The Hesitance of Nurses to Apply for Midwifery Specialization: Explorative Qualitative Study ()
1. Introduction
Midwifery is a healthcare profession that deals with a childbearing woman from the time of pregnancy, childbirth, and postnatal period to involve the care of the new-born babies as well as the family. According to the International Confederation of Midwives (ICM), “A midwife is a person who has completed a midwifery education programme that is based on the ICM Essential Competencies” [1] .
Many countries across the world are facing an ongoing shortage of midwife practitioners due to several reasons such as increased workload, working overtime, poor-quality midwifery care, low staff morale, stress and burnout, lack of opportunity for training, lack of management support, financial issues and lack of recognition [2] . According to World Health Organization [3] there is a global shortage of health workers, in particular nurses and midwives, who represent more than 50% of the current shortage in health workers. According to the joint statement by WHO, UNFPA, UNICEF, and the World Bank, a health worker with midwifery skills should be present at every birth. WHO recommends a level of 2.8 healthcare professionals per 1000 population. Health worker density is negatively associated with maternal mortality and potentially child mortality [4] . If access to skilled birth attendant improves, women’s lives could be saved, and morbidity dramatically reduces. Midwives who work within the framework for maternal and new-born care and within an enabling environment have the potential to bring care close to women and communities as well as tailoring it to their social and cultural needs [5] .
In Oman, midwifery education was established for Omani nurses in 1994. The Ministry of Health developed the program under the administration of the Muscat Nursing Institute. The Midwifery specialization program was paused due to a lack of educational cadre. Then, it was relaunched in 1999 at Oman Specialized Nursing Institute which is now known as the Higher Institute of Health Specialties due to the demands for midwives in maternity services. The program was further extended to meet the demands of the midwifery services in the other governorates to include the education service at three more governorates.
Midwives are the pillar of reproductive health programmes, and it is crucial to understand their role in the health system and support them [6] . There is proven evidence that midwives play an essential role in improving the quality of patient care, as well as providing rapid, and sustained reductions in maternal and new-born mortalities. Poor maternal and new-born care is considered the determinant of maternal and neonatal morbidity and mortality globally [6] .
There is a global call for urgent investment in high-quality midwifery services to prevent maternal and new-born deaths [7] . Barker [8] stated that the extreme working patterns of midwives contribute to a fast withdrawal from the profession. In addition, Barker added that midwives continue to go the extra mile by staying late, missing breaks, and experiencing heavy and challenging workloads. For midwives, ever-increasing dedication and crisis management seem to be the only response to rising workloads, whereas staffing deficits contribute to poor clinical outcomes and may affect midwives’ health, morale, and retention.
Turnover may appear to be a normal part of work life which could be advantageous in some situations. However, it becomes alert when it is speedy and leads to manpower shortage or maldistribution [9] . Therefore, there is a need to explore the midwives’ and nurses’ work outcomes such as the relationship between the level of job satisfaction and the work environment at healthcare institutions [10] . A shortage of midwives was found to be a problem in developed countries and middle-income countries specifically [11] . The United Nations Population Fund (UNFPA) [12] reported on State of the World’s Midwifery 2014 bringing to light that midwives make up 36% of the midwifery workforce across 73 countries. In addition, in a study conducted by the WHO [6] , it has been found that midwifery, including family planning and interventions for maternal and new-born health, could avert a total of 83% of all maternal deaths, stillbirths, and neonatal death. As a result of turnover, job satisfaction is a challenging aspect of healthcare. Therefore, this study aimed to explore the hesitance of Omani nurses to apply for midwifery specialization.
2. Research Design and Methodology
2.1. Study Design
This is an explorative qualitative study that was conducted at the largest tertiary hospital in Oman. Data collection started in March 2022 and was completed in April 2022.
2.2. Sample and Sampling Method
Purposive sampling was applied for participant recruitment. The participants were assessed for their eligibility to be included in the study. Then, the interviews were conducted at a convenient time and in a quiet environment to allow the participants to talk freely and express their thoughts. The study inclusion criteria are general nurses who are working in maternity unit and not performing midwives role, nurses in charge working in the maternity unit to assess the view of leadership perceptions as well as nurses whose applications were accepted to study midwifery specialization and dropped for some reason. However, the qualified midwives who are working in delivery suite and perform midwifery roles were excluded from this study. The data collection process yielded twenty-five nurses.
2.3. Data Collection Tool/Interview Protocol
All interviews were conducted in English and according to an interview protocol that was prepared in English as well. The interview protocol was constructed by two researchers and then reviewed by experts in qualitative research. The protocol included demographic data such as age, marital status, geographical location, and years of experience. (See Appendix Section A) Additional information about their future professional career in the maternity unit was added as well. Moreover, participants were allowed to express the motivating and demotivating factors associated with their hesitance to apply for the midwifery specialization. The interview protocol highlighted the impact and perception of the midwifery specialization on nurses’ careers. In addition, the researchers explored through interviews the required support for the nurses to be specialized in midwifery. The interview protocol ended with a closing question asking the participants about their vision of the midwifery specialization. All face-to-face interviews lasted for 20 to 30 minutes whereas focus group interviews were conducted over 30 to 50 minutes. All interviews were audio recorded and transcribed verbatim.
2.4. Data Analysis
Collected data was analyzed following thematic analysis, focusing on the study’s aims, and using the inductive approach [13] . The inductive approach is collecting data from broader descriptions and conclusions [14] . Data collection and analysis were running simultaneously, and topic guides were continuously updated based on emerging themes. Although the transcribing task is time-consuming, it is very useful to carry out data analysis [15] . All interview transcripts were stored in a secured database as Microsoft Word documents with backup documents as hard copies. The database was screened thoroughly by the researchers and the transcripts were read independently to develop an overall impression of the data. Significant texts were recognized and labelled accurately. All relevant labels were gathered into codes. These codes were again gathered into higher-order codes using a process of comparing and contrasting. Finally, the main themes were identified by repeating the same process. After examining the emerging themes, it was possible to bring them together and develop the final over-arching themes. Compared to other types of data analysis in qualitative research, thematic coding analysis is flexible, easy for a novice researcher, and easy to disseminate the results [15] . Therefore, the researchers in this study decided to use a thematic analysis.
2.5. Ethical Consideration
This study was approved by the institution’s scientific research ethical committee with the approval number SRC #3/2022. Participants voluntarily signed informed consent before the interviews and focus group discussions and were assured that they have the right to voluntarily withdraw at any point during the study. All interviews were conducted in a quiet locked room to ensure the participants’ privacy. All focus group discussions and interviews were audio recorded and transcribed verbatim.
3. Results
Three major over-arching themes were identified after analyzing the data using thematic analysis. These are 1) nurses’ perceptions about working in maternity units, 2) factors influencing the decision to study midwifery programme, and 3) support and recommendations required for midwives. Several sub-themes were identified under each major theme.
3.1. Theme: Nurses’ Perceptions about Working in Maternity Units
3.1.1. Sub-Theme: Nature of Work in the Maternity Unit
Nurses’ perceptions about working in a maternity unit can be influenced by a variety of factors related to their clinical experience, training and education, workplace culture, support systems, patient outcomes, communication and feedback, and personal values, culture, and beliefs. Most participants had a positive perception of working in a maternity unit since working in the maternity unit means working exclusively with female patients and their babies.
“Dealing with female patients is easier than with male patients”. (FG1)
Local culture plays a major role as well for the nurses to work in the maternity unit as they are dealing with female patients only. Other participants thought that working in the maternity unit means dealing with less critical patients, however, taking care of two patients: a mother and a baby.
“not dealing with a sick patient but dealing with two people, mother, and baby …who are rarely sick”. (FG1)
The participants added, working in the maternity unit makes nurses feel proud of what they are doing. Moreover, the knowledge gained during the time in maternity units can help nurses to educate their own families and society.
3.1.2. Sub-Theme: Perception of Nurses on the Nature of Work at the Delivery Suite (DS)
Midwives feel proud, strong, and confident working in a delivery suite. However, the majority of maternity nurses are not planning to apply for midwifery education for several reasons including lack of interest, absence of career goal, high educational requirements, low job opportunities, perception of midwifery, and work-life imbalance. Working in a delivery suit is considered a very stressful atmosphere, FG2:
“It is a stressful place”. (FG2)
Nurses believe that stress may lead to work-life imbalance
“Work-life imbalance is common”. (FG1)
Nurses at the maternity unit think that working in a delivery suite can affect their social life, while other nurses think that working in the delivery suite may affect their physical health. Furthermore, nurses believe that due to various reasons, being a midwife can impact their health status.
“Most of the nurses in the Delivery Suite are having medical conditions, mainly back (spine) problems,”. (FG1)
The current midwives play a major role in marketing and promoting midwifery careers and education.
3.2. Theme: Factors Influencing the Decision to Study Midwifery Education
Participants were asked about factors that can influence their decision either positively or negatively to apply for midwifery education. The following sub-themes were generated:
3.2.1. Sub-Theme: Stressful and Exhausting Area and Work Overload Due to Shortage of Nurses
The delivery suite is a busy area where the midwife conducts deliveries independently. It is a very stressful area and the participants expressed that working there is a hard job.
The main reason behind the nurse’s hesitance to apply for midwifery education is the current midwife-woman ratio in DS which is approximately 1:3 due to the shortage of midwives. This is considered harmful for the care provider and the patient and leads to a lot of stress.
“I went once to DS to cover my colleague who was absent, I remember that night it was a very busy night”. (FG2).
Maintaining a nurse-woman ratio of 1:1 will influence participants’ decisions toward midwifery education. However, with the current situation, the unrealistic ratio may affect the health of the nurses themselves.
Furthermore, participants reflected on the potential consequences of hesitation/not applying for midwifery education as there is currently a huge shortage which means the workload will increase and ultimately this may lead to poor patient care and a lot of reported incidents.
“increased incidents may occur,”. (FG1)
Eventually, the “patient will not get proper care”. (P3)
On the other side, nurses believe midwifery education can affect their social life. Keeping this in their mind can impact the decision to go for midwifery education.
“I have changed my living place” and became “very far” from the hospital. (P1)
3.2.2. Sub-Theme: Leadership/Teamwork and Motivation
Nurses are complaining that there is no teamwork and unfair nurses’ treatment in the Delivery Suite which leads to nurse’s frustration and affects the management in the delivery suite. Moreover, nurses believe that midwives are not motivated due to their pay as there is no difference in the salary between a general nurse and a midwife. The nurses are not supported by their supervisors as well in cases of incidents and emergencies.
“area is stressful and demotivating”. (P6)
3.2.3. Sub-Theme: Transfer out from Delivery Suite
One of the most repeated factors that hindered the nurses to apply for midwifery education is that nurses are not allowed to ask for a transfer out of DS after being certified as midwives.
“In the future, I want to go out of DS, I don’t want to be stuck there”. (P6)
3.3. Theme: Support and Recommendations Required for Midwives
Participants were asked about the support they need and recommendations to encourage them and their colleagues being specialized as midwives. There was a great consensus in their responses. These responses can be sub-themed as the following:
3.3.1. Sub-Theme: Support and Motivation
Participants pointed out an important aspect as they stated that changing the financial grade, giving midwives allowance, or financial support will encourage them to apply for midwifery education. Furthermore, extra working hours or staying back after the shift should be compensated financially, and an extra working hours allowance must be considered.
“Sometimes when a midwife is conducting a delivery and needs to stay back maybe more than two hours, she should be financially compensated”. (FG2)
Moreover, participants stated that since midwives are serving the institution, they deserve special treatment once they give birth at the same institution. This makes the midwives feel motivated and consider it as a type of encouragement/ emotional compensation.
Nurses’ appreciation and acknowledgment can take different shapes. One way of leadership support is a thank you letter or an email from the hospital administration.
“writing letters and emails to encourage me could be a good idea”. (P3)
or another kind of support such as
“a special celebration for midwives … with special commercial offers could be a motivational act”. (P6)
Moreover, special occasions and celebrations should be considered, and midwives can be given the chance to celebrate special events with their families.
3.3.2. Sub-theme: Work Overload at DS Should Be Reduced
Participants argued about the workload in the DS and suggested future strategies that could mitigate the workload such as establishing a new maternity hospital. The other idea was to recruit an assistant nurse to help midwives and reduce the workload.
“… we need a special hospital for deliveries because I think our DS is not enough for our patients”. (P2)
Since DS is a very busy area and a midwife-woman ratio should be considered as one-to-one care.
3.3.3. Sub-Theme: Allow the Midwives to Move out of DS
The participants emphasized that the graduated midwife should be allowed to work outside the DS. They have proposed that from the midwifery programme, they will have at least six months in DS then they should go back to their original ward, not to sign compulsory to work in DS for six or seven years.
“Midwife can work in health centres as a community midwife”. (P3)
3.3.4. Sub-Theme: Midwifery Education
Midwifery education is regulated by the Ministry of Health which sets standards for the educational program, licensing requirements, and ongoing professional development. This ensures that midwives have the necessary knowledge and skills to provide safe and effective care to women and newborns. Participants believe that midwifery should be taught within basic nursing education as a mandatory subject for nursing students and not as a separate program.
“They will be graduated just like a general nurse plus a midwife so that they will not suffer from shortages of midwives”. (FG2)
3.3.5. Sub-Theme: Midwifery Identity
Midwifery identity refers to the unique characteristics and values that define the profession of midwifery. Midwives are healthcare professionals who provide care to women during pregnancy, childbirth, and the postpartum period, as well as reproductive healthcare services and care to newborns. The identity of midwifery is shaped by several factors, including historical traditions, cultural practices, professional standards, and personal values.
Participants believe that midwives in the Ministry of Health should have an official designation as registered midwives to promote their identity. Unfortunately, under the current system, there is no designated midwife post and instead the midwife is considered a nurse.
“We don’t have the designation as a midwife”. (P1)
3.3.6. Sub-Theme: Being Oriented to DS nature of Work
Participants believe that maternity nurses should go into an orientation to Delivery Suite so that they become aware of the nature of the midwifery roles. Keeping the nurses oriented about the nature of work at DS during their internship, talking to the midwives about midwifery, attending short courses with them, and in between going to DS for clinical attachment to see the situation there.
“They will be more excited and oriented if they will have a chance to see DS during their internship”. (P6)
Understanding more, about what is midwifery and what is the role of the midwife, might give them the chance to change their decision.
4. Discussion
The purpose of this study is to explore the hesitance of nurses to apply for midwifery programme. The objectives of this study were to understand the challenges that lie in front of Omani nurses and the motivational factors for applying for a midwifery programme. Thematic analysis of the interviews found that the majority of the participants raised issues related to work overload due to the staff ratio imbalance in Delivery Suite. This study will add to the existing body of knowledge about healthcare professionals’ beliefs, barriers toward application for midwifery education, and strategies that could mitigate the problem. To the authors’ knowledge, this is the first study that has been conducted in a Middle Eastern country that focuses on the exploration of nurses’ hesitance towards application for midwifery education.
4.1. Nurses’ Perceptions of Working in the Maternity Units
The study participants expressed their emotions being in postnatal or prenatal wards as blessed environments. They love being with women and taking care of women who bring new lives. Moreover, nurses felt satisfied being with women and taking care of both the woman and her baby. This feeling is even boosted once they are considered a reference to the community.
Nurses perceive that being a nurse at the maternity unit adds to their knowledge and helps them in their social life as the community requests their assistance in terms of women’s health. This finding is in parallel with [16] and [17] that midwives and nurses working in the maternity unit are satisfied being with women and working for women as well as being a resource to the community. This satisfaction could also be related to the Omani culture as it is a more conservative culture that encourages women to serve women. This was evident by a statement from some participants as they reported that they feel more comfortable providing care for women rather than caring for men.
The Omani culture supports that women work with women make them more comfortable and encourage them to provide their maximum care. However, work overload, stress may affect their performance toward patients care. Moreover, the staff express that being a midwife may affect their social life positively by being recognized in their community as a midwife, nevertheless can affect their life negatively that they are not allowed to function like others socially due to shortage of staff and being called regularly to come for duty. Addition to that, most of the staff are working in the public holidays.
4.2. Factors Influencing the Decision to Study in the Midwifery Programme
The participants stated that being midwives can affect their health status and social life as most of the midwives in the DS are sick and have back pain. Ejebu [18] supported the concept and highlighted that the long shifts at work are difficult to combine with family and social life, and when combined with the heavy workload this affects midwives both psychologically and physically. They reported that the heavy lifting and the long hours cause back aches and disc prolapses. A possible solution is proper posturing for midwives while conducting deliveries as this will reduce back pain. Moreover, support from the administration and for such staff may affect their health status. This evidence was supported by [19] stating that the most common pain site was the lower back (72.7%), followed by the neck (52.8%) and shoulders (42.7%). Of those who reported lower back symptoms during the last 12 months, 24.3% had been prevented from carrying out normal activities.
Moreover, DS is a stressful and busy area that needs hard work, yet not all the midwives will be able to cope with the stressful workplace. They have mentioned that the staff-to-patient ratio is not according to international standards. This evidence is supported by all the participating midwives reporting a substantially higher patient-nurse ratio than the one recommended at the hospital [20] . This can be mitigated through more collaboration and teamwork in the delivery suite to balance out the workload among the midwives. Moreover, prioritizing the work in the DS and adhering to the international staff-to-patient ratio will help in reducing the stress among midwives, moreover, there is a proposal of launching first stage of labor with one midwife looking after 4 patients, thus will reduce the midwives load when the patients are in active labor and recruit obstetric staff to assist the midwives in monitoring the patients before and after the birth. This statement is supported by [20] that increasing the number of staff seen as one of the most important factors for improving the working conditions and the care provided to patients.
The nurses are complaining about the lack of leadership support which leads to burnout and frustration among the midwives. This is supported by [17] that several midwives expressed feeling insecure and uncertain in their employment and their relationships with their supervisors. Moreover, the midwives should be treated fairly and get support and encouragement from the leadership so that they will get the power to work peacefully without any stress.
Most of the nurses highlighted that the midwives and nurses are equal in their salary although the midwives are working independently. This is supported by [21] that the midwives also experienced a loss of motivation at work due to limited support from their superiors. However, midwives’ recognition and identity as having their designation will help to increase the application to the midwifery programme. Financial support can play a major factor to increase the number of midwives in Oman. According to [17] and [21] “Not being allowed to practice their profession and not receiving recognition for their work made it very demanding to continue their job, leading the midwives to feel frustrated and undervalued also a need for support from the local midwifery association was expressed” [17] .
One important factor that participants emphasized is the opportunity of moving out of the delivery suit once they are specialized. Participants stated that being a specialized nurse or going for the postgraduate certification in midwifery will reduce their chance of getting other job opportunities such as changing the workplace within the hospital or moving to different healthcare institutions. This factor was frequently mentioned by participants as their social life is significantly affected once they are midwives working only at the delivery suite. O’Farrell [22] confirmed that extrinsic factors affecting the nurses to pursue postgraduate education are the job opportunities. To relate more to the participants of this study, they are from a conservative community and social life is considered a major factor that is valued. Therefore, nurses feel committed to their social life and their job. This factor leads to the decision of nurses in pursuing postgraduate education in midwifery as the family commitment is contradicting the nature of work in the delivery suite [22] .
Transferring out of DS was the main reason why the nurses are hesitant to apply for midwifery as they believe will be stuck in DS and not able to transfer out to another institution. No evidence from other studies has been found to support this statement, but this may be due to the fact that this limitation only exists in Oman and not elsewhere. However, giving chance of the midwives to be transferred out of DS will refresh their basic skills and the stress will be released eventually.
4.3. Support and Recommendations Required for Midwives
Participants insisted on the importance of providing support and motivation for midwives in the workplace such as financial support, leadership support, and recognition. Many participants highlighted the need to have financial grades or allowance due to their nature of work such as changing their financial degree, giving incentives, or increasing their salary. Furthermore, participants express their opinion about leadership support. In addition, the participants underlined the need for acknowledgment and appreciation for midwives, such as appreciation letter and best midwife in the month. All these findings are aligned with other many studies, [23] stated that job satisfaction for midwives was influenced by working hours per week, workplace agreements, workload, and the lack of recognition by medical staff. Similarly, the job satisfaction of midwives was found to be associated with their working relationship with colleagues, and supervisors, manageable working hours, and a good salary [16] . Furthermore, [24] emphasized that positive experienced workplace qualities and occupational satisfaction for midwives enhance their chances to remain in their positions for longer and consequently reduce turnover.
Midwives continue to go the extra mile by staying late and missing breaks to ensure that they get through what is often a heavy and challenging workload. For midwives, ever-increasing dedication and crisis management can seem to be the only response to rising workloads, whereas staffing deficits may contribute to poor clinical outcomes and may affect midwives’ health, morale, and retention [8] .
5. Methodological Considerations and Limitations
The data collection tool used in this study was validated by a qualitative research expert and three other experts who have no direct relationship with the study. For the data collection process, the lead researcher trained the other researchers in conducting focus group discussions and face-to-face interviews. Most of the researchers of this study had participated in qualitative published articles previously. To ensure the maximum comfort of the staff during the interviews, all participants were interviewed anonymously in a separate room. Moreover, triangulation was applied during data collection to allow the maximum data required to answer the research question. The triangulation used were three focus group discussions with nurses who are working at the maternity unit and not willing to pursue the midwifery qualification, five face-to-face interviews with ward nurses at the maternity unit to explore the challenges from the perspectives of leadership and two face-to-face interviews with nurses who applied for midwifery education and dropped. The study needed to have a proper data management and analysis system because of the nature of this research, and a significant amount of data was produced.
This qualitative study cannot be generalized to the whole population of Oman because the number of participants was few. Furthermore, this study was conducted in one tertiary hospital in Oman. This brings attention to the need of exploring the other hospitals’ reasons for not applying for the midwifery programme and the lack of Omani midwives all over Oman.
6. Conclusion
In summary, this study explored the general nurses’ hesitance in applying for midwifery education. This study proved that nurses appreciate the nature of working with women but feel hesitant to be assigned to highly specialized areas such as DS due to several reasons. Firstly, the negative perception that midwives cannot work outside the delivery suit. Secondly, the stress that midwives encounter at DS, and this was perceived by nurses who did not work at DS. Nurses perceived the idea that leaders should communicate with midwives at the same hospital to express their stress and work overload. Finally, work overload was a major contributing factor that makes nurses hesitant not to apply for midwifery education. These challenges could be mitigated through several strategies that were discussed by participants of this study. One and the most important strategy is the leadership and organizational support to midwives such as incentives for the extra working hours, and non-financial support such as thank you letters from leaders.
Acknowledgements
The authors would like to acknowledge the Royal Hospital Administration for its support. The Principal Investigator would like to acknowledge the Co-authors for their participation in this study, for their expertise in the qualitative study analysis, and for the human recourses database that received all the data required from the collection tools.
Appendix
The interview protocol used for the hesitant general nurses to apply for the midwifery Specialization
Section A:
Demographic Data: age:
Marital Status:
Geographical Location:
Years of Experience:
Participants Demographic Data
Table of Abbreviations: