PROFESSIONAL BURNOUT AMONG

MIDWIVES: CAUSES AND

CONSEQUENCES

E. BRIE THUMM, CNM, PHD, MBA

Work came to evoke the same response as getting

caught in LA rush hour traffic. Hopelessly helplessly

stuck somewhere I didn’t want to be; there was

seemingly no way for me to get where I wanted to go.

The system in all its complexities felt to be specifically

and particularly bent on impeding my efforts to provide

quality, efficient and effective care.

Anonymous midwife

OBJECTIVES

Objective 1: Define burnout, including causes and symptoms.

Objective 2: Identify conditions of provider distress related to and frequently mistaken for burnout.

Objective: Compare the prevalence of burnout among CNMs/CMs to related groups.

Objective 3: Identify structural characteristics of midwifery practices that are related to high levels of burnout.

Objective 3: Identify modifiable characteristics of the midwifery practice climate that are related to high levels of burnout.

Objective 6: Create strategies to cultivate engagement and prevent burnout.

I was burned out from

exhaustion, buried in the hail

Poisoned in the bushes an’

blown out on the trail

Hunted like a crocodile,

ravaged in the corn

“Come in,” she said, “I’ll give

you shelter from the storm”

Bob Dylan

DEFINE BURNOUT

A psychological condition in which an individual responds to chronic professional stressors with pathologic levels of:

• Emotional exhaustion

• Depersonalization/Cynicism

• A sense of lack of personal accomplishment/efficacy

(Maslach et al., 2001)

The extinction of motivation or incentive, especially

where one’s devotion to a cause or relationship fails to

produce the desired result.

(Freudenberger, 1974)

I felt like a pod person---every activity of every day was just a mindless process of going through the motions---the minimal amount of activity just to get through--- from getting up, to showering, to getting dressed, getting to work and then being at work---just rote motion after rote motion after rote motion. I just felt like my motor completely died---I had zero reserve---and yet I just kept going, kept pushing even though I couldn't really think. I felt dead.

Anonymous midwife

SYMPTOMS OF BURNOUT

Exhaustion

Impaired concentration

Insomnia

Anxiety

Loss of appetite

Feeling hopeless

Increased illness

Loss of enjoyment

Cynicism

Detachment

Isolation

Irritability

DIFFERENTIAL DIAGNOSES

▪ Compassion Fatigue

▪ Moral Distress

▪ Vicarious trauma

▪ Post Traumatic Stress Disorder

COMPASSION FATIGUE

“Progressive and cumulative process that is caused by prolonged,

continuous, and intense contact with patients, the use of self, and

exposure to stress… a state where the compassionate energy that is

expended by [midwives/NPs] has surpassed their restorative

processes, with recovery power being lost.” (Coetzee, & Klopper,

2010)

MORAL DISTRESS

“The person is aware of a moral problem, acknowledges moral

responsibility, and makes a moral judgement about the correct action; yet, as

a result of real or perceived constraints, participates in perceived moral

wrongdoing.” (American Nursing Association, 2015)

VICARIOUS TRAUMA

“The response of those persons who have witnessed, been subject to

explicit knowledge of, or had the responsibility to intervene in a

seriously distressing or tragic event” (Lerias & Byrne, 2003)

• Also known as secondary trauma

POSTTRAUMATIC STRESS DISORDER

Exposure to actual or threatened death, serious injury, or sexual violence in one of

the following ways:

• Directly experiencing the traumatic event.

• Witnessing, in person, the event as it occurred to others.

• Learning that the traumatic event occurred to a close family member or close

friend. In cases of actual or threatened death of a family member or friend, the

event must have been violent or accidental.

• Experiencing repeated or extreme exposure to aversive details of the

traumatic event (e.g. first responders collecting human remains).

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA: American Psychiatric Publishing.

Burnout

Compassion fatigue

Vicarious traumaPTSD

Moral Distress

Stamm, 2010; Mathieu, 2012

Consequences of Burnout

Patient level

Patient satisfaction1

Quality of care2

Failure to rescue3

Longer discharge recovery time4

Hospital acquired infections5

Provider level

Physical health

• Hypothalmic pituitary axis6

• Alcohol dependence7

• Depression8

Organization levelJob satisfaction9

Absenteeism10

Intention to leave one’s job11

Profession levelLeaving the profession

• UK12

• Sweden13

1,2Aiken et al., 2012, 3 Aiken et al., 2002,4Halbesleben & Rathert, 2008; 5 Cimiotti, Aiken, Sloane & Wu, 2012, 6 Pruessner, Hellhammer & Kirschbaum, 1999, 7Sinokki et al., 2009,8 Govardhan, Pinelli & Schnatz,

2012, 9Govardhan, Pinelli & Schnatz, 2012, 10 Hanebuth, Meinel, & Fischer, 2006, 11 Leiter, M. P., & Maslach, 2009,11 Leiter & Maslach, 2009, Gregory et al., 2009, 12 Curtis, Ball & Kirkham, 2006, 13 Hildingsson,

Westlund & Wiklund, 2013

WorkEngagement

ProfessionalBurnout

WorkforceOutcomes

Job Demands-Resources Model

-

-

-

+Patient

Outcomes

Adapted from “The Job Demands-Resources Model: State of the art,” by A.B. Bakker & E. Demerouti, 2007, Journal of Managerial Psychology, 22(3), p. 309-328.

Perceiveddemands & resources in the practice environment

+

+

-

n=330 x 2 subsamples (n=660) of 330 respondents who completed MPCS in its

entirety randomly selected for EFA and CFA

n= 2685 completed all or part of the scales(202 did not complete any scale items)

n=2887 met inclusion criteria(555 did not meet inclusion criteria)

n=3442 CNMs/CMs responded to survey (30.8%)

n=1673 remaining sample for model testing

352 cases removed for missing >20% of any of the 5 scales

Remaining 2025 respondents assessed for missing data

Burnout Survey(n=2,333)

ACNM 2012(n=1,970)

AMCB 2013

(n=1,323)

Age 47.23 (11.8) 51.4 (11.6) 45.5 (15.2)

Years as a midwife 13.86 (10.3) 15.9 (10.8) 19.3 (8.0)

Gender

Female

Male

Transgender

Missing/Unknown

2273 (99.0)

20 (0.9)

2 (0.1)

38 (1.6)

1925 (97.7)

19 (1.0)

NA

26 (1.3)

348 (26.3)

4 (0.3)

NA

971 (73.4)

Race

American Indian/Alaskan Native

Asian

Black/African American

Caucasian/White

2 or more races

Other

Unknown/missing/not reporting

6 (0.3)

17 (0.7)

84 (3.7)

2064 (90.0)

64 (2.8)

13 (0.6)

83 (3.6)

5 (0.3)

9 (0.5)

58 (2.9)

1804 (91.6)

NA

43 (2.2)

48 (2.4)

6 (0.4)

13 (1.0)

38 (2.9)

724 (54.7)

1 (0.1)

4 (0.3)

519 (39.2)

Employment status

Full-time

Part-time

Per diem

Unknown/missing

1849 (79.3)

387 (16.6)

95 (4.1)

2 (0.1)

1392 (70.7)

379 (19.2)

NA

4 (0.2)

529 (40.0)

202 (15.3)

NA

369 (27.9)Fullerton, J., Sipe, T. A., Hastings-Tolsma, M., McFarlin, B. L., Schuiling, K., Bright, C. D., . . . Krulewitch, C. J. (2015). The Midwifery Workforce: ACNM 2012 and AMCB 2013 Core Data. J Midwifery Womens Health, 60(6), 751-761. doi:10.1111/jmwh.12405

Burnout Survey(n=2,333)

ACNM 2012(n=1,970)

AMCB 2013

(n=1,323)

Public hospital/university-affiliated

hospital

596 (25.6) 543 (27.6) 363 (27.4)

Private hospital/medical center 441 (18.9)

Educational Institution NA 238 (12.1) 115 (8.7)

Private physician-owned group practice 513 (22.0) 414 (21.0) 197 (14.9)

Private midwifery-owned group practice 86 (3.7) 157 (8.0) 91 (6.9)

Private solo CNM/CM practice 60 (2.6) NA NA

Private birthing center 88 (3.5) NA NA

HMO 114 (4.9) NA NA

Community health center 222 (9.5) 148 (7.5) 81 (6.1)

Family planning clinic 41 (1.8) NA NA

Nonprofit Health Agency NA 83 (4.2) 71 (5.4)

Military hospital or sites 61 (2.6) 25 (1.3) 17 (1.3)

Federal Government NA 35 (1.8) 19 (1.4)

Correctional facility/detention center 2 (0.1) NA NA

Other 108 (4.6) 119 (6.0) 0 (0.0)

Unknown/missing 1 (0.0) 208 (10.6) 369 (27.9)Fullerton, J., Sipe, T. A., Hastings-Tolsma, M., McFarlin, B. L., Schuiling, K., Bright, C. D., . . . Krulewitch, C. J. (2015). The Midwifery Workforce: ACNM 2012 and AMCB 2013 Core Data. J Midwifery Womens Health, 60(6), 751-761. doi:10.1111/jmwh.12405

Instruments

Midwifery Practice Climate Scale (10 items)2 subscales (Support for the Midwifery Model of Care and Practice Leadership and Participation)

Cronbach’s alpha coefficient 0.87-0.90 (Thumm, 2017)

Maslach Burnout Inventory (22 items)Gold standard in burnout instruments (Maslach & Jackson, 1981)

3 subscales (emotional exhaustion; depersonalization; lack of efficacy)

Cronbach’s alpha in U.K. midwife sample 0.69-0.80 (Sandall et al., 1998)

Utrecht Work Engagement Survey (9 items)3 subscales (vigor, dedication, absorption)

Cronbach’s alpha in 2 Irish midwife samples 0.88 and 0.90 (Freeney & Fellenz, 2013a, 2013b)

Job outcomes scale (4 items)3 items with low Cronbach’s alpha (0.32) (Van Bogaert, Kowalski, Weeks, & Clarke, 2013)

Inter-item correlation “fair to moderate” (0.15-0.21)

Personal communication with author of scale reported the “scale” performed well in modeling

Midwife-perceived quality of care scale (2 items)Items validated to correlate with standard care indicators (Aiken et al., 2012)

Cronbach’s alpha in Irish midwife sample 0.75 (Freeney & Fellenz, 2013a)

BURNED

OUT

40.6%59.4%

PREVALENCE OF BURNOUT AMONG CNMS/CMS

n=2,333

2017 40.6%

23.9

(12.61)

5.47

(5.38)

40.98

(5.66)

0

10

20

30

40

50

EMOTIONAL EXHAUSTION DEPERSONALIZATION LACK OF SENSE OF PERSONAL

EFFICACY

THE 3 ELEMENTS OF BURNOUT

Subscales MBI test

norms

(n=11,041;

Maslach &

Jackson,

1981)

England

(n=128;

Yoshida &

Sandall,

2013)

Poland

(n=59;

Kalicinska,,

Chylinska,

& Wilczek-

Rozyczka,

2012)

Australia

(n=56;

Mollart,

Skinner,

Newing &

Foureur,

2013)

CNMs

/CMs in

the U.S. in

2017

(n=2,333)

Emotional

Exhaustion22

(5.53)

32.9

(9.70)

23.6

(11.03)

20.23

(11.20)

23.9

(12.61)

Depersona

lization7

(5.22)

9.1

(4.35)

7.10

(5.74)

4.98

(4.83)

5.5

(5.34)

Lack of

Personal

Efficacy

43.7

(7.34)

45.8

(5.97)

21.2

(11.10)

34.5

(7.53)

41.0

(5.66)

CONSEQUENCES OF BURNOUT

BURNOUTWORKFORCE

STABILITY

r2= .238, p<.001

n=1673

= .488, p<.001

I saw no alternative but to get out; but now I’ve

lost far more than my income. I’ve lost my

community. I’ve lost purpose and meaning, an

identity that I had had for most of my adult life.

Anonymous midwife

BURNOUTQUALITY OF

CARE

r2=.115, p<.001

n=1673

-.340= . p<001

I felt so mad at both of them [patient and family

member]. I felt myself blaming them in an ugly, of

course, unwarranted, way, mad at myself, of course,

just mad---and exhausted.

Anonymous midwife

CAUSES OF BURNOUT

STRUCTURAL CHARACTERISTICS

PRACTICE CLIMATE

Do I feel

supported by

my practice?

STRUCTURAL CHARACTERISTICS

Upstate University Hospital, accessed 2018

NO

YES

NO

NO

YES

YES

YES

Patient acuity

Patient SES

Attend births

Practice location

Training of

decision-makers

Patient insurer

Daily patient loadAll findings p<.05, n=2333

Number of Birth

Locations

Birth Location

All findings p<.05, n=2333

Size of practice

Shift versus call

Birth volume

Shifts Worked

YES

NO

NO

YES

YES

YES

PRACTICE LOCATION

2.61

(1.41)

2.68

(1.40)2.58

(1.37)

2.82

(1.41)

0

1

2

3

4

5

6

Urban (n=936) Rural (n=353) Suburban (n=550) Mixed (n=459)

F(3,2294)=2.93,

p=.032; n=2298

DELIVERY LOCATION

2.65

(1.38)

2.65

(1.27)1.70

(1.44)

2.70

(1.34) 2.14

(1.30)

2.83

(1.40)2.64

(1.12)

0

1

2

3

4

5

6

Hospital

(n=1625)

Birth center

(n=49)

Home

(n=27)

Hospital &

birth center

(n=118)

Hospital &

home (n=14)

Birth center

& home

(n=28)

Hospital,

birth center

& home

(n=9)

n=1870; p<.05

F(6,1863), p=.018;

n=1868

BIRTH VOLUME (BIRTHS/YEAR)

2.07

(1.42)

2.70

(1.35)

2.75

(1.41)2.60

(1.34)

0

1

2

3

4

5

6

<50 (n=113) 50-199 (n=380) 200-499 (n=630) >500 (n=745)

F(3,1864)=8.35,

p<.001; n=1868

DAILY OUT-PATIENT PATIENT LOAD

2.21

(1.36)

2.50

(1.33)

2.75

(1.37)

2.76

(1.43)

3.17

1.50

2.16

(1.38)

0

1

2

3

4

5

6

<10 pts/day

(n=178)

10-15 pts/day

(n=530)

16-20 pts/day

(n=868)

21-25 pts/day

(n=437)

>25 pts/day

(n=181)

I don't work in an

out-patient

setting (n=104)

F(5,2292)=14.00,

p<.001; n=2298

2.41

(1.38)

2.66

(1.37)

3.00

(1.49)

0

1

2

3

4

5

6

Low risk (569) Moderate risk (n=1350) High risk (n=379)

F(2,2295)=20.21,

p<.001; n=2298

PATIENT ACUITY

TRAINING OF PRIMARY DECISION-MAKER

2.42

(1.31)

2.95

(1.45)

0

1

2

3

4

5

6

CNM/CM Non-CNM/CM

t(2122.45)=-9.05,

p<.001; n=2,294

SHIFTS WORKED

1.97

(1.23)

2.63

(1.44)

2.67

(1.38)

0

1

2

3

4

5

6

Nights (n=51) Day (n=654) Mixed days/nights (n=1589)

F(2,2291)=6.66,

p<.001; n=2,294

EMPLOYMENT STATUS

2.72

(1.40) 2.43

(1.35)2.24

(1.52)

0

1

2

3

4

5

6

Full-time (n=1823) Part-time (n=383) Per diem (n=91)

F(3,2295)=7.58,

p<.001; n=2,299

PRACTICE CLIMATE

Nicole Monet, 2017

BURNOUT RISK FACTORS: THEORY OF WORKLIFE

MISMATCH

Leiter & Maslach, 1999

Reward

Control

Community

Fairness

Values

MIDWIFERY PRACTICE CLIMATE SCALE

Practice Leadership and Participation

Support for the Midwifery Model of Care

Thumm, 2017

Practice Leadership and Participation

I feel valued in my practice environment.

Practice leadership is open to midwife ideas to improve patient care.

Midwives are represented on important committees in my practice and/or

hospital.

Practice leadership takes midwife concerns seriously.

Practice leadership makes efforts to improve working conditions for midwives.

I regularly get feedback about my performance from my practice leadership.

There is effective communication between midwives and practice leadership.

Support for the Midwifery Model of Care

My practice environment understands the Midwifery Model of Care.

My practice environment values the Midwifery Model of Care.

Midwifery care is based on a Midwifery Model of Care, rather than a medical

model.

PRACTICE

LEADERSHIP AND

PARTICIPATION

r2= .256, p<0.001

n=1673

= -.506 p<.001

r2= .156, p<0.001

n=1673

SUPPORT

MIDWIFERY MODEL

OF CARE

= -0.40, p<.001

THE INTERSECTION OF STRUCTURE AND CLIMATE

Nicole Monet, 2017

Training of

decision-

makers 3.6%

Practice

Climate21.4%

BURNOUT

25.0%

*NOTE: ANALYSIS CONDULTED USING HIERARCHTICAL REGESSION ANALYSIS, % REFERS TO VARIANCE IN

BURNOUT SCORE EXPLAINED; ALL SIGNIFICANT AT p,.001

Daily

patient

load 1.7%

Practice

Climate 23.4%

BURNOUT

25.3%

Patient

Acuity 1.5%

Practice

Climate 23.5%BURNOUT

25.0%

Training of

Decision-

maker

3.6%Practice

Climate

21.4%

????

75%

WHAT CAN WE TO PREVENT AND TREAT BURNOUT?

•Practice/Management Level

•Individual Level

•The Midwife Level

MANAGEMENT LEVEL

• Increase participation of midwives on meaningful committees

• Improve leadership

•Allow for employment status flexibility

• Foster support for the midwifery model of care

• Start the conversation with your organization about midwife well-being

I HAVE COME TO BELIEVE THAT CARING FOR MYSELF IS NOT SELF INDULGENT. CARING FOR MYSELF IS AN ACT OF SURVIVAL.

AUDRE LORDE

Nicole Monet, 2017

THE MIDWIFE LEVEL

1. Create HR toolkit

2. Participate in inter-disciplinary trainings

3. Clinical teaching/shadowing

4. Talk with colleagues about midwifery

5. Become involved

6. Give positive feedback

7. Allow colleagues to have boundaries

8. Integrate a 3-5 minute mindfulness mediation into staff meetings/handoffs

9. Random acts of kindness for each other

10. Graciously allow for flexibility of practice members

11. Monitor your practice for burnout

12. Avoid stigmatization and judgement around burnout

14th Dalai Lama

If you want others to be happy, practice

compassion. If you want to be happy,

practice compassion.

WHAT ABOUT THE MIDWIVES WHO DIDN’T RESPOND?

WHAT CAUSES THE OTHER 75%?

DEVELOPING AND TESTING INTERVENTIONS BASED ON THESE

FINDINGS?

HOW SHOULD WE DISSEMINATE THESE FINDINGS TO CHANGE

PRACTICE?

FUTURE RESEARCH

New Statesman; accessed 2018

WHERE TO NEXT MIDWIVES?

Ahola, K., Honkonen, T., Pirkola, S., Isometsa, E., Kalimo, R., Nykyri, E.. . Lonnqvist, J. (2006). Alcohol dependence in relation to burnout among the Finnish

working population. Addiction, 101(10), 1438-1443. doi:10.1111/j.1360-0443.2006.01539.x

Aiken, L. H., Clarke, S. P., Sloane, D. M., Sochalski, J., & Silber, J. H. (2002). Hospital nurse staffing and patient mortality, nurse burnout, and job

dissatisfaction. JAMA, 288(16), 1987-1993.

Aiken, L. H., Sermeus, W., Van den Heede, K., Sloane, D. M., Busse, R., McKee, M., . . . Kutney-Lee, A. (2012). Patient safety, satisfaction, and quality of

hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States. BMJ, 344, e1717. doi:10.1136/bmj.e1717

Atallah, F., McCalla, S., Karakash, S., & Minkoff, H. (2016). Please put on your own oxygen mask before assisting others: a call to arms to battle burnout.

Am J Obstet Gynecol, 215(6), 731 e731-731 e736. doi:10.1016/j.ajog.2016.08.0298Shanafelt, T.D., Hasan, O., Dyrbye, L.N., et al. (2015). Changes in burnout and satisfaction with work-life balance in physicians and the

general U.S. working population between 2011 and 2014. Mayo Clinic Proceedings, 90, 1600-1613.54Govardhan, L.M., Pinelli, V., Schnatz, P.F., (2012) Burnout depression and job satisfaction in obstetrics and gynecology residents.

Connecticut Medicine, 76, 389-95.37Block, M., Ehrenworth, J.F., Cuce, V.M., (2013) Measuring handoff quality in labor and delivery: development, validation, and application

of the Coordination of Handoff Effectiveness Questionnaire. Joint Commission journal on quality and patient safety, 39, 213-20.55 Beaver, R. C., Sharp, E. S., & Cotsonis, G. A. (1986). Burnout Experienced by Nurse-Midwives. Journal of Nurse-Midwifery, 31(1), 3-

15.56Rath, K.S., Huffman, L.B., Phillips, G.S., Carpenter, K.M., Fowler, J. M., (2015) Burnout and associated factors among members of the Society

Gynecologic Oncology. American Journal of Obstetrics and Gynecology, 213 (824), e1-9.57Gabbe, S. G., Webb, L.E. Moore, D. E. Jr., Mandel Melville, J.L., Spickard, W.A. Jr., Can mentors prevent and reduce burnout in new chairs of

departments of obstetrics and gynecology: results from a prospective, randomized pilot study. American Journal of Obstetrics and Gynecology,

198 (824), e1-7.

Bakker, A. B., & Demerouti, E. (2007). The job demands-resources model: State of the art. Journal of Managerial Psychology, 22(3), 309-328.

Cimiotti, J. P., Aiken, L. H., Sloane, D. M., & Wu, E. S. (2012). Nurse staffing, burnout, and health care-associated infection. American Journal of Infection

Control, 40(6), 486-490. doi:10.1016/j.ajic.2012.02.029

Clarke, S. P. (2006). Organizational climate and culture factors. Annual Review of Nursing Research, 24, 255.

Coetzee, S. K., & Klopper, H. C. (2010). Compassion fatigue within nursing practice: A concept analysis. Nursing & health sciences, 12(2), 235-243.

REFERENCES

Fenwick, J., Sidebotham, M., Gamble, J., & Creedy, D. K. (2017). The emotional and professional wellbeing of Australian

midwives: A comparison between those providing continuity of midwifery care and those not providing continuity. Women

and Birth.

Freudenberger, H. J. (1974). Staff burn‐out. Journal of Social Issues, 30(1), 159-165.

Fullerton, J., Sipe, T. A., Hastings-Tolsma, M., McFarlin, B. L., Schuiling, K., Bright, C. D., . . . Krulewitch, C. J. (2015). The Midwifery

Workforce: ACNM 2012 and AMCB 2013 Core Data. J Midwifery Womens Health, 60(6), 751-761. doi:10.1111/jmwh.12405

Govardhan, L. M., Pinelli, V., & Schnatz, P. F. (2012). Burnout, depression and job satisfaction in obstetrics and gynecology

residents. Connecticut Medicine, 76(7), 389.

Gregory, B. T., Harris, S. G., Armenakis, A. A., & Shook, C. L. (2009). Organizational culture and effectiveness: A study of values,

attitudes, and organizational outcomes. Journal of Business Research, 62(7), 673-679. doi:10.1016/j.jbusres.2008.05.021

Halbesleben, J. R. B., & Rathert, C. (2008). Linking physician burnout and patient outcomes: exploring the dyadic relationship

between physicians and patients. Health Care Management Review, 33(1), 29.

Hanebuth, D., Meinel, M., & Fischer, J. E. (2006). Health-related quality of life, psychosocial work conditions, and absenteeism in

an industrial sample of blue- and white-collar employees: a comparison of potential predictors. Journal of Occupational and

Environmental Medicine, 48(1), 28-37. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16404207

Henriksen, L., & Lukasse, M. (2016). Burnout among Norwegian midwives and the contribution of personal and work-related

factors: A cross-sectional study. Sexual & Reproductive Healthcare, 9, 42-47.

Hildingsson, I., Fenwick, J., Avdelningen för, o., Fakulteten för, h., & Mittuniversitetet. (2015). Swedish midwives' perception of

their practice environment – A cross sectional study. Sexual & Reproductive Healthcare, 6(3), 174-181.

doi:10.1016/j.srhc.2015.02.001

Hildingsson, I., Westlund, K., & Wiklund, I. (2013). Burnout in Swedish midwives. Sex Reprod Healthc, 4(3), 87-91.

doi:10.1016/j.srhc.2013.07.001

James, L. A., & James, L. R. (1989). Integrating work environment perceptions: Explorations into the measurement of meaning.

Journal of Applied Psychology, 74(5), 739-751. doi:10.1037/0021-9010.74.5.739

Cohen, R., Leykin, D., Golan-Hadari, D., & Lahad, M. (2017). Exposure to traumatic events at work, posttraumatic

symptoms and professional quality of life among midwives. Midwifery, 50, 1-8.

Creedy, D. K., Sidebotham, M., Gamble, J., Pallant, J., & Fenwick, J. (2017). Prevalence of burnout, depression, anxiety and

stress in Australian midwives: A cross-sectional survey. BMC Pregnancy and Childbirth, 17(1), 13. doi:10.1186/s12884-016-

1212-5

Curtis, P., Ball, L., & Kirkham, M. (2006). Ceasing to practise midwifery: working life and employment choices. British

journal of midwifery, 14(6), 336-338.

Denison, D. R. (1996). What is the Difference between Organizational Culture and Organizational Climate? A Native's

Point of View on a Decade of Paradigm Wars. The Academy of Management Review, 21(3), 619-654.

Jepsen, I., Juul, S., Foureur, M., Sørensen, E. E., & Nøhr, E. A. (2017). Is caseload midwifery a healthy work-form? A survey

of burnout among midwives in Denmark. Sexual & Reproductive Healthcare, 11, 102-106.

Kalicinska, M., Chylinska, J., & Wilczek-Rozyczka, E. (2012). Professional burnout and social support in the workplace

among hospice nurses and midwives in Poland. International Journal of Nursing Practice, 18(6), 595-603.

doi:10.1111/ijn.12003

Leiter, M. P., & Maslach, C. (2009). Nurse turnover: the mediating role of burnout. Journal of Nursing Management, 17(3),

331-339.

Lerias, D., & Byrne, M. K. (2003). Vicarious traumatization: Symptoms and predictors. Stress and Health, 19(3), 129-138.

Newton, M. S., McLachlan, H. L., Willis, K. F., & Forster, D. A. (2014). Comparing satisfaction and burnout between

caseload and standard care midwives: Findings from two cross-sectional surveys conducted in Victoria, Australia. BMC

Pregnancy and Childbirth, 14(1), 426. doi:10.1186/s12884-014-0426-7

Panagioti, M., Panagopoulou, E., Bower, P., Lewith, G., Kontopantelis, E., Chew-Graham, C., ... & Esmail, A. (2017).

Controlled interventions to reduce burnout in physicians: a systematic review and meta-analysis. Jama internal

medicine, 177(2), 195-205.

Pruessner, J. C., Hellhammer, D. H., & Kirschbaum, C. (1999). Burnout, perceived stress, and cortisol responses to awakening. Psychosomatic Medicine, 61(2), 197.

Schaufeli, W. B., Martinez, I. M., Marques Pinto, A., Salanova, M., & Bakker, A. B. (2002). Burnout and engagement in university students: A cross-national study. Journal

of Cross-Cultural Psychology, 33(5), 464-481. doi:http://dx.doi.org/10.1177/0022022102033005003

Sidani, J. E., Shensa, A., Radovic, A., Miller, E., Colditz, J. B., Hoffman, B. L., ... & Primack, B. A. (2016). Association between social media use and depression among US

young adults. Depression and anxiety, 33(4), 323-331.

Sinokki, M., Hinkka, K., Ahola, K., Koskinen, S., Klaukka, T., Kivimäki, M.. . Virtanen, M. (2009). The association between team climate at work and mental health in the

Finnish health 2000 study. Occupational and Environmental Medicine, 66(8), 523-528. doi:10.1136/oem.2008.043299

Thumm, E. B., & Flynn, L. (2018). The Five Attributes of a Supportive Midwifery Practice Climate: A Review of the Literature. J Midwifery Womens Health, 63(1), 90-

103. doi:10.1111/jmwh.12707

Van Bogaert, P., Kowalski, C., Weeks, S. M., Van Heusden, D., & Clarke, S. P. (2013). The relationship between nurse practice environment, nurse work characteristics,

burnout and job outcome and quality of nursing care: A cross-sectional survey. International Journal of Nursing Studies, 50(12), 1667.

doi:10.1016/j.ijnurstu.2013.05.010

Yoshida, Y., & Sandall, J. (2013). Occupational burnout and work factors in community and hospital midwives: A survey analysis. Midwifery, 29(8), 921-926.

doi:10.1016/j.midw.2012.11.002