In recent years, perinatal care in Japan has undergone marked changes that have included the concentration and prioritization of delivery facilities due to the declining birth rate and a shortage of obstetricians, as well as an increased number of high-risk deliveries resulting from advances in perinatal medicine. Accordingly, the construction of a safe and high-quality system of perinatal medical   care   is   becoming   an   issue.   Midwives  are responsible for caring for independent low-risk mothers and children, and striving to ensure a safe and comfortable delivery, while also being called upon to provide life-saving and intensive care to high-risk mothers and children, including the psychological, social, and ethical aspects entailed by the care that goes along with this. It has been reported that approximately 40% of midwives working  in university hospitals  responsible  for advanced perinatal care have less than five years of experience (Saitō et al., 2011). This demonstrates the high turnover rate among midwives and the reality that care is for the most part provided by midwives with little experience, and so it is easy to imagine the stress felt by midwives working in these situations.

Studies of stress among midwives have included reports of difficult feelings with respect to burnout (Fenwick et al., 2018), workplace stress (Geraghty et al., 2018) and professional stress (Wright et al., 2018). In Japan, studies of the few midwives employed at hospitals are limited, and in most cases, midwives are regarded as a subcategory of the nursing profession. Although these reports focused on how to prevent negative outcomes, more recent interest has targeted positive working factors, in the context of which the idea of “work engagement” (WE) has drawn considerable attention. WE have been defined as “a positive, fulfilling, work-related state of mind” (Schaufeli et al., 2002). Improving WE has been shown to positively influence mental health among nurses and contribute to improvements in quality of care (Havens et al., 2018; Bakker, 2018).

Although studies of WE in Japan are gradually drawing more attention in the field of occupational health, studies in the context of nursing occupations-especially midwifery-remain few in number.  Therefore, this study sought to clarify the present situation and associated factors with regard to WE among midwives working in advanced care facilities, which bear the brunt of care for high-risk pregnancies, as well as the contribution of WE to quality of care. In doing so, we hoped to help the education for midwives, who represent a minority of staff in any one facility, as well as their work commitment, mental health, and quality of care, at the same time we expected to gain knowledge about how studies of WE among nursing occupations conducted overseas can be applied in Japan, which has a different culture and work environment.

Participants and procedure

The study was designed as a quantitative cross-sectional study conducted by questionnaire survey. From among 104 general perinatal centers in Japan, we focused on midwives working in 36 hospitals that consented to participate in the survey. As a control group to compare with midwives, we administered the same survey to nurses working at a hospital affiliated with a national university in Japan. Institutional consent was written and individual participant’s consent was agreed with the return. The questionnaire was mailed to the hospital and requested for distribution. The questionnaire forms were unsigned and were collected by mail. The period of the study was from February to March 2016. The response rate for midwives was 54%, with 503 questionnaires subjected to analysis after excluding 8 invalid responses. The response rate for nurses was 18%, with 125 questionnaires subjected to analysis after excluding 9 invalid responses. In the comparison of midwives and nurses, we performed multiple regression analysis using the  forced input method, with individual factors (that is, age, working hours, and the presence or absence of night shifts) as adjustment factors. In addition, we performed multiple regression analysis using the stepwise method to analyze factors affecting quality of care. Here, dummy variables were input for working hours and the presence or absence of night shifts. We used IBM SPSS Statistics Version 25.0 for statistical analysis.

Measures

For WE, we used the Japanese short version of the Utrecht Work Engagement Scale (UWES-J) (Schaufeli et al., 2002; Shimazu et al. 2008). The scale considers the three factors of vigor, dedication, and absorption, with answers on a 7-point Likert scale from 0 (never) to 6 (always). The score is calculated as the average value of nine items, with higher scores associated with higher WE.

For occupational stress, we used the Brief Job Stress Questionnaire (BJSQ) (Kawakami, 2012).  We used 15 items from 6 measures related to feelings of work burden, 15 items from 5 measures related to job characteristics, 15 items from 5 measures related to support, 18 items from 5 measures related to mental stress, 11 items from 1 measure related to physical stress, and 9 items from 5 measures related to outcomes. One of the outcome measures, “Work satisfaction” was analyzed as individual performance. Responses were scored on a 4-point Likert scale from 1 (disagree) to 4 (agree). The scale score uses the average value of the items, with higher scores associated with stronger agreement.

For sense of self-efficacy, we used 16 items from the General Self-Efficacy Scale (GSES) (Sakano and Tohjyo, 1986). We used the total number of items for which respondents answered “true.” The higher the GSES score, the higher a respondent’s sense of self-efficacy. As a measure of organizational performance, respondents were also asked to rank the statement “the quality of care in my department is high,” as well as “there is a midwife (or nurse) in my department to whom I look as a role model,” which sought to determine the presence or absence of a role model. For these, responses were obtained on a 4-point Likert scale from 1 (disagree) to 4 (agree).

As attributes, we asked questions about age, sex, basic nursing education institution, years of service, working hours per week, and the presence or absence of night shifts, as well as of partners and childcare experience. This study was approved by the Medical Ethics Committee of the University of Tsukuba Hospital (approval number H27-201,January 4, 2016).

Participant characteristics

The mean age of the midwives was 34.6 years, with a standard deviation (SD) of 9.0 years, and that of nurses was 33.3 years (SD 8.2), with no significant difference between the two groups. Those who had received nursing education in university accounted for 39.0% of midwives and 40.0% of nurses, with no significant difference. Whereas 90% of midwives responded affirmatively to working night shifts, only 68.8% of nurses did so, which constitutes a significantly higher proportion for midwives (P < 0.05). No significant differences were found with respect to the presence or absence of partners or childcare experience (Table 1).

Comparisons of work engagement, self-efficacy, presence of a role model, and quality of care between midwives and nurses

Midwives and nurses were compared in terms of WE, self-efficacy, presence of a role model, and quality of care. Multiple regression analysis using the forced input method was performed with individual factors (that is, age, working hours, and the presence or absence of night shifts) as adjustment factors (Table 2).

WE scores according to the UWES-J were 3.17 (SD 0.98) for midwives and 3.05 (SD 1.13) for nurses, with no significant differences observed in terms of WE score. Self-efficacy scores according to the GSES were 7.21 (SD 2.36) for midwives and 7.37 (SD 2.42) for nurses, with no significant differences observed just as with WE. For the question “there is a midwife (or nurse) in my department to whom I look as a role model” (presence of a role model), whereas midwives scored 2.79 (SD 0.90), nurses scored 2.61 (SD 0.94), representing a significantly higher score for midwives (P < 0.05). For the statement “the quality of care in my department is high” (self-evaluated quality of care), whereas midwives scored 2.79 (SD 0.67), nurses scored 2.48 (SD 0.80), representing a significantly higher score for midwives.

Comparison of occupational Stress between midwives and nurses

Using multiple regression analysis with individual factors (that is, age, working hours, and the presence or absence of night shifts) as adjustment factors, we compared scores on the various BJSQ scales for midwives and nurses (Table 2). Midwives were found to have significantly higher scores with regard to “job control”, “meaningfulness of work”, “career opportunity”, “coworker support”, “supervisor leadership”, “work-life balance (positive)”, and “work satisfaction”. Conversely, they had significantly lower scores than nurses with regard to “role conflict”, “novelty”, “physical stress response”, and “workplace harassment”.                                                         

Factors associated with work engagement for midwives

Taking midwives’ WE measured by the UWES-J as a dependent variable and individual factors (that is, age and presence or absence of night shifts, of partners, and of childcare experience) as independent variables, we introduced self-efficacy measured by the  GSES  and  job factors according to the BJSQ and performed multiple regression analysis using the stepwise method. Factors identified as having a significant positive relationship with WE among the individual factors were higher age and higher self-efficacy, and the presence of a partner; among the job factors were “meaningfulness of work” and “predictability”; and among the support factors were “presence of a role model” and “doctor support”. “Physical stress response” was negatively related (adjusted R²=0.302, P < 0.05) (Table 3).

Factors associated with quality of care

Taking “self-evaluated quality of care” as a dependent variable and individual factors (that is, age and presence or absence of night shifts, of partners, and of childcare experience), we introduced WE as measured by UWES-J,  self-efficacy  as  measured  by  the   GSES,   and   job factors according to the BJSQ and performed multiple regression analysis using the stepwise method. As a result, in addition to WE, the BJSQ “career opportunity” and “presence of a role model” remained as two additional related factors (adjusted R²=0.137, P < 0.05) (Table 4).

WE among midwives working in general perinatal centers in Japan was not significantly different from that among nurses working at the university hospital in Japan; meaningful work was perceived as an opportunity for personal growth and did not escalate into conflict or stress. At the same time, job satisfaction and self-evaluation of the quality of care among midwives were found to be higher than those among nurses. “Doctor support” and the “presence of a role model,” which enhanced WE for midwives, were both factors that represented the occupational characteristics of midwifery.  Furthermore, it became clear that WE among midwives contributed to improving quality of care.  Below, we discuss the characteristics of WE among midwives and prospective directions for management.

WE   among  midwives  working   in   general   perinatal centers was not significantly different from that among nurses working at the university hospital. This result ran contrary to our expectation that WE for midwives working at advanced medical facilities would be low as a result of working in a stressful job environment. Midwives did not perceive any contradiction in the qualitatively distinct duties of caring for high-risk and low-risk mothers and children, but rather perceived it to be a profession in which they were able to feel a sense of self-growth. This may be due to the fact that the consistency of the subjects of care-as mothers and children and as families-did not produce any sense of difficulty with regard to the direction of care.

However, WE among the midwives and nurses surveyed in this study was higher than among the Japanese women in their thirties surveyed by Shimazu et al. (2014). Although a high job turnover rate prevails among nursing professionals, it appears that pride in having meaningful work serves to enhance WE.

Among the factors serving to enhance WE among midwives, the “presence of a role model” and “doctor support” were both factors that represented the occupational characteristics of midwifery.  Midwives, who possess outstanding “skills,” including delivery assistance and breastfeeding care, and who are able to provide autonomous care, are fine educators who can serve as  a mentor for their junior colleagues and personnel, exhibiting an ability to stimulate their organizations. On the other hand, relationships of trust and collaboration with obstetricians are indispensable when dealing with non-routine deliveries. Nakayama and Nojima (2001) reported “management systems,” “interpersonal relationships in the workplace,” “professionalism,” and “self-actualization as nurses” as four factors inherent to nurses’ job satisfaction. Kawauchi and ÅŒhashi (2011) reported the existence of a correlation between WE and job satisfaction for people intending to leave their jobs, suggesting that the more pride one takes in being a nursing professional, the more likely they will be to leave their job in order to find self-actualization. Hospitals in which midwives feel more engaged should be organizations staffed by midwives who are respected and regarded as something to aspire to by their colleagues; by obstetricians who are able to build relationships of trust with midwives; and which are able to provide high-quality care. Organizations that are able to provide high-quality care may be said to produce positive effects not only for the party receiving care, but also for the party providing it. In addition to managing turnover among midwives from the standpoint of job satisfaction, management is also required to promote the growth of midwives as experts. Although the Japanese workforce is characterized by some of the lowest levels of WE in global terms, it has been suggested that this is related to the emphasis placed on cooperativeness and the relative scarcity of self-expression (Shimazu et al., 2010). Because of this emphasis on cooperativeness, even when they possess the capability, many people remain unwilling to demonstrate leadership and become nursing administrators. Enhancing WE on the part of administrators themselves as personnel able to become role models may be a step on the path to building a more positive organization.

WE among midwives working at advanced perinatal care facilities in Japan different from that found among nurses, they also perceived midwifery as an occupation contributing to their own personal growth.  The presence of a role model and relationships of trust with physicians served to enhance WE among midwives. WE contribute to improving quality of care and management that supports midwives’ professional growth is to be desired. As a limitation of this paper, it cannot be generalized because it targets midwives working in Japan and the response rate was low.

The authors have not declared any conflict of interests.

This study was supported by KAKENHI Grant-in-Aid for Scientific Research (C) from the Japan Society for the Promotion of Science Grant Number 26463405 and the midwives and nurses were appreciated in the present study for their participation.