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Motivation and burnout in human service work

The case of midwifery in Denmark

Sunniva Engelbrecht

AMI 2006. Ph.d. afhandling 281 s.
Bogomtale fra forlaget.

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 (2002- 2003), 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; Büssing, 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 author’s 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 of the midwife’s 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 one’s 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 post 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.