to the work task, and the reduced resources in
modern health care systems is perceived as a general problem in modern
midwifery. Therefore, the findings from the present study are interpreted as
being transferable to other settings. Beyond these findings, it is important to note
that the case study also revealed a tendency in birthing which points to the
fundamental sell-out of ideological and ethical convictions in midwifery. The
findings about generational differences between midwives and between birthing
generations propose a shift in midwifery towards a medicalised and planned
process. From the perspective of the midwives, the organisational structure of
birthing in modern maternity wards (like the one investigated here) is not only
counterproductive but also takes the pinch of mystery away which is inherent in
the primary task of helping to give birth. The more and more sophisticated
prenatal diagnostics further a tendency towards the totally controlled, explicitly
designed, and expectably received child. Maybe, also on the background of this,
the findings indicate insecurity in the present job role, being more and more set
aside or even replaced by a medical doctor. Midwives in Denmark are
increasingly forced to engage in secondary tasks, such as consultations during
pregnancy, teaching of younger midwives, administration and routine tasks in
order to stay motivated in an otherwise less satisfying job.

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

incidences. Low (time) resources lead to the accumulation of negative


feelings and might end in sudden breakdowns.
With the perspective of reaching highest impact (enhanced motivation and less
burnout), the following recommendations for the practice of midwifery are
drawn from the findings of the investigation.
(1) Recent structural and value changes in midwifery have led to a re-definition
of the core actions of the primary task. With reference to Visholm (2004), it is
regarded as important by the author of this Ph.D. thesis to re-define the primary
task, the traditional beliefs, and the borders to other systems in recent Danish
midwifery in order to give back the strong occupational identity which has been
commonly found in midwifery. Assurance about the occupational identity
strengthens the position of the midwife and leads to a more realistic self. The
frictions with clients reported by the participating group of midwives might also
be understood as one example and image of an entangled and distracted selfunderstanding in midwifery being provoked by distressing conditions which
define the borders of the recent system of midwifery.
(2) A formal procedure to support and follow those being confronted with
trauma at work is regarded as being an essential method to minimize the
traumatic stress related to these incidents.
(2) Re-think resource allocation practice and base a new model of resource
allocation on cases at the ward and not number of births per midwife.
(3) As Tausig & Fenwick (2001) proposed, the easiest way to solve the feeling
of work-family imbalance is by giving control over working time back to those
who bind time in the organization. Giving control over shift planning back to the
midwives would have an educating and healing effect for the leadership as well
as for the staff.
254

(4) Offer flexible solutions of work organization in order to take generation


differences and specific needs into account.
(5) Compare different forms of midwifery practice (e.g., the Dutch community
midwife, the British model of maternity care) in regard to the impact they have
on the relationship between motivation and burnout. From the findings of the
present investigation and related research done by others (Bakker et al., 1996;
Hunter, 2004; Hyde & Roche-Reid, 2004), it can be concluded that a different
form of work organization in midwifery in Denmark will have a positive
influence on the serious health status of Danish midwives found in the PUMA
study.
The conclusions drawn from the present case need to be interpreted on the
background of the specific context investigated. New understanding about
burnout and motivation in midwifery in Denmark has grown and at the same
time new questions came about, as new knowledge sets everything known
before into new perspective. The wisdom from this case is regarded as being
creative source for new projects, especially those which put high priority on
understanding well researched phenomena in a specific context.

255

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List of Figures

Figure 2.1 Existential model of burnout.


Figure 2.2 Emotion psychological triangle.
Figure 3.1 Model of different research strategies.
Figure 3.2 Stages of the project investigating the relationship between
motivation and burnout in human service work.
Figure 8.1 Primary and secondary tasks, agents, and structural and conditional
aspects of midwifery.
Figure 8.2 Vicious cycle of declining resources.

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List of Tables

Table 2.1 List of symptoms of burnout


Table 2.2 Chronological listing of common burnout definitions
Table 2.3 Strength and weaknesses of contemporary burnout research
Table 3.1. The average scores on the CBI burnout scales of the jobs in the
PUMA baseline study
Table 3.2. Job classifications in midwifery in Denmark
Table 3.3. Types of observation
Table 3.4. Age profile of midwives working at the ward
Table 3.5. Demographic profile of interview partners in the single interviews
Table 3.6. Research questions and related interview questions
Table 3.7 Interview guide for group interview

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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

Appendix A: Copenhagen Burnout Inventory


Kristensen et al, 2005a
Personal Burnout: a state of prolonged physical and psychological exhaustion.
1.
2.
3.
4.
5.
6.

How often do you feel tired?


How often are you physically exhausted?
How often are you emotionally exhausted?
How often do you think: I cant take it anymore?
How often do you feel worn out?
How often do you feel weak and susceptible to illness?

Response categories: Always, Often, Sometimes, Seldom, Never/Almost never


Less than three questions answered: non-respondent
Work burnout: a state of prolonged physical and psychological exhaustion,
which is perceived as related to the persons work.
1.
2.
3.
4.
5.
6.
7.

Is your work emotionally exhausting?


Do you feel burned out because of your work?
Does your work frustrate you?
Do you feel worn out at the end of the working day?
Are you exhausted in the morning at the thought of another day at work?
Do you feel that every working hour is tiring for you?
Do you have enough energy for family and friends during leisure time?

Response categories: To a very high degree, To a high degree, somewhat, to a


low degree, to a very low degree
Last four questions: Always, Often, Sometimes, Seldom, Never/Almost never
Reversed score for last question
Less than four questions answered: non-respondent
Client burnout: a state of prolonged physical and psychological exhaustion,
which is perceived as related to the persons work with clients. Clients can be
patients, students, children, inmates, or other kinds of recipients of service. It is
recommended to set the wording according to the setting investigated.
1. Do you find it hard to work with clients?
2. Do you find it frustrating to work with clients?
3. Does it drain your energy to work with clients?
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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

273

Appendix B: Demographic questions


Tilmelding til interview
(Send venligst tilbage senest den 1. november 2002. Jeg kan desvrre ikke garantere at alle
tilmeldte vil blive interviewet.)
Navn ___________________________________________
Adresse _________________________________________
Telefon/evt. trffetid ______________________________
Hvad er din jobfunktion?
Ledende jordemoder {
Afdelingsjordemoder {
Jordemoder {
Hvor lnge har du vret ansat p denne afdeling?
Cirka: ____ r og ____ mneder
Hvor lnge har du sammenlagt arbejdet som jordemoder?
Cirka: ____ r og ____ mneder
Har du en anden erhvervsuddannelse og hvis ja, hvilken?
Ja, ______________________________________________
Nej {
Hvor gammel er du? ____ r
Er du gift/samboende?
Ja {
Nej {
Hvor mange hjemmeboende brn har du?
Antal: _____
Hvor mange af disse er under 7 r?
Antal: _____
Har du deltaget i PUMA-undersgelsen?
Ja, i frste runde {
Ja, i anden runde {
Ja, i begge runde {
Nej {
Tak for oplysningerne. Jeg kontakter dig s snart jeg har valgt interviewpersonerne ud fra de
blanketter jeg har fet tilbage.
Venlig hilsen
Sunniva Engelbrecht

274

Appendix C: Interviewguide for single interviews

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?
275

5. Emotions in relation to motivation


Do you remember a situation were you were very motivated?
How would you describe the emotional experience in that situation?
Do you remember a situation where you lost you involvement in the
work? Can you describe the situation and your behaviour?
Exactly, what happened when you lost your motivation?
How would you describe the emotional experience in that situation?
Who/what helped you in that situation?
6. Question about the future
If you imagine you could look ahead in time, where do you stand in
relation to your work one year from today?
7. Closure
Is there something you want to supply?
Thank you!
Ask for permission to contact the interview partner again if necessary.

276

Appendix D: Rules for transcription

All participants get an identification number at the beginning of the


investigation. No names are connected to the transcribed form of the interviews
in order to assure anonymity of the participant.
In case the name of the participant is said in the course of the interview it is
exchanged by IP plus the number of the interview person.
The text is transcribed as heard from the recording. Pauses are marked (pause),
her or other small remarks are also written down in order to be able to take a
look at the flow of the conversation (e.g., hesitation).
The text is formatted in Times New Roman style, 12 point.
Not finished sentences should be finished with . .
Any sound from the tape e.g. latter, which is not spoken is noted in [] brackets.
Spoken words, which are not to understand, are written down as [utydelig tale]
The interviewer is marked as S: (return), the interview person is marked as IP:
(return).
With change of subject should there be double space.
As soon as I have received the transcribed text, the file should be deleted from
your computer (wait until I have affirmed the delivery of the file).
Work address

Home address

Sunniva Engelbrecht
Lers Parkall 105
2100 Kbenhavn

Sunniva Engelbrecht
Katharinenkirchhof 1
20457 Hamburg
Tyskland

sen@ami.dk
0049-40-33395092

277

Appendix E: Guidelines for qualitative research


Malterud, 2001; Steinke, 2000
Aim
Is the research question a relevant issue?
Is the aim sufficiently focused, and stated clearly?
Does the title of the article give a clear account of the aim?
Reflexivity
Are the researchers motives, background, perspectives, and preliminary
hypotheses presented, and is the effect of theses issues sufficiently dealt
with?
Method and design
Are qualitative research methods suitable for exploration of the research
question?
Has the best method been chosen with respect to the research question?
Data collection and sampling
Is the strategy for data collection clearly stated (usually purposive or
theoretical, usually not random or representative)?
Are the reasons for this choice stated?
Has the best approach been chosen; in view of the research question?
Are the consequences of the chosen strategy discussed and compared with
other options?
Are the characteristics of the sample presented in enough depth to
understand the study site and context?
Theoretical framework
Are the perspectives and ideas used for data interpretation presented?
Is the framework adequate, in view of the aim of the study?
Does the author account for the role given to the theoretical framework
during analysis?

278

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