Exploring midwives' coping and functioning in the labour wards during the Covid-19 pandemic from the Labour Ward Head Nurses' perspective: A qualitative study.

AIM: The aim of this study is to explore midwives' coping and functioning in the labour wards during the Covid-19 pandemic from the Labour Ward Head Nurses' perspective.
BACKGROUND: The World Health Organization announced the Covid-19 outbreak to be a pandemic in March 2020. Midwives worldwide were affected by this outbreak, working in risky environments, confronting the anxiety and fear of childbearing women.
METHODS: A qualitative study using thematic analysis was conducted using semi-structured interviews done over the telephone. Thirteen Labour Ward Head Nurses were interviewed, and the texts were analysed. The study took place in April 2020 during the first Covid-19 lockdown in Israel.
RESULTS: Three main themes were generated in the coding process: (a) stress, fear and anxiety, (b) joint efforts and (c) frustration.
CONCLUSION: Our study illustrates the difficulties that arose at the beginning of the pandemic, a new and unfamiliar chaotic period. Midwives' managers can use the current research to learn about actions that may assist in improving staff resilience and cohesion during times of crisis. IMPLICATIONS FOR NURSING MANAGEMENT: Understanding the psychological impact of the Covid-19 pandemic among health care professionals is crucial for guiding policies and interventions to maintain staff's psychological well-being.

INTRODUCTION

The Covid‐19 outbreak was announced as a pandemic on 11 March 2020 by the World Health Organization (WHO, 2020). Midwives worldwide were affected by this outbreak, working in risky environments, confronting the anxiety and fear of childbearing women. This was a challenging period for the head nurses in the labour wards and required establishing new regulations. Additionally, it required new management skills that will be useful in future unpredictable events. A scoping review of several studies regarding Covid‐19's effects on maternity staff found that structural challenges and subjective effects on the maternity staff were cause by the crisis. Structural challenges were noted as staff shortages and restructuring; personal protective equipment and tests; switching to virtual communication; handling women with a positive SARS‐CoV‐2 infection and excluding accompanying persons from attending births. The pandemic also strongly affected the staff's mental health: Attempting to meet challenges posed by the pandemic while afraid of contamination, suffering overwork and exhaustion and struggling to resolve ethical‐moral dilemmas had severe negative subjective effects. Several studies indicated increased depression, anxiety, stress levels and risk of post‐traumatic stress symptoms, although the crisis also generated strong occupational solidarity (Schmitt et al., 2021).

Nurse‐midwives were designated as essential personnel, since midwifery services must be provided during the pandemic (Bick, 2020). Midwives all over the world have been affected by this outbreak, working in risky environments while confronting the anxiety and fear of the childbearing women. Midwives needed to adapt to the new reality, which affected them physically and emotionally (Kucukturkmen et al., 2022; O'Connell et al., 2020). The work environment changed from the usual routine, becoming chaotic (González‐Timonedaa et al., 2021). The Labour Ward Head Nurses needed to participate in problem solving and become role models in health care delivery during dangerous situations, while providing empathy and encouragement to their staff (Mollahadi et al., 2021).

The first reference by the Israeli Ministry of Health (MOH) to the coronavirus was on 20 January 2020. On 14 March 2020, the education system was closed, and 3 days later, a national lockdown was declared (Walla News, 2020).

In 2019, 177,000 babies were born in Israel, and during April 2020 alone, there were 13, 052 births. Most births in Israel occur at 25 hospitals and are attended by certified midwives (Central Bureau of Statistics, 2019; Israel Midwives Association, 2020; Liebergall‐Wischnitzer et al., 2016; Ministry of Health, 2020). The labour wards are managed by Labour Ward Head Nurses. The labour ward's staff includes certified midwives who are also registered nurses and physicians who are Obstetrician‐Gynaecologists (Ob‐Gyn); however, management of the labour units is the responsibility of the Labour Ward Head Nurses.

At the peak of the Covid‐19 pandemic in Israel, the local media reported health care professionals' difficulties. Labour Ward Head Nurses who are responsible for organizing the midwives and their activities grappled with even more challenges due to the pandemic.

Deldar et al. (2021) found that nurses' managers described their experiences about facing COVID‐19 pandemic into three categories: ‘facing the personnel's mental health’, ‘managerial and equipment provision challenges’ and ‘adaptability and exultation process’. Management in critical situations requires the use of flexible and situational management principles to recruit, arrange and retain workforce and to compensate for the lack of manpower (Poortaghi et al., 2021).

Information, however, regarding what was occurring in the labour wards while working in very challenging situations remained unknown and became the impetus for the present study. As labour wards in Israel are managed by the Labour Ward Head Nurses, the research question was how Covid‐19's stressful situation affected the Labour Ward Head Nurses and their ability to manage their units. The aim of the study was to examine the coping and functioning of the labour wards' staff during the Covid‐19 pandemic from the Labour Ward Head Nurses' perspective.

METHODS

Study design

A qualitative study using thematic analysis was conducted through telephone semi‐structured interviews. Telephone was the chosen tool as it is simple and available, and both interviewees and researchers were able to maintain social distancing in accordance with the Israel Ministry of Health directives for Covid‐19. Due to the lockdown and interviewees' workload, this was the best option of capturing the experience of the Labour Ward Head Nurses.

Sample and recruitment

For a representative sample, a list of all the country's labour wards was used which included an account of total births at each hospital. This gave context to the labour wards as those that have more births have more staff midwives but have more burden of care and more responsibility on the midwives than a ‘quieter’ ward. Using the total number of births per month at the last 5 years, four labour ward category types were noted: ≤300 births; ≥301–600; ≥601–1,000 and ≥1,001–1,500. We planned to interview a minimum of two or three participants from each category. The inclusion criteria were certified midwives who were employed as Labour Ward Head Nurses in Labour and Delivery Units in Israel. There were no exclusion criteria.

Interviews

The interviews took place in April 2020 by telephone and were conducted by two researchers (M.L.W. and O.H.), who are midwives with a position in Academia. Thematic analysis was performed by the two interviewers and two more independent researchers who reviewed the transcripts. Codes were grouped together to achieve a higher level of conceptual categories, which were verified and refined as the analysis progressed. The conceptual categories were analysed by all the researchers until agreement on the themes was reached by consensus.

To explore midwives' coping and functioning in the labour wards during the Covid‐19 pandemic, four main questions were included in the interview with the Labour Ward Head Nurses:

How would you describe the conditions, in general, in the labour wards during the Covid‐19 crisis?

What are the main difficulties pertaining to the function of the labour wards in the Covid‐19 crisis?

How would you describe the midwives' conditions and their function during the Covid‐19 crisis?

What types of support do you receive regarding managing the labour wards during the Covid‐19 crisis?

The researchers scheduled a phone meeting, estimating it would take approximately half an hour with a range of 20–40 min. Thirteen interviews were conducted, 11 were recorded and 2 written down during the interview. All interviews were recorded and written during the interview. In retrospect, in two interviews, some of the recording was unclear, so we referred to text written in addition to the recording. All the recorded interviews were transcribed. Confidentiality was preserved using codes of abbreviations and numbers. Before or after the interview, a demographic questionnaire was also completed. There was agreement between the researchers to accept other topics that may come up.

Analyses

The study adopted the thematic analysis approach (Braun & Clarke, 2006; Clarke & Braun, 2013). All the recorded interviews were printed, scanned and reviewed by the researchers in order to identify categories by consensus. We started with reading and re‐reading the interview transcripts and then analysing our data in a meaningful, systematic manner. We coded each segment of data that were relevant to or captured something interesting about our research questions. We used open coding; that is, we did not have pre‐set codes, rather developing and modifying the codes as we worked through the coding process. This process led to sub‐themes, such as fear of infecting family members, uncertainty, flexibility according to needs and lack of a clear procedure. We discussed these and developed some preliminary ideas about codes, such as ups and downs, availability, total recruitment and lack of a clear procedure. Then, each of us set about coding a transcript separately. We worked through each transcript, coding every segment of text that seemed to be relevant to or specifically address our research question. When we finished, we compared our codes, discussed them and modified them before moving on to the rest of the transcripts. As we worked, we generated new codes and sometimes modified existing ones. We did this by hand initially, working through hardcopies of the transcripts with pens and highlighters. We examined the codes, and most of them clearly fit together into a theme. The codes had been organized into broader themes that seemed to say something specific about the research questions.

We read the data associated with each theme and considered whether the data really supported it. Sample citations are presented as findings (see Tables 2, 3, 4).

TABLE 2

Stress, fear and anxiety

Theme	Sub‐theme	Categories	A representative quote/characteristic
Stress, fear and anxiety	Uncertainty	Ups and downs	There have been ups and downs and updates and more updates and there are staff members who came to work a little more stressed at first. I had a few older staff members who decided to stop working. Lots of fluctuations in terms of manpower, in terms of team pressure, I have to say the team has learned to be more relaxed now (6 weeks of pandemic). (Interviewee 1)
		Fear of infecting family members	There is fear, the midwives worry, especially that they will infect their family members. (pregnant) women come with no masks, it's also stressful, and it creates a bit of discomfort. (Interviewee 4)
		Uncertainty regarding wearing masks	The feeling that we did not actually receive accurate information whether to put on masks, not to put on masks, whether to fully wear protective clothing or not, whether it is a suspicious woman or a verified woman. (Interviewee 7)
		Uncertainty in the face of rapid changes in guidelines	Uncertainty, there is a load, there is a flood of guidelines, and everyone says something different. There are several administrators, the guidelines also change, and the instructions of the same administrator change every five minutes … (Interviewee 13)
	Calming actions	Providing information	Look, when the crisis started there was a very, very big panic and then I think I took command and decided I had to calm the midwives down. First, I gave them accurate information as much as possible at that moment, because the data changed from moment to moment and I just listened to them and answered every question, every panic that arose. (Interviewee 2)
		Availability	They called me a lot, both in the evenings and at nights for consultations and questions; I usually do not get phone calls at unreasonable hours. (Interviewee 8)
		Contact with infection unit	One of my midwives who was worried about us not being covered enough, not being protected enough, so I encouraged her to take responsibility on the matter, and she was very active directly with the infection unit and helped us feel safe. (Interviewee 5)
		Professional network	I motivated a midwife who graduated a course on how to deal with extreme situations, and she made effective assistance sessions for the team via the zoom. (Interviewee 3)

TABLE 3

Joint efforts

Theme	Sub‐theme	Categories	A representative quote/characteristic
Joint efforts	Recruitment and contribution	Willingness to reach more and contribute time	I want to tell you that simply the staff is much more accurate these days than on other days. This is something that is surprising … there are midwives who are willing to add more and more and contribute from their time and come and they cooperate amazingly. (Interviewee 10)
		Total recruitment	There is an admirable collaboration, really, they are all fully mobilized for everything. If someone comes who is suspicious to Covid‐19 there are no quarrels about who will enter, who will not enter. They all collaborate amazingly, really. (Interviewee 13)
			Their performance is amazing …. There is an admirable collaboration, really, they are all fully recruited for everything … (Interviewee 9)
			First, until now there was no absenteeism, which usually we have. (Interviewee 3)
		Flexibility according to needs	The willingness, the flexibility of the people, not all of them of course, but some of them, good people, people who understand that there is a need. (Interviewee 11)
	Collaboration and support	Full cooperation	The general feeling is that there is full cooperation. (Interviewee 2)
		Ability to switch midwives quickly based on collaboration	I found myself several times quickly finding midwives to replace others at an impressive speed. (Interviewee 1)
		Mutual support	Overall, there is a lot of mutual support from the staff. (Interviewee 6)
		Collaboration between midwives and doctors, regular communication and updating	There is very good cooperation between the doctors and us, there are constant interfaces of communication between us, and they constantly updating us. (Interviewee 8)

TABLE 4

Frustration

Theme	Sub‐theme	Categories	A representative quote/characteristic
Frustration	Factors of frustration	Inability to act properly	At first it was difficult to explain, train and teach everyone how to behave, when a woman arrives who is suspicious for Covid‐19 or with symptoms … it is not easy, it's frustrating because we learned to function properly while performing. (Interviewee 12)
		Lack of a clear procedure	When there are very clear procedures—it reduces the confusion and the source of anxiety. (Interviewee 3)
		Rapid changes to guidelines and difficulty in conveying the messages to a large team	There is always change. I sent the procedure to the midwives and after a day, I needed to change the procedure. It makes it very difficult for me as a manager, and it causes distrust towards me … do not forget that I have a team of over 100 midwives, that it also makes it difficult to transfer information that is changing all the time. (Interviewee 6)
	Coping mechanisms	A strategy of group survival and preservation	I'm constantly surviving figuring out what to do, how to get through it, how the team stays functioning in all this chaos and that's it. (Interviewee 1)

The theme of uncertainty did not seem to be distinct enough to be considered as a separate theme. The categories led to the identified three main themes.

Ethical considerations

The study was approved by the Max Stern Academic College of Emek‐Yezreel Ethics Committee (EMEK YVC 2020‐61). The respondents' ethical rights were protected by ensuring voluntary participation. Oral informed consent was obtained after explaining the purpose and study procedures. The respondents were assured that the data would be kept strictly confidential.

RESULTS

Thirteen Labour Ward Head Nurses were interviewed and included in the study (Table 1) in order to examine the managerial challenges faced by the head nurses during the first closure.

TABLE 1

Participants background characteristics

Variables	Background characteristics	Number (%)
Basic professional education	Nursing school	(100) 13
Midwifery education	Midwifery course	(100) 13
Academic degree	Bachelor's degree	(23.1) 3
	Master's degree	10 (76.9)
Labour wards births per month	≤300	(23.1) 3
	≥301–600	(38.5) 5
	≥601–1000	(15.4) 2
	≥1,001–1,500	(23.1) 3
No. of shifts in the last month	3 times a week 12‐h shifts	5 (38.4)
	4 times a week 12‐h shifts	2 (15.4)
	5 times a week 12‐h shifts	(23.1) 3
	5 times a week 8‐h shifts	(23.1) 3

The thematic analysis revealed three main themes emphasizing the main management challenges encountered during this unique period: (a) stress, fear and anxiety; (b) joint efforts and (c) frustration.

Stress, fear and anxiety

The study took place during the first lockdown in Israel. The findings during this time indicated that the most common theme was stress, fear and anxiety. This theme was characterized by a number of components, described in Table 2. The first sub‐theme was the situation as described by the interviewees, characterized as ups and downs, some midwives absent from work, fluctuations in human resources and staff pressure, lack of personal protective equipment (PPE) and training in its usage.

There are staff members who came to work a little more stressed at first; I had a few older staff members who decided to stop working …. (Interviewee 1)

Most of the midwives after going through the initial stage, the initial stress that was within the team, some had mental stress, only a few, thank God. (Interviewee 2)

However, as the epidemic continued, a process of adaptation began.

The second sub‐theme was the uncertainty expressed by the interviewees regarding instructions, wearing masks and fear of infecting family members. The midwives felt stress and anxiety that they would cause their own family members to become infected due to their exposure to women giving birth without wearing a mask.

One of my midwives was worried about us not being covered enough, not being protected enough, so she was very active in this matter directly with the infection unit and helped us feel safe. (Interviewee 5)

The Labour Ward Head Nurses spoke about the proactive measures they used to reassure the staff. These included ensuring proper personal protection and regular supply of protective equipment, calming actions, such as providing up‐to‐date information in the face of rapid changes in guidelines, availability to answer questions and advise staff after formal working hours, contact with Infection Control to reduce the anxiety of contracting the virus and enlisting the help of midwives who had taken a professional course in dealing with extreme situations.

Joint efforts

Joint efforts were the second theme found in the present study. The word ‘recruitment’ in Hebrew is usually reserved for a state of concentrated effort during a war or crisis. This word was repeated throughout the interviews. As shown in Table 3, the joint efforts included coming to work with a minimum of absences, a willingness to contribute beyond formal working hours and total recruitment for whatever was needed. These efforts also included collaboration between the physicians and the midwifery teams.

The interviewees described their experience regarding team recruitment. Only one interviewee described a dialectical situation in which there were midwives who avoided recruitment while there were others who stepped up to the plate:

You have the staff members—it was very stressful for them and they looked to step back and not be cooperative, and at the same time you had staff midwives who sent messages like—do you need help? Can I add shifts? Can I help? Those who are truly revealed in their greatness. (Interviewee 3)

Although frustration and a sense of loneliness were described in the second theme, the strength of the teamwork, the mutual support and the overall recruitment were invaluable.

Frustration

Frustration was the third most common theme, stemming directly from the situation which included great uncertainty, rapid changes and ups and downs as described in Table 2.

At first it was difficult to explain, train and teach everyone how to behave, when a woman arrives who is suspicious for Covid‐19 or with symptoms … it is not easy, it's frustrating because we learned to function properly while performing. (Interviewee 12)

Table 4 demonstrates that the theme of frustration included its causes, such as the inability to function properly, lack of clear instructions for the rapid changes in guidelines which were considered by many as policy overload and a sense of loneliness. Additionally, coping mechanisms, such as a survival strategy and group cohesion, were used to maintain the team.

There is always change. I sent the procedure to the midwives and after a day, I needed to change the procedure. It makes it very difficult for me as a head nurse, and it causes distrust towards me … do not forget that I have a team of over 100 midwives, that also makes it difficult to transfer information that is changing all the time. (Interviewee 6)

DISCUSSION

The aim of the current study was to explore the coping and functioning of midwives in labour wards during the Covid‐19 pandemic, from the labour ward head nurses' perspective. The findings include three themes, with the most common being stress, fear and anxiety. Midwives experienced added stress from multiple sources. The lack of personal protective equipment (PPE) and training in its usage caused many of them to question whether they had been exposed to Covid‐19, leading to fear that they could infect their family and loved ones. Midwifery practice is usually conducted according to clear, familiar protocols. The early Covid‐19 era was characterized by rapid changes in guidelines, leading to uncertainty. Another important issue was related to policy overload, in addition to different policies dictated by different levels or sources. For example, each subspecialty (e.g., nursing, anesthesiology, critical care medicine respiratory therapy) followed guidelines provided by their respective professional societies for various procedures, in addition to new policies developed by the hospital. This finding was similar to other research findings regarding holistic efforts to conform to a wide range of guidelines within a short period of time; these were, however, largely absent at the system level, resulting in confusion and frustration (Sasangohar et al., 2020). Moreover, many of the midwives worked longer hours. The usual shift is 8 h long, but at the time, 12‐h shifts were instituted because of the Covid‐19 emergency situation. These findings are in congruence with the current literature.

Experience from the 2003 Severe Acute Respiratory Syndrome (SARS) outbreak and early reports related to Covid‐19 revealed that health care professionals experienced considerable anxiety, stress and fear (Lai et al., 2020; Styra et al., 2008). The Covid‐19 pandemic posed unique challenges to health care teams in general, and the field of obstetrics in particular, a field in which treatment could not be postponed. Treatment had to meet changing requirements and adhere to staff and patient safety, along with maintaining close and direct contact with the patients (Shanafelt et al., 2020; Tomlin et al., 2020). A qualitative study of health care professionals during the Covid‐19 outbreak in Israel showed that anxiety pertaining to personal safety and risk of infecting loved ones conflicted with their professional duty to provide patient care (Karnieli‐Miler et al., 2021). The psychological effects related to the current pandemic are driven by many factors, including uncertainty about the duration of the crisis, lack of proven therapies or a vaccine (at the time of the interviews) and potential shortages of health care resources, including PPE. Health care professionals are also distressed by the effects of social distancing, balanced against the desire to be there for their families and the possibility of personal and family illness. All these concerns are amplified by the rapid availability of information and misinformation on the internet and social media (Lai et al., 2020).

The current Covid‐19 pandemic has heightened uncertainty over professionals' employment, economy, finances, relationships and, of course, physical and mental health. Yet, as human beings, we crave security. We want to feel safe and have a sense of control over our lives and well‐being. Uncertainty can leave a person feeling stressed, anxious and powerless over the direction of his/her life (Pfefferbaum & North, 2020). Understanding the psychological impact of the Covid‐19 outbreak among health care workers is crucial in guiding policies and interventions to maintain their psychological well‐being, as well as ensuring worker confidence in adequate PPE (Tan et al., 2020). Ali et al. (2020) reported that psychological distress is prevalent among health care workers during the COVID‐19 pandemic; therefore, screening for adverse mental and emotional outcomes and developing timely tailored preventative measures with effective feedback are vital for the protection of their psychological well‐being, both short and long terms. In view of the complex situation, it is evident from the findings of the present study that Labour Ward Head Nurses were proactive, available to the staff, provided information as much as possible, kept in contact with Infection Control on a regular basis and strengthened the professional network.

Health care professionals are essential for any response to a pandemic and are on the front lines, thereby increasing their exposure to infection. Responding effectively to a pandemic relies on a majority of the staff continuing to work normally (Nguyen et al., 2020). A pandemic involving contagion or contamination has the potential to influence the number of health care employees who report for duty. Personnel absenteeism during a pandemic due to fear of contracting an illness may result in a significant personnel shortage (Gohar et al., 2020). In our study, most of the midwives reported for work and absenteeism did not increase. Unlike the situation described in the literature, the midwives tended to feel motivated to work due to a sense of obligation. Woyessa et al. (2021) found that 30% of health care providers would be unwilling to continue work if COVID‐19 peaked and reported that they would stop going to work before they were at a greater risk. In Poland, Malesza found that 28% of health workers reported a hesitation to work in a pandemic stemming from their concern for themselves and their families (Malesza, 2021). During the pandemic, the experience of the majority of labour wards' midwives in Israel had a reasonably high level of morale. There was a great sense of ‘pulling together’ and ‘getting the job done’ among the staff.

Similar to other places in the world during the Covid‐19 pandemic (Bartsch et al., 2021; Catania et al., 2020; Meese et al., 2021), in our study, the Labour Ward Head Nurses demonstrated leadership and strengthened staff resilience by collaborating in a multidisciplinary team, practising flexibility as needed and emphasizing mutual support among the staff.

Strengths and limitations

The key strength of the present study was our effort to describe the experience of the Labour Ward Head Nurses in real time, thereby preventing complete or partial forgetfulness, particularly during a pandemic, a unique and challenging era for all.

In addition, the interviews enabled us to understand the perspective of Labour Ward Head Nurses as a key role working with large teams. The main limitation of the study was that the interviews took place by telephone, causing somewhat limited communication (‘hearsay’ only) with no body language, although this was the best way to capture the experience of the Labour Ward Head Nurses at that point in time.

CONCLUSIONS

The study's findings revealed the psychological impact of the Covid‐19 outbreak on the midwives. Our study illustrates the difficulties that arose during the pandemic as a new and unfamiliar chaotic state. Based on our findings, we recommend further research aimed at examining nursing teams' internal motivation and ways of encouraging it on a regular basis, not only during a crisis.

IMPLICATIONS FOR NURSING MANAGEMENT

Understanding the psychological impact of the Covid‐19 outbreak among health care professionals is crucial in guiding policies and interventions aimed at maintaining their psychological well‐being. Midwifery managers can use the current research to learn about actions that may assist in improving staff resilience and cohesion during times of crisis. The present study found that the nursing staff management during this crisis included the appropriate recruitment, employment and replacement of staff. These staff face many challenges; therefore, managers should take measures to increase motivation and reduce risk of infection and stress. Nursing managers with a strong presence in the field, despite facing difficulties, were a good role model for other staff. Nurse managers need more organisational support in the realms of structural and emotional support, assisting in problem solving and ensuring the safety of health care professionals.

Better training focused on disaster management, ethical decision making, leading in times of uncertainty and maintaining well‐being will help nurse managers lead better their teams during times of crisis and unpredictable events (Gab Allah, 2021).

CONFLICT OF INTEREST

The authors have no conflict of interest to disclose.

ETHICS STATEMENT

The study was approved by the Max Stern Yezreel Valley College Ethical Committee, No. 2020‐61.