The substantive theory explains the process of health-promoting facilitative conditions in midwives’ work situation
The aim of this study was to explore health-promoting facilitative conditions in the work situation of labour ward midwives, hence having a salutogenic health-promoting approach. The substantive theory of attained
Professional courage to create a pathway within midwives’ fields of work emerged as an explanation of a process of health-promoting facilitative conditions in midwives’ work situations. When fulfilled, the four-stage process of facilitative conditions led to professional courage that can be seen as a resistance resource in the salutogenic model of health [
30]. This courage contributed to sustainable occupational health, where midwives felt empowered, competent and resourceful, as well as having the assets to handle their work situation. Then they had a possibility of developing their profession and standing up for normal births. Another Swedish study found similar results and suggested that the important factors for work satisfaction among midwives and nurses were the possibility of being able to make use of and develop professional competence [
10].
The concept of professional courage was according to this study a prerequisite that made it conceivable to find a health-promoting way of handling the complex and constant changing work situations and managing the movement of creating a pathway between midwives’ fields of work. This professional courage can be interpreted as facilitating a balance between the salutogenic resources and deficits in the work situation [
11] as well as a balance between the different fields of midwives’ work. Further, the findings show that courage led to resistance against being over-medicalised, and the midwives could create a pathway between normal and medicalised births as well as between being autonomous and regulated.
The present substantive theory relates to the three important SOC concepts: comprehensible, manageable and meaningful work situation [
15,
31]. The result of visualising the midwifery profession on an individual, group and societal level can be seen as making the organisation of care more comprehensive for the inter-professional team around the birthing woman. Comprehensibility is described as an important work resource for the possibility of being able to perceive a SOC in the salutogenic theory [
11,
16]. When the organisation clearly visualised the midwifery profession as being responsible for normal births, there were more distinct decision paths and clear roles in the inter-professional team around the birthing woman in this study. This could be understood as making the work comprehensive and enabling a SOC related to the work situation [
11].
One other aspect of the theory was the ability to work autonomously, which has been found in earlier studies to enhance the capacity to cope with the environment even when it is strained [
32]. To be autonomous in work situations can be related to meaningfulness and motivation in regards to work commitment [
12]. Creating the pathway between midwives’ fields of work was a health-promoting resource that led to a feeling of expertise. It is known that autonomy is a job resource that leads to high levels of work engagement [
11]. This engagement can, according to Gregor et al. [
11], in turn lead to a motivational process that buffers the health-impairment process and job-demand deficits, and strengthens job resources. This is supported by a qualitative study that states that practising autonomously increases midwives’ resilience and their feeling of usefulness [
33]. According to the salutogenic model, there is a need for motivational factors [
16], such as autonomy presented in this substantive theory, to access the resistance resources. On the other hand, the findings from this study showed that there was a work overload and time pressure that may inhibit access to these resistance resources [
16].
Sufficient organisational resources is, in this substantive theory, interpreted as leading to an experience of balance between demands and resources and a feeling of manageability. This is supported by Nilsson et al. [
34], who found manageability to be a work-related, specific enhancing resource that increased the employees’ control over their work situation. The interviewed midwives expressed an often-experienced lack of human resources. They were understaffed, but when the employer took control of those factors and created conditions that balanced demands and resources, the midwives experienced a health-promoting workplace for the individual, for the group and within the organisation [
35]. Such a salutogenic and sustainable work situation can in turn affect the performance of high-quality care. In the salutogenic theory, job satisfaction and commitment are described as positively related to resources in the organisation as well as to the intention to stay in a job [
31].
A reflective and learning environment and the feasibility of working as a midwife were noted to create meaningfulness in the work situation and in the profession. During education, midwives pass on knowledge and midwifery skills to the students by a reflective dialog and this was continuously an important part of building the profession to enhance reflexivity and being able to meet the demands in the work situation.
According to the present substantive theory, professional courage and a strong sense of autonomy in the profession are health-promoting and could be understood as facilitating resistance against work stress [
16]. When midwives had a strong professional identity and developed professional courage, they seemed to be able to resist the role of regulated medicalised obstetrical nurses, and instead felt confident in their own abilities and were advocates for normality and midwifery. This result corresponds with a study [
36] about midwives’ professional identity that was described as a negotiation between the external medical model (obstetrical nurse) and the internal definition (professional midwife) connected to the midwives’ philosophy of normal births. It also complies with Hunter and Warrens’ [
37] results of midwives’ workplace resilience when they experience professional belonging and a professional identity.
Women-centred care is interrelated with the salutogenic approach, according to studies from Europe, and is a main goal in midwifery as well as a theoretical perspective [
38,
39]. In this study, women-centred care was seen as an organisational resource to achieve a health-promoting work situation. Although one-to-one care is not offered in Sweden due to the organisation of care, where midwives often care for more than one woman, midwives in this study emphasised that one-to-one care was a health-promoting way of working. On the other hand, medicalised care was considered a deficiency in the work situation. Medicalisation has, according to Johansson et al. [
40], led to the increased involvement of obstetricians and to medical interventions becoming routine in normal childbirth.
The medicalised power structure has generated an overregulation of midwives’ work with a focus on risk factors, where the midwives’ scope of practice has become inferior and invisible, according to the midwives. This may be seen as a generalised resistance deficit [
17]. This is in line with Larsson et al.’s findings that increased medicalisation and organisational changes lead to midwifery handcraft skills and clinical experience being less valued and that this could enhance feelings of a loss of control [
41]. The midwives in the present study could when medicalised feel trapped in the regulated field, unable to create a pathway to the other fields of midwives’ work. This generates resistance from the midwifery profession against medicalised care and against the insufficient room for manoeuvring due to the power hierarchy between midwifery and the prevailing medicalised care. Working between different belief systems and philosophical views on birth can be problematic [
42] and, according to the results in this study, midwives must be able to transact a pathway between the different fields of midwives’ work to enhance reflexivity and to be able to exercise their scope of practice.
To attain
Professional courage and to be able to
create a pathway within midwives’ fields of work, there were preconditions that needed to be fulfilled in a four-stage process to deal with the midwives’ main concern:
Feasibility of working as a midwife. A workplace that provides a supportive social and physical environment and that enables the feasibility of working as a midwife could be seen as a workplace that enabled resources. In a strained and unpredictable work situation, the resources may prevent the tension from being transformed into stress [
43]. Midwives in the present study expressed how they placed high demands on themselves and on the profession. However, if the profession was visualised and they had strong support and high levels of control in a reflective and learning environment that provided organisational resources, it was perceived as manageable. When a work situation is comprehensive and manageable, then positive developments in the work situation and health are possible, according to Gregor et al. [
11].
It is often assumed and demanded from the organisation that a midwife should develop a
professional identity and
grounded knowledge without the prerequisite conditions in the work situation. Thus, demands are made solely of the individual rather than the organisation. The organisation needs to cater for high-quality care and the well-being of its employees; it should not be up to the individual midwife. Hence, the organisation needs to provide the right working conditions and cherish as well as visualise the midwives’ competence. This is in line with a mixed method study that states that midwives’ work in a strained context with lack of support for the supporter and that it could be beneficial to implement midwifery models of care to strengthening midwifery practice [
44].
Taking the theory of Professional courage to create a pathway within midwives’ fields of work to a practical level, we suggest that the emerged organisational resources need to be adapted to the job demands on labour wards, including the midwives’ feasibility of doing their work in accordance with theory, evidence and best practice. Even more concretely, this would mean that the organisation utilises and strengthens the health-promoting facilitative conditions: Visualising midwifery, Organisational resources and a Reflective and learning environment. That, in turn, will enable the feasibility of working as a midwife when fulfilled. Then midwives will have the possibility of developing their professional identity, grounded knowledge and professional courage to move within the different fields of midwives’ work, extending between normal to medicalised birth and being autonomous and regulated. This, in turn, may enable a professional building, characterised by a sustainable work situation with the possibility of being able to mobilise salutogenic resistance resources. This needs to be studied further in future research.
Limitations and strengths
Purposive sampling was used, aiming for a variation in age, time as a midwife and work experience in the current workplace. This turned out to be more difficult than expected. One limitation of this study was that the majority of midwives interested in participating had long work experience. However, when comparing the coding of the different interviews, we could not see any systematic differences between the midwives with long vs. short experiences connected to the main concern. So, the goal of having a wide variety of work experience was shown to be overrated.
Another possible limitation was that the inclusion criteria might have created a sampling bias. The first criterion, being able to understand and speak Swedish, did not lead to sampling bias due to the fact that every midwife had to adhere to that criterion to be able to work on the labour ward. The last criterion, having at least 1 year of work experience as a midwife on the labour ward, was decided on because the first year is assumed an evolutionary period during which it is presumed that it is difficult to reflect on the work situation.
A constant comparative CGT was used to ensure the credibility of the results in this study [
45]. Four of the authors are midwives with experience of labour ward work, which is a strength. However, this could lead to interpretive bias due to a pre-understanding of the interviews, context and emerged theory. This potential bias is counterbalanced by the fact that two of the authors are not midwives but operate in other fields, which enables another understanding of the material, context and analysis. The pre-understanding was continuously discussed during the whole process.
Another strength is that the results focus on salutogenic health-promoting facilitative conditions in midwives’ work situations and therefore on what retains them in their work on labour wards – an area that has scarcely been researched.
CGT should be abstracted from time, place and people [
25] and is considered to be valid in another similar context, even if the study is done within a certain geographic area. The results in this study could therefore be valid in similar labour ward contexts where midwives work autonomously and is responsible for the professional domain of normal births. Although the strong connection to the profession probably exists regardless of organisation, country or context.
To review the validity and reliability of this study, we used the CGT criteria: fit, relevance, workability and modifiability [
25]. During the analysis, a constant comparison of the concepts and the empirical data was undertaken, which led to a modification of the concepts so that they fitted the events they represented. This study seems to have relevance in the area of salutogenic health-promoting facilitative conditions in midwives’ work situations on labour wards since it evoked recognition by clinical colleagues when presented to them prior to publication. The professional courage to create a pathway within midwives’ fields of work represents the CGT concept of “workability” and the way in which midwives solve their main concern:
Feasibility of working as a midwife. However, the emergent prerequisite conditions needed to be fulfilled to be able to attain that level of reflexivity. The theory of professional courage to create a pathway within midwives’ fields of work was modified during the analytical process. The generated substantive theory is also modifiable if new data were to be collected from other labour wards or other fields of practice in future studies [
45]. There is a need for further research about primarily salutogenic but also pathogenic aspects of midwives’ work situations to ensure health-promoting working lives for midwives.