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Exploring the relationship between midwives’ work environment, women's safety culture, and intent to stay

      Abstract

      Background

      The shortage of midwives is a concern for healthcare systems as it compromises the quality maternity care. Various studies argue that a favorable work environment increases nurses’ job satisfaction and intention to continue working at their current workplace.

      Aim

      To analyze the work environment and its relationship with women’s clinical safety culture and midwives’ intention to stay in their current job and the midwifery profession.

      Methods

      A cross-sectional, correlational study was performed on N = 218 midwives working in Spain. Standardized instruments were used, including The Practice Environment Scale of the Nursing Work Index (PES-NWI) and the Hospital Survey on Patient Safety Culture (HSOPSC). Descriptive and bivariable statistics were used. The study followed the STROBE guidelines.

      Results

      The work environment in the labor wards was mixed, according to the PES-NWI classification. The mean total score of the PES-NWI significantly and positively correlated with the mean total score of the HSOPSC (rs = 0.498, p < 0.001), indicating that as the quality of midwives’ work environment increased, women’s clinical safety increased. Significant correlations were observed between the midwives’ intent to stay in the hospital where they work and features of women’s safety culture.

      Conclusion

      The results of this study showed significant relationships between the work environment, women’s safety culture, and midwives’ intentions to leave their job/profession. Creating a favorable working environment could be a potentially effective strategy that encourages improvement in the women’s safety culture in healthcare organizations and greater intention of midwives to stay at their current job.

      Keywords

      Statement of significance

      Problem
      Currently, the shortage of nurses and midwives puts the provision of safe and high-quality care in the future at risk and calls for effective recruitment and retention strategies.
      What is already known?
      The work environment influences the satisfaction and retention of nurses, as well as quality healthcare outcomes. However, little is known about the impact of the work environment on midwives' intentions to stay in their job and profession and its relationship with women’s safety culture in labor & delivery wards.
      What this paper adds?
      This study shows significant relationships between work environment, safety culture for women and midwives' intentions to stay that could assist managers and leaders in decision-making to effectively control the midwifery shortage and ensure quality of care for women and babies in the future.

      1. Introduction

      Midwives are internationally recognized as a cornerstone of the health and wellbeing of women and their newborns [
      • Bekru E.T.
      • Cherie A.
      • Anjulo A.A.
      Job satisfaction and determinant factors among midwives working at health facilities in Addis Ababa city, Ethiopia.
      ]. Their relevance in delivering safe, effective and efficient care is becoming increasingly recognized with studies supporting consistent evidence of improved outcomes for women and babies [
      • Callander E.
      • Sidebotham M.
      • Lindsay D.
      • Gamble J.
      The future of the Australian midwifery workforce – impacts of ageing and workforce exit on the number of registered midwives.
      ]. Therefore, the role of the midwifery workforce is essential to high-quality maternity care [
      • Uchmanowicz I.
      • Manulik S.
      • Lomper K.
      • Rozensztrauch A.
      • Zborowska A.
      • Kolasińska J.
      • et al.
      Life satisfaction, job satisfaction, life orientation and occupational burnout among nurses and midwives in medical institutions in Poland: a cross-sectional study.
      ].
      According to the World Health Organization (WHO), midwives play a crucial role in maternal-fetal health care and safety, preventing 80% of deaths derived from childbirth and reducing premature births by 24% [

      Organización Mundial de la Salud, Orientaciones estratégicas mundiales para el fortalecimiento de la enfermería y la partería 2016–2020, 2016. 〈https://www.who.int/hrh/nursing_midwifery/global-strategic-midwifery2016-2020.pdf〉, (Accessed 20 March 2021).

      ]. Also, midwife-led care has been linked to the perception of better care and increased satisfaction among expectant women [
      • Knupp A.M.
      • Patterson E.S.
      • Ford J.L.
      • Zurmehly J.
      • Patrick T.
      Associations among nurse fatigue, individual nurse factors, and aspects of the nursing practice environment.
      ,
      • Sandall J.
      • Soltani H.
      • Gates S.
      • Shennan A.
      • Devane D.
      Midwife-led continuity models versus other models of care for childbearing women.
      ]. Most European countries are committed to integrating the figure of the midwife as an essential professional in the high-quality maternity care of their healthcare systems [
      • Bekru E.T.
      • Cherie A.
      • Anjulo A.A.
      Job satisfaction and determinant factors among midwives working at health facilities in Addis Ababa city, Ethiopia.
      ]. Therefore, a well-educated stable and sustainable midwifery workforce is required [
      • Harvie K.
      • Sidebotham M.
      • Fenwick J.
      Australian midwives' intentions to leave the profession and the reasons why.
      ]. However, the number of midwives needed is in jeopardy due to the global crisis in available human resources for health that is expected in coming years [
      • Chen Q.
      • Gottlieb L.
      • Lio D.
      • Tang S.
      • Bai Y.
      The nurse outcomes and patient outcomes following the High-Quality Care Project.
      ]. Specifically, there is expected to be an estimated shortage of 7.6 million nurses and midwives in 2030 [

      Organización Mundial de la Salud, Orientaciones estratégicas mundiales para el fortalecimiento de la enfermería y la partería 2016–2020, 2016. 〈https://www.who.int/hrh/nursing_midwifery/global-strategic-midwifery2016-2020.pdf〉, (Accessed 20 March 2021).

      ]. This problem has become one of the main concerns of healthcare organizations that is worsened by the aging of midwives and dissatisfaction with the work environment [
      • Harvie K.
      • Sidebotham M.
      • Fenwick J.
      Australian midwives' intentions to leave the profession and the reasons why.
      ,
      • Bloxsome D.
      • Ireson D.
      • Doleman G.
      • Bayes S.
      Factors associated with midwives’ job satisfaction and intention to stay in the profession: an integrative review.
      ].

      1.1 Background

      The work environment is defined as “the organizational characteristics of the work setting that facilitate or limit professional practice” [
      • Lake E.T.
      Development of the practice environment scale of the Nursing Work Index.
      ]. Several studies show that characteristics of the work environment influence the satisfaction and retention of health professionals [
      • Kutney-Lee A.
      • Witkoski A.
      • Sloane D.M.
      • Ciiotti J.P.
      • Quinn L.
      • Aiken L.H.
      Changes in patient and nurse outcomes associated with magnet hospital recognition.
      ,
      • Mohammad K.I.
      • Al-Reda A.N.
      • Aldalaykeh M.
      • Hayajneh W.
      • Alafi K.K.
      • Creedy D.K.
      • Gamble J.
      Personal, professional and workplace factors associated with burnout in Jordanian midwives: a national study.
      ], as well as health outcomes and the quality of care provided to the patient [
      • Yanarico D.M.I.
      • Balsanelli A.P.
      • Gasparino R.C.
      • Bohomol E.
      Classification and evaluation of the environment of the professional nursing practice in a teaching hospital.
      ,
      • Falguera C.C.
      • De los Santos J.A.A.
      • Galabay J.R.
      • Firmo C.N.
      • Tsaras K.
      • Rosales R.A.
      • et al.
      Relationship between nurse practice environment and work outcomes: a survey study in the Philippines.
      ]. Midwives are responsible for ensuring the safety and care of both mother and child, facing a twofold challenge that has been exacerbated by the Covid-19 pandemic [
      • Crowther S.
      • Maude R.
      • Zhao I.Y.
      • Bradford B.
      • Gilkison A.
      New Zealand maternity and midwifery services and the COVID-19 response: a systematic scoping review.
      ]. Therefore, understanding the influence of the work environment on clinical safety is crucial for midwives, given their high commitment to maternal and fetal safety during prenatal, labor and postpartum care [
      • Fleming T.
      • Creedy D.K.
      • West R.
      Cultural safety continuing professional development for midwifery academics: an integrative literature review.
      ,
      • Ribeliene J.
      • Blazeviciene A.
      • Nadisauskiene R.J.
      • Tameliene R.
      • Kudreviciene A.
      • Nedzelskiene I.
      • et al.
      Patient safety culture in obstetrics and gynecology and neonatology units: the nurses’ and the midwives’ opinión.
      ].
      On the other hand, clinical safety is defined as “reducing the risk of harm associated with healthcare to an acceptable minimum” [

      Organización Mundial de la Salud, Seguridad del paciente, 2020. 〈https://www.who.int/patientsafety/es/〉, (Accessed 20 March 2021).

      ]. In this context, it is the conscious attempt by healthcare professionals to avoid causing injury to the woman during their healthcare practice [
      • Rocco C.
      • Garrido A.
      Seguridad del paciente y cultura de seguridad.
      ]. The degree to which an organization promotes, supports, and commits to safe practices is known as clinical safety culture [
      • Mella-Laborde M.
      • Gea-Velázquez M.T.
      • Aranaz-Andrés J.M.
      • Ramos-Forner G.
      • Compañ-Rosique A.F.
      Análisis de la cultura de seguridad del paciente en un hospital universitario.
      ]. This term encompasses the beliefs, values, and norms that all members of the professional team share and that influence their behavior and actions [
      • Hao H.S.
      • Gao H.
      • Li T.
      • Zhang D.
      Assessment and comparison of Patient Safety Culture among health-care providers in Shenzhen hospitals.
      ]. Organizations with a strong safety culture are able to prevent adverse effects and quickly correct errors before harm occurs through good communication and interprofessional trust, awareness of the importance of safety, and the implementation of effective preventive measures [
      • Hao H.S.
      • Gao H.
      • Li T.
      • Zhang D.
      Assessment and comparison of Patient Safety Culture among health-care providers in Shenzhen hospitals.
      ,
      • Reis C.T.
      • Paiva S.G.
      • Sousa P.
      The patient safety culture: a systematic review by characteristics of Hospital Survey on Patient Safety Culture dimensions.
      ].
      The potential influence of the work environment on safety culture and midwives’ intention to leave is well documented. Previous research has associated a favorable work environment with a lower risk of injuries in the workplace [
      • Smith J.G.
      • Plover C.M.
      • McChesney M.C.
      • Lake E.T.
      Rural hospital nursing skill mix and work environment associated with frequency of adverse events.
      ], and a lower rate of morbidity and mortality [
      • Gaalan K.
      • Kunaviktikul W.
      • Akkadechanunt T.
      • Wichaikhum O.A.
      • Turale S.
      Factors predicting quality of nursing care among nurses in tertiary care hospitals in Mongolia.
      ]. There are also studies showing favorable results in the clinical safety of labor wards and lower rates of maternal-fetal mortality due to the improvement of the work environment and quality of maternity care [
      • Ribeliene J.
      • Blazeviciene A.
      • Nadisauskiene R.J.
      • Tameliene R.
      • Kudreviciene A.
      • Nedzelskiene I.
      • et al.
      Patient safety culture in obstetrics and gynecology and neonatology units: the nurses’ and the midwives’ opinión.
      ,
      • Akbari N.
      • Malek M.
      • Ebrahimi P.
      • Haghani H.
      • Aazami S.
      Safety culture in the maternity unit of hospitals in Ilam province, Iran: a census survey using HSOPSC tool.
      ,
      • Raftopoulos V.
      • Savva N.
      • Papdopoulou M.
      Safety culture in the maternity units: a census survey using the Safety Attitudes Questionnaire.
      ]. However, the understanding about associations between work environment and the clinical safety culture in labor wards is scarce and requires investigation in future research [
      • Tang J.H.
      • Hudson P.
      Evidence based practice guideline: nurse retention for nurse managers.
      ,
      • Bell M.
      • Sheridan A.
      How organisational commitment influences nurses’ intention to stay in nursing throughout their career.
      ,
      • Marufu T.C.
      • Collins A.
      • Vargas L.
      • Gillespie L.
      • Alghairbi D.
      Factors influencin retention among hospital nurses: systematic review.
      ]. Evidence suggests that the work environment might be also decisive in midwives’ outcomes, including the intent of those within the profession to remain in their position [
      • Hildingsson I.
      • Fenwick J.
      Swedish midwives’ perception of their practice environment – a cross sectional study.
      ]. There is a growing body of literature that suggests many midwives suffer from work-related burnout, stress and emotional distress, and as a result are making decisions to leave the profession [
      • Harvie K.
      • Sidebotham M.
      • Fenwick J.
      Australian midwives' intentions to leave the profession and the reasons why.
      ,
      • Hunter B.
      • Fenwick J.
      • Sidebotham M.
      • Henley J.
      Midwives in the United Kingdom: levels of burnout, depression, anxiety and stress and associated predictors.
      ,
      • Henriksen L.
      • Lukasse M.
      Burnout among Norwegian midwives and the contribution of personal and work-related factors: a cross-sectional study.
      ]. Despite the urgent need to propose strategies to recruit and retain midwives, the relationship between the work environment and the intention to stay of midwives needs further analysis. The lack of studies on the influence of midwives’ work environment on the clinical safety culture of their hospitals, as well as on the intention of midwives to remain working there and in the midwifery profession motivated the development of this research. The objective of this study was to analyze the work environment and its relationship with women's clinical safety culture and midwives’ intention to stay in their current job and midwifery profession.

      2. Methods

      2.1 Study design

      A cross-sectional, correlational study was carried out following the STROBE checklist [
      • Von Elm E.
      • Altman D.
      • Egger M.
      • Pocock S.
      • Gotxsche P.
      • Vandenbroucke J.P.
      The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies.
      ].

      2.2 Study context and participants

      In Spain, there are 508 hospitals which maternity care, of which 54.7% are public (278 hospitals) and 45.3% are private (230 hospitals). Those hospitals are distributed throughout the 17 autonomous communities into which Spain is geographically and politically divided [

      Ministerio de Sanidad, Atención perinatal en España: Análisis de los recursos físicos, humanos, actividad y calidad de los servicios hospitalarios, 2010–2018, 2021. 〈https://www.sanidad.gob.es/estadEstudios/estadisticas/docs/Informe_Atencion_Perinatal_2010-2018.pdf〉, (Accessed 7 March 2022).

      ].
      In this context, the study explored the perspectives of midwives who worked in public and private general hospitals in Spain, and specifically in 15 (see Table 1) of the 17 autonomous communities. The potentially eligible study subjects were Spanish midwives who worked in the labor & delivery ward. There was a potential population of 7184 midwives working in labor and delivery suites in the 15 hospital autonomous communities [

      Instituto Nacional de Estadística, Profesionales sanitarios colegiados 2018. No. de Enfermeros con especialidad de Matrona por Comunidades, Ciudades autónomas y Provincias de colegiación, situación laboral y sexo, 2018. 〈https://www.ine.es/jaxi/Datos.htm?path=/t15/p416/a2018/l0/&file=s08007.px〉, (Accessed 29 March 2022).

      ]. A sample of 218 participants was obtained through intentional snowball sampling; thus, the response rate was 3.03%. The inclusion criteria were the following: (1) being a midwife, (2) currently working in the labor & delivery ward, (3) and signing the informed consent form. The exclusion criteria were: (1) working in a non-hospital setting, (2) working outside of Spain, and (3) not having a good command of spoken and written Spanish.
      Table 1Sociodemographic characteristics of the sample.
      Variablen%
      Sex


      Female

      Male
      198

      20
      90.8

      9.2
      Age35.63
      Mean.
      8.83
      Standard deviation.
      Education level
      Midwife Certification

      Master

      PhD
      174

      37

      7
      79.8

      17

      3,2
      Years of professional experience9.48
      Mean.
      8.92
      Standard deviation.
      Hospital autonomous community
      Andalucía

      Aragón

      Islas Baleares

      Islas Canarias

      Castilla La Mancha

      Castilla León

      Cataluña

      Extremadura

      Galicia

      Madrid

      Melilla

      Murcia

      Navarra

      País Vasco

      Comunidad Valenciana
      118

      3

      1

      7

      1

      1

      21

      2

      6

      3

      6

      5

      10

      19

      15
      54.1

      1.4

      0.5

      3.2

      0.5

      0.5

      9.6

      0.9

      2.8

      1.4

      2.8

      2.3

      4.6

      8.7

      6.9
      Healthcare system
      Public

      Private
      215

      3
      98.6

      1.4
      Work shift


      Rotating

      8-h day/evening shift

      10-h night shift
      189

      21

      8
      86.7

      9.6

      3.7
      Intention to stay in their hospital workplace


      Yes

      No
      189

      29
      86.7

      13.3
      Intention to stay in the midwifery profession


      Yes

      No
      217

      1
      99.5

      0.5
      a Mean.
      b Standard deviation.

      2.3 Variables and instruments

      The following sociodemographic variables were collected: sex, age, education, years of professional experience, hospital autonomous community, hospital denomination (public or private), work shift (day/evening, rotating, nights), intention to stay in the hospital where they currently work and intention to stay in the midwifery profession the following year. The midwives’ were working on a full time basis, working 40 h per week. The working shifts were categorized into: day/evening (five 8-h day/evening shifts), rotating (two 8-h day shifts, two 8-h evening shifts and one 10-h night shift) and nights (four 10-h night shifts). Midwives’ intention to stay in their current hospital/profession was measured using the question: ‘Do you plan to stay in your current hospital/profession during the following year?’.

      2.3.1 The Practice Environment Scale of the Nursing Work Index (PES-NWI)

      The Spanish version of the PES-NWI validated by Fuentelsaz-Gallego (α = 0.90) [
      • Fuentelsaz-Gallego C.
      • Moreno-Casbas M.T.
      • González-María E.
      Validation of the Spanish version of the questionnaire practice environment scale of the nursing work index.
      ] was used to measure the nursing practice environment. The PES-NWI consists of 31 items classified into five subscales or factors: F1: Staffing and resource adequacy; F2: Collegial nurse/midwife-physician relationships; F3: Nurse/midwife manager ability, leadership and support of nurses/midwives; F4: Nursing/Midwifery foundations for quality of care; F5: Nurse/Midwife participation in hospital affairs. The answers were measured using a 4-point Likert scale (1 = completely disagree, 2 = disagree, 3 = agree, 4 = completely agree). A high score indicates a high degree of agreement with the corresponding item. Considering the version used in this study refers to nurses, midwives were asked to respond to the items from a professional midwifery perspective to minimize potential bias. The PES-NWI classifies a hospital as favorable if it has four or five factors with a mean score greater than or equal to 2.5, mixed if it has two or three factors with a mean score greater than or equal to 2.5, and unfavorable if it has one or no factors with an average score greater than or equal to 2.5. In this study, Cronbach’s alpha was 0.90.

      2.3.2 Hospital Survey on Patient Safety Culture (HSOPSC)

      The Spanish version of the HSOPSC was used, validated by the Agency for Healthcare Research and Quality [

      Agency for Healthcare Research and Quality, Hospital Survey on Patient Safety Culture Version 2.0: Items and Composite Measures, 2019. 〈https://www.ahrq.gov/sites/default/files/wysiwyg/sops/surveys/hospital/hospitalsurvey2-spanishitems.pdf〉, (Accessed 26 May 2021).

      ], with a Cronbach’s alpha of 0.77. This instrument consists of 28 items classified in 12 dimensions: D1: Teamwork, D2: Pressure and pace of work, D3: Organizational learning – Continuous improvement, D4: Response to errors, D5: Support given by supervisors, directors, or clinical managers for patient safety, D6: Communication and information on errors, D7: Communication and responsiveness, D8: Reporting on events related to patient safety, D9: Support given by administrators for patient safety, D10: Transfer and exchange of information, D11: Number of reported incidents, and D12: Patient safety rating. The responses of the subjects were measured on a 5-point Likert scale with values that vary from on item to another. Negative questions were converted to positive equivalents for the scale analysis. In general, the responses to the questionnaire were recorded into three categories: negative – completely disagree/never, disagree/rarely; neutral- neither agree nor disagree/sometimes; and positive - agree/almost always, completely agree/always. This coding made it possible to subsequently classify the items and dimensions of the instrument as strengths and opportunities for improvement.

      2.4 Data collection

      Data collection was carried out between November 2020 and January 2021 through an online questionnaire created by the researchers using Google Forms. The questionnaire consisted of the following sections: (1) study information and informed consent, (2) sociodemographic characteristics of the participants, (3) PES-NWI, and (4) HSOPSC. The questionnaire was dispersed online by posting on social networks and via email. Midwives from different Spanish hospitals (see Table 1 for the list) were contacted to request their collaboration in the study and were asked to share the questionnaire with other potentially eligible midwives. In addition, reminders were sent to participants to encourage participation. The estimated amount of time to complete the questionnaire was 15–20 min. The completion of the questionnaires implied the participants’ acceptance of online consent.

      2.5 Ethical aspects

      This study was approved by the corresponding Ethics and Research Commission (Registration no.: XXXX). The midwives were informed on the purpose of the study and the voluntary and anonymous nature of their participation. The data collected was treated confidentially at all times by the researchers. Participating subjects indicated their willingness to participate through an online informed consent form, maintaining the right to withdraw from the study at any time. The ethical principles of the Declaration of Helsinki were followed [
      • World Medical Association
      World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects.
      ].

      2.6 Statistical analysis

      The data were coded and analyzed using the statistical program SPSS v. 26. Percentages and frequencies were calculated for the categorical variables and measures of central tendency (mean) and dispersion (standard deviation, maximum, and minimum) for the quantitative variables. The Kolmogorov-Smirnov (K-S) test was performed to explore the normality of the variables. Depending on the distribution of the variables, parametric tests (t-Student and ANOVA) and non-parametric tests (Mann-Whitney U and Kruskal Wallis) were carried out. The Spearman correlation coefficient was calculated to analyze the relationship between variables. The confidence level was 95% considering p < 0.05 as significant.

      3. Results

      3.1 Sociodemographic characteristics

      The study sample consisted of a total of 218 subjects (N = 218), of which 90.8% (n = 198) were female, and 9.2% (n = 20) were male. The average age of the participants was 35.63 (SD=8.83), with a minimum age of 25 and a maximum age of 59. Regarding education, only 17% (n = 37) midwives had a master's degree and 3.2% (n = 7) had completed their Phd studies. The average amount of work experience was 9.48 (SD = 8.92) years, with a minimum of one year and a maximum of 39 years. The majority of midwives (98.6%; n = 215) worked in public hospitals, had a rotating shift (86.7%; n = 189), and had the intention to continue working for the same hospital (86.7%; n = 189) and in the midwifery profession (99.5%; n = 217) over the coming year. There was only one midwife, who intended to leave the profession. The rest of the sociodemographic characteristics of the participants are detailed in Table 1.
      The Chi-square test showed statistically significant associations between the work shift and the intention to remain in the hospitals where they work (X2(2) = 9.52, p = 0.009) and in the midwifery profession (X2(2) = 9.424, p = 0.009). The intention to stay in their current hospital and midwifery profession was significantly greater in midwives working rotating shifts (n = 169, 89.4% and n = 15, 7.9%) compared to those working on a day/evening shift schedule (n = 5, 2.6% and n = 189, 87.1%) or night shifts (n = 20, 9.2% and n = 8, 3.7%).

      3.2 The Practice Environment Scale of the Nursing Work Index (PES-NWI)

      The mean scores for the factors and the total of the PES-NWI are shown in Table 2. The mean total score of the PES-NWI was 2.47 (SD = 0.43). The PES-NWI factors with the highest mean scores were “Collegial nurse/midwife-physician relationships” (M = 2.69, SD = 0.67) and “Staffing and resource adequacy” (M = 2.58, SD = 0.63). On the contrary, the factor “Nurse/Midwife participation in hospital affairs” obtained the lowest mean score (M = 2.18, SD = 0.52). The hospitals were found to be mixed (neither unfavorable or favorable) according to the PES-NWI classification, as only two of the five factors obtained a mean score greater than or equal to 2.5.
      Table 2Mean and standard deviation for the PES-NWI.
      PES-NWIM (SD)
      F1. Staffing and Resource Adequacy2.58 (0.63)
      F2. Collegial Nurse/Midwife‐Physician Relations2.69 (0.67)
      F3. Nurse/Midwife Manager Ability, Leadership and Support of Nurses2.46 (0.76)
      F4. Nursing/Midwifery Foundations for Quality of Care2.46 (0.52)
      F5. Nurse/Midwife Participation in Hospital Affairs2.18 (0.52)
      Total2.47 (0.43)
      M (SD): Mean (Standard deviation).
      PES-NWI: The Practice Environment Scale of the Nursing Work Index.
      When comparing the mean scores, statistically significant associations were found for the mean score of the factor “Staffing and resource adequacy” with respect to sex (U = 1347, Z = 2.371, p = 0.018) and work shift (X2 (2) = 7.791, p = 0.020). The females’ perception (M = 2.61, SD = 0.62) of the endowment and adequacy of resources was significantly higher than that of the males (M = 2.25, SD = 0.62). The midwives who worked a rotating shift (M = 2.62, SD = 0.62) showed significantly higher scores for this factor than those who worked the day/evening shift (M = 2.29, SD = 0.58) or nights (M = 2.25, SD = 0.69). No statistically significant associations were observed when comparing the total mean scores of the PES-NWI questionnaire with the rest of the sociodemographic variables of the sample (p > 0.05). Nor were there significant associations in the intention of the midwives to remain working in their hospitals and in the profession according to the PES-NWI scores (p > 0.05).

      3.3 Hospital Survey on Patient Safety Culture (HSOPSC)

      The total mean score of the questionnaire was 3.01 (SD = 0.28). The HSOPSC dimensions with the highest mean scores were “Patient safety rating” (M = 3.58, SD = 0.74) and “Teamwork” (M = 3.40, SD = 0.46). On the contrary, the dimensions “Number of reported incidents” and “Organizational learning-Continued improvement” obtained the lowest mean scores, with values of 1.55 (SD = 0.69) and 2.77 (SD = 0.64), respectively. The percentages of positive and negative responses, as well as the mean scores of the HSOPSC are detailed in Table 3.
      Table 3HSOPSC means and percentages of positive and negative responses.
      HSOPSC composite measures% positive response% negative

      response
      M (SD)
      D1. Teamwork75.006.603.40 (0.46)
      D2. Staffing and Work Pace37.7233.603.08 (0.54)
      D3. Organizational Learning—Continuous Improvement33.0330.732.77 (0.64)
      D4. Response to Error29.1234.153.07 (0.59)
      D5. Supervisor, Manager, or Clinical Leader Support for Patient Safety52.4619.732.92 (0.62)
      D6. Communication About Error47.4020.603.35 (0.91)
      D7. Communication Openness53.8017.453.19 (0.48)
      D8. Reporting Patient Safety Events39.0022.003.22 (0.92)
      D9. Hospital Management Support for Patient Safety42.0322.163.25 (0.58)
      D10. Handoffs and Information Exchange55.8017.732.77 (0.61)
      D11. Number of Events Reported90.400.501.55 (0.69)
      D12. Patient Safety Rating94.000.903.58 (0.74)
      M (SD): Mean (Standard Deviation).
      HSOPSC: Hospital Survey on Patient Safety Culture.
      Statistically significant associations were obtained when comparing the mean scores of the HSOPSC. The mean of the dimension “Transfers and exchange of information” varied significantly with respect to sex (U = 1402.50, Z = − 2.185, p = 0.029), being higher in males (M = 3.12, SD = 0.77) than in females (M = 2.74, SD = 0.59). Therefore, male midwives perceived safer transfers and exchange of information than females. The dimension “Organizational learning-Continuous improvement” was negatively correlated with age (rs = − 0.175, p = 0.010); meaning that at a younger age, midwives tend to perceive a better learning environment and continuous improvement in women’s safety. In addition, a negative correlation was found between the years of professional experience and the dimensions “Pressure and pace of work” (rs = − 0.183, p = 0.007) and “Organizational learning” (rs = − 0.214, p = 0.002). Therefore, the less experience one has, the greater the feeling of pressure and a faster pace of work, and a greater intention to become trained in organizational culture. The dimensions “Pressure and pace of work” and “Patient safety rating” showed significant associations depending on the education level of the midwives (See Table 4). Specifically, the most highly-educated midwives reported lower work pressure and better women's safety rates. Likewise, the dimensions “Organizational learning-continuous improvements” and “Support given by supervisors, directors or clinical managers for patient safety” varied significantly according to the work shift (See Table 4). Midwives working on day/evening shifts perceived lower organizational learning-continuous improvements and greater support by leaders for women's safety than those working on rotating or night shifts. On the other hand, the dimension “Teamwork” showed significant associations according to the type of system (public or private). Midwives from public hospitals (M = 3.41, SD = 0.46) had a greater awareness of teamwork than those from private organizations (M = 2.89, SD = 0.19). There were no significant associations found between the intention of midwives to remain working in their hospitals and in their profession according to the HSOPSC scores (p > 0.05).
      Table 4HSOPSC mean scores according to educational level and working shift.
      Educational level (Mean ± SD)
      HSOPSC dimensionMidwives (N = 174)Master (N = 37)PhD (N = 7)χ²dfp


      D2

      D12




      3.06 ± 0.54

      3.61 ± 0.73


      3.23 ± 0.47

      3.32 ± 0.74


      2.60 ± 0.66

      4.29 ± 0.75


      6.828

      11.031


      2

      2


      0.033
      p < 0.05 derived from Kruskal-Wallis test.


      0.004
      p < 0.01 derived from Kruskal-Wallis test.
      Working shift (Mean ± SD)
      rotation shift (N = 189)day/evening shift (N = 21)Night shift (N = 8)
      D32.76 ± 0.642.69 ± 0.663.33 ± 0.436.66520.036
      p < 0.05 derived from Kruskal-Wallis test.
      D52.87 ± 0.593.38 ± 0.712.92 ± 0.6212.10820.002
      p < 0.01 derived from Kruskal-Wallis test.
      SD: Standard deviation.
      a p < 0.05 derived from Kruskal-Wallis test.
      b p < 0.01 derived from Kruskal-Wallis test.

      3.4 Correlations between the PES-NWI, HSOPSC, and the intention of midwives to stay in their current job and profession

      The total mean score of the PES-NWI significantly and positively correlated with the total mean score of the HSOPSC (rs = 0.498, p < 0.001), indicating that as the quality of the midwives’ work environment increases, the women’s clinical safety culture increases (See Table 5). The HSOPSC dimension “Support given by supervisors, directors, or clinical managers for patient safety” showed a strong, positive and significant correlation with the PES-NWI factor “Nurse/midwife manager ability, leadership and support of nurses/midwives” (rs = 0.632, p < 0.001). The HSOPSC dimensions “Communication of errors”, “Communication and responsiveness”, “Support from administrators for patient safety” and “Patient safety rating” correlated significantly and positively with all of the factors of the PES-NWI.
      Table 5Spearman correlation coefficient between PES-NWI and HSOPSC.
      HSOPSCPES-NWI
      F1F2F3F4F5
      D1r. s.,058,171
      p < 0.05 (two-tailed).
      ,028,323
      p < 0.01 (two-tailed).
      ,111
      Sig.,394,012,681,000,102
      D2r. s.,001,111-,236
      p < 0.01 (two-tailed).
      ,125,016
      Sig.,989,101,000,066,816
      D3r. s.,164
      p < 0.05 (two-tailed).
      ,150
      p < 0.05 (two-tailed).
      ,048,439
      p < 0.01 (two-tailed).
      ,418
      p < 0.01 (two-tailed).
      Sig.,015,027,482,000,000
      D4r. s.-,112-,122-,388
      p < 0.01 (two-tailed).
      -,029-,090
      Sig.,098,071,000,667,184
      D5r. s.,085,060,632
      p < 0.01 (two-tailed).
      ,146
      p < 0.05 (two-tailed).
      ,310
      p < 0.01 (two-tailed).
      Sig.,212,375,000,032,000
      D6r. s.,295
      p < 0.01 (two-tailed).
      ,262
      p < 0.01 (two-tailed).
      ,373
      p < 0.01 (two-tailed).
      ,439
      p < 0.01 (two-tailed).
      ,468
      p < 0.01 (two-tailed).
      Sig.,000,000,000,000,000
      D7r. s.,207
      p < 0.01 (two-tailed).
      ,298
      p < 0.01 (two-tailed).
      ,247
      p < 0.01 (two-tailed).
      ,299
      p < 0.01 (two-tailed).
      ,303
      p < 0.01 (two-tailed).
      Sig.,002,000,000,000,000
      D8r. s.,205
      p < 0.01 (two-tailed).
      ,062,162
      p < 0.05 (two-tailed).
      ,200
      p < 0.01 (two-tailed).
      ,213
      p < 0.01 (two-tailed).
      Sig.,002,366,016,003,002
      D9r. s.,187
      p < 0.01 (two-tailed).
      ,194
      p < 0.01 (two-tailed).
      ,163
      p < 0.05 (two-tailed).
      ,409
      p < 0.01 (two-tailed).
      ,349
      p < 0.01 (two-tailed).
      Sig.,006,004,016,000,000
      D10r. s.-,163
      p < 0.05 (two-tailed).
      -,003-,199
      p < 0.01 (two-tailed).
      -,174
      p < 0.05 (two-tailed).
      -,250
      p < 0.01 (two-tailed).
      Sig.,016,968,003,010,000
      D11r. s.-,033,026-,145
      p < 0.05 (two-tailed).
      ,015,033
      Sig.,626,707,032,830,629
      D12r. s.,336
      p < 0.01 (two-tailed).
      ,224
      p < 0.01 (two-tailed).
      ,286
      p < 0.01 (two-tailed).
      ,291
      p < 0.01 (two-tailed).
      ,293
      p < 0.01 (two-tailed).
      Sig.,000,001,000,000,000
      r.s. Spearman correlation coefficient.
      a p < 0.05 (two-tailed).
      b p < 0.01 (two-tailed).
      Midwives’ intention to stay in the midwifery profession was not associated with any other variable. However, the intention of midwives to remain in the hospital where they currently work was correlated with the item “A10: When staff make mistakes, this unit focuses on learning instead of looking for someone to blame” (rs = − 0.134, p = 0.049), of the dimension “Response to errors” and with the items “F5: During shift changes, important information about patient care is frequently lost” (rs = 0.154, p = 0.023), and “F6: During shift changes, there is enough time to exchange all important information about patient care” (rs = − 0.149, p = 0.028), from the dimension “Transfers and Information Exchange” of the HSOPSC. No significant correlations were observed between the intention of midwives to continue working in their current hospital and the PES-NWI.

      4. Discussion

      The objective of this study was to analyze the work environment and its relationship with women´s clinical safety culture and midwives’ intention to stay in their current job and the midwifery profession. This study contributes to the available literature by revealing the relationships between the work environment, women´s clinical safety culture, and midwives intention to stay. The results suggest that the improvement of the work environment promotes better results in the clinical safety of women. Likewise, achieving leadership and support for workers is crucial for successfully establishing a safety culture in healthcare organizations.
      The work environment of the midwives in this study was mixed (neither unfavorable nor favorable), differing from the perceptions of Australian and Swedish midwives, according to previous studies [
      • Hildingsson I.
      • Fenwick J.
      Swedish midwives’ perception of their practice environment – a cross sectional study.
      ,
      • Sheehy A.
      • Smith R.M.
      • Gray J.E.
      • Homer C.S.E.
      Midwifery pre-registration education and mid-career workforce participation and experiences.
      ]. The scores obtained for the collegial nurse/midwife-physician relations factor were similar to those of other studies, in which it was the most highly valued [
      • Sheehy A.
      • Smith R.M.
      • Gray J.E.
      • Homer C.S.E.
      Midwifery pre-registration education and mid-career workforce participation and experiences.
      ,
      • Pallant J.F.
      • Dixon L.
      • Sidebotham M.
      • Fenwick J.
      Adaptation and psychometric testing of the practice environment scale for use with midwives.
      ]. These results support the relevance of good communication and relationships between professionals in labor wards for improving the quality of labor, birth and postpartum care for women [
      • Aiken L.H.
      • Sermeus W.
      • Van den Heede K.
      • Sloane D.M.
      • Busse R.
      • Mckee M.
      • Bruyneel L.
      • Rafferty A.M.
      • Griffiths P.
      • Moreno-Casbas M.T.
      • Tishelman C.
      • Scott A.
      • Brzostek T.
      • Kinnunen J.
      • Schwendimann R.
      • Heinen M.
      • Zikos D.
      • Sjetne I.S.
      • Smith H.L.
      • Kutney-Lee A.
      Patient safety, satisfaction, and quality of hospital care: cross sectional surveys of nurses and patients in 12 countries in Europe and the United States.
      ]. Furthermore, staffing and resource adequacy was the second most valued factor in this study, unlike other research carried out with midwives [
      • Sheehy A.
      • Smith R.M.
      • Gray J.E.
      • Homer C.S.E.
      Midwifery pre-registration education and mid-career workforce participation and experiences.
      ] and professionals involved in the provision of maternity care [
      • Pallant J.F.
      • Dixon L.
      • Sidebotham M.
      • Fenwick J.
      Adaptation and psychometric testing of the practice environment scale for use with midwives.
      ], in which this factor obtained the lowest score. According to the literature [
      • Sheehy A.
      • Smith R.M.
      • Gray J.E.
      • Homer C.S.E.
      Midwifery pre-registration education and mid-career workforce participation and experiences.
      ,
      • Matlala M.S.
      • Lumadi T.G.
      Perceptions of midwives on shortage and retention of staff at a public hospital in Tshwane District.
      ], adequate staffing and resource adequacy help to reduce the intention of workers to leave their workplace, which could explain the high probability of midwives in this study to remain working in their workplace and in their profession in the coming years.
      In general, the midwives’ perception of the work environment was significantly more unfavorable when they had night shifts. This may be because those who work night shifts need to alter their life routines and sleeping habits. In addition, night hours negatively influence the work capacity of healthcare personnel due to physical stress, changes in circadian rhythms, and reduced cognitive ability [
      • Korompeli A.
      • Muurlink O.
      • Tzayara C.
      • Velonakis E.
      • Lemonidou C.
      • Sourtzi P.
      Influence of shiftwork on greek nursing personnel.
      ], which could explain the findings observed in this research study.
      Women's safety was rated in this study as very good or excellent by more than half of the midwives, showing better results in those observed in the study by Arrieta et al. [
      • Arrieta A.
      • Suárez G.
      • Hakim G.
      Assessment of patient safety culture in private and public hospitals in Peru.
      ] in Peruvian hospitals. In terms of dimensions, teamwork was a strong dimension of women's safety culture, coinciding with the results of previous research [
      • Chen Q.
      • Gottlieb L.
      • Lio D.
      • Tang S.
      • Bai Y.
      The nurse outcomes and patient outcomes following the High-Quality Care Project.
      ,
      • Akbari N.
      • Malek M.
      • Ebrahimi P.
      • Haghani H.
      • Aazami S.
      Safety culture in the maternity unit of hospitals in Ilam province, Iran: a census survey using HSOPSC tool.
      ]. On the contrary, the midwives showed their dissatisfaction with the notification of safety incidents and the response to adverse events by the professionals themselves, teammates, and managers. Despite being the worst-rated dimension, the average positive response rate in this study was higher than that found in studies conducted in other countries [
      • Jabarkhil A.Q.
      • Tabatabaee S.S.
      • Jamali J.
      • Moghri J.
      Assessment of patient safety culture among doctors, nurses, and midwives in a public hospital in Afghanistan.
      ,
      • Santiago T.H.R.
      • Turrini R.N.T.
      Cultura e clima organizacional para segurança do paciente em Unidades de Terapia Intensiva.
      ].
      A positive and significant relationship was observed between perceived support from the supervisor and the midwives’ satisfaction with their work environment. Supervisors represent organizational leadership and influence the work environment [
      • Stetler C.B.
      • Ritchie J.A.
      • Rycroft-Malone J.
      • Charns M.P.
      Leadership for evidence-based practice: strategic and functional behaviors for institutionalizing EBP: leadership for EBP.
      ]. The support received from supervisors influences productivity and job satisfaction, as well as the desire of midwives to continue working in the hospital by creating a favorable working environment [
      • Bannon E.M.
      • Alderdice F.
      • McNeills J.
      A review of midwifery leadership.
      ,
      • Gifford W.A.
      • Squires J.E.
      • Angus D.E.
      • Ashley L.A.
      • Brosseau L.
      • Craik J.M.
      • et al.
      Managerial leadership for research use in nursing and allied health care professions: a systematic review.
      ]. Furthermore, the intention of midwives to continue working in their hospital was associated with response to errors and the transfer of women’s information. Therefore, this study suggests that support from management when errors are made by personnel and the use of these errors as opportunities for learning and improvement not only provide the midwives with professional security in their job [
      • Lopes de Figueiredo M.
      • D´Innocenzo M.
      Eventos adversos relacionados às práticas assistenciais: uma revisão integrativa.
      ], but could also be considered a potential retention strategy. Likewise, having an adequate amount of time to transfer women’s information during shift changes was associated with the safety and intention of the midwives to continue working in the hospital [
      • Guevara Lozano M.
      • Arroyo Marlés L.P.
      El cambio de turno: un eje central del cuidado de enfermería.
      ,
      • Whiting L.
      • O´Grady M.
      • Whiting M.
      • Petty J.
      Factors influencing nurse retention within children’s palliative care.
      ].

      4.1 Implications for clinical practice

      The findings of this research show associations that could be considered to create a safe and favorable working environment where a strong women’s safety culture and institutional support is perceived that increases the midwives’ commitment to their hospitals and their intention to continue working there. Considering these findings in decision-making could help to create effective recruitment and retention strategies in light of the anticipated shortage of midwives in the future.

      4.2 Limitations and future research

      The results of this study should be interpreted considering several limitations. The study sample was obtained by snowball sampling, a non-probability sampling technique, which limits the generalization of results. The nature of the study design enabled the establishment of relationships between the variables, but not causality; therefore, additional studies are required to confirm whether there is a causal relationship between the variables. Some issues should be considered with caution when drawing conclusions. The response rate based on the potential population of midwives. Associations based upon sex with only 20 male midwives compared to 198 female midwives as well as type of system (public or private) with only one midwife from the private sector. There was only one midwife who intended to leave the profession. The sample size of this subgroup was not large enough for significant results; thus, study associations should be carefully interpreted considering such limitations. The inclusion of hospitals from different geographical locations could generate dispersion in the data since the resources available to each hospital are different. More specifically, there was a wide dispersion of responses within each ‘hospital autonomous community’ with ten having less than 10 midwives represented, four having between 10 and 21 and only one dominating representation with 118 midwife responses. Given the sample size and the dispersion of the data used, it would be interesting to carry out future research to delve more deeply into this topic both nationally and internationally. During the study conceptualization, the use of the adapted version of the practice environment scale (PES) for midwifery [
      • Sheehy A.
      • Smith R.M.
      • Gray J.E.
      • Homer C.S.E.
      Midwifery pre-registration education and mid-career workforce participation and experiences.
      ] was considered. However, there is no adaptation and psychometric testing in the Spanish context and, thus, its use was limited in this study. Additional research should address the translation to other languages, cultural adaptation and psychometric analysis of the instrument in different contexts and midwives samples to allow a wider use worldwide. In addition, further studies should undertake multivariable analysis.

      5. Conclusion

      The midwives perceived a mixed (neither unfavorable nor favorable) work environment with good interprofessional relationships and adequate staffing and resources. The results of this study showed significant relationships between the work environment, women's safety culture, and midwives’ intention to stay in their profession. These findings could assist midwife leaders in making decisions to reduce the expected shortage of midwives in the coming years and ensure high-quality maternity and newborn care. The creation of a favorable working environment could be a potentially effective strategy that encourages an improvement in women's safety culture in healthcare organizations and in the number of midwives who intend to stay in hospitals.

      Ethical Statement

      This study was approved by the corresponding Ethics and Research Commission (Registration no.: EFM 129/2021). The midwives were informed on the purpose of the study and the voluntary and anonymous nature of their participation. The data collected was treated confidentially at all times by the researchers. Participating subjects signed the informed consent form, maintaining the right to withdraw from the study at any time. The ethical principles of the Declaration of Helsinki were followed.

      Funding

      This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

      CRediT authorship contribution statement

      MC Rodríguez-García: Conceptualization, Formal analysis, Investigation, Methodology, Visualization, Writing – original draft, Writing – review & editing. IM Martos-López: Formal analysis, Writing – original draft, Writing – review & editing. G Casas-López: Formal analysis, Writing – original draft, Writing – review & editing. VV Márquez-Hernández: Conceptualization, Formal analysis, Methodology, Supervision, Visualization, Writing – original draft, Writing – review & editing. G Aguilera-Manrique: Visualization, Writing – review & editing. L Gutiérrez-Puertas: Visualization, Writing – original draft, Writing – review & editing.

      Conflict of interest

      None declared.

      Acknowledgements

      The authors express their gratitude to all of the midwives who participated in this study.

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