In this study, the aim was to identify factors associated with job satisfaction in midwives and to compare how midwives assessed their work environment with Swedish reference data. In the final model, thirteen scales were identified that explained 65% of the variance in how midwives scored on job satisfaction. These scales represent different aspects of the organisational and psychosocial work environment. When comparing midwives’ assessment of their work environment with Swedish benchmarks, we found that midwives reported significantly more adverse values for work pace, role conflicts, burnout, quantitative and emotional demands, influence, recognition, organisational justice and self-rated health. However, midwives beneficially differed from the reference data with higher values for meaningfulness and variety of work.
Beneficial work environmental factors
The regression analyses revealed beneficial factors in the organisational and psychosocial work environment with variety and meaningfulness of work that were associated with midwives’ job satisfaction. Only these two scales had beneficial MID with higher values than the Swedish benchmarks. These findings are in line with our previous qualitative research, indicating that midwives’ work is highly varied and enables midwives to autonomously develop professional knowledge and skills with support from relevant organisational prerequisites [2]. The same applies to meaningfulness of work, where midwives’ relationships with pregnant and birthing woman and their partners gives them a feeling of being professionally useful. This is in line with Bloxsome et al. [10, 24], who emphasise the importance of making a difference and being of use. Other beneficial factors that were associated with job satisfaction in midwives included being able to influence the work being done and being able to provide high quality care in a context with prerequisites for professional development and recognition. These results correspond with an integrated review of midwives’ job satisfaction and intention to stay in the profession [10].
Adverse work environmental factors
Factors with an adverse association with job satisfaction were high levels of burnout, role conflicts and emotional demands. In addition, we found that midwives adversely differed from the reference population in terms of work pace, quantitative and emotional demands, role conflicts and burnout as well as reporting lower levels of influence, recognition, organisational justice and self-rated health. Thus, our study found that midwives work in an organisational and psychosocial work environment characterised by high demands and low control, which is supported by previous research [2, 13, 14, 25,26,27]. In this study, emotional demands, in particular, adversely differed from the Swedish benchmarks with a difference in mean values of 20.6 higher emotional demands of midwives. The high emotional demands in midwifery have previously been described [28, 29] and the midwifery profession is known to be inherently emotional demanding. Our results are in line with previous research about midwives’ work environment, which has consistently found that midwives have a demanding work situation [2, 13, 14, 25, 27, 30]. In addition, midwives have been found to experience high levels of work-related stress [25, 27, 30], burnout [25,26,27, 31,32,33], poor organisational climate, insufficient work resources and under-staffing [26, 30]. A qualitative study of midwives’ emotional work found that conflicting ideologies in the organisation can be a source of additional emotional demands and ethical stress that can aggravate the work situation further due to competing ethical standpoints [34].
Role conflict and recognition at work were included in the multivariable model and were together with influence at work and organisational justice, scales that adversely differed from the Swedish benchmarks. These results are in line with two reviews of midwives’ work environments [10, 19], which described the importance for midwives of having influence at work and being able to practice midwifery autonomously without role conflict. Receiving recognition and working in a just organisation were shown to be the main determinants of job satisfaction according to Papoutsis et al. [35]. Similar results were obtained by Dixon et al. [29], who found that midwives’ emotional well-being was affected by professional recognition. Consequently, it is worrying that midwives in Sweden report low influence at work, high role conflicts, low recognition and low organisational justice, which are fundamental components of the organisational and psychosocial work environment. It is equally concerning that midwives’ assess their self-rated health significantly lower than does the reference population. Poor self-rated health has been shown to be an independent risk factor for both morbidity and mortality [36]. It is notable that midwives’ job satisfaction is associated with burnout and that gainfully employed midwives scored significantly higher than the Swedish benchmarks on the burnout scale. These results are in line with previous research on burnout in midwives [6, 27, 33, 37,38,39].
The results in relation to the salutogenic theory and professional autonomy in midwifery
The exploratory approach taking into account multiple factors was informative since both positive and negative factors in the midwives’ organisational and psychosocial work environment were identified. Particularly interesting was the identification of beneficial factors in midwives’ work environment, which supports the importance of a salutogenic perspective on the organisational and psychosocial work environment in addition to the more traditional risk factor focus.
Researchers in salutogenic theory argue that resources and stressors in the work situation can be perceived as both positive and negative. Thus, a specific factor in the work environment cannot necessarily be designated as a stressor but, rather, the outcome of the factor depends on the work context and individual characteristics [40, 41]. This can be interpreted as an opportunity for employers to support and facilitate consistency and balance between underload and overload. The salutogenic theory also emphasises the importance of participating in decision-making [41, 42]. Another assumption in the salutogenic theory is that high demands at work can be balanced with a strong individual sense of meaningfulness and by the perception that work is comprehensible and manageable [41]. This sense of coherence generates the ability to use one’s resources to minimize the impact of the stressors. Thus, Antonovsky and Mittelmark mean that a sense of coherence can be seen as a personal resource that reduce work strain and lead to a perception of stressors as challenges rather than threats [43, 44].
The present results also indicate that the ability to influence one’s own work and provide high quality care was associated with job satisfaction. Previous research has found midwives’ professional identity and autonomy to be important in supporting a health-promoting work situation and job satisfaction [2, 3, 13, 19, 45]. Other associations with job satisfaction in this study were being recognised and respected in the professional scope of practice without role conflicts. A review of midwives’ job satisfaction obtained similar results, finding that job satisfaction was negatively affected by insufficient time for professional activities, low autonomy and high demands [19]. This aligns well with salutogenic theory, which highlights that the ability to work autonomously can lead to increased meaningfulness and motivation and can also balance high demands [40].
In order to achieve a health-promoting workplace, it is important to strengthen the workplace’s health-promoting factors, but also to work preventively based on the risk factors that exist in the specific workplace. A salutogenic assumption is that each individual, workplace and organisation has resources that can be used to maintain and develop health and a sense of coherence [40]. However, the specific resources and stressors of the workplaces need to be identified, which this study has contributed to for the field of midwifery.
Strengths and limitations
The main strengths of this study are its nation-wide sample of midwives and its focus on both positive and negative factors in the work environment of midwives. Another strength is the diversity of the participants; for example, midwives’ place of work varied, whereas previous research has generally focused on the work environment in labour wards or inpatient care. Another strength is that, besides investigating the demands in the workplace, this study focuses on the workplace characteristics that contribute to job satisfaction.
No causal assumptions or conclusions can be made based on this study due to the cross-sectional design. Selection bias cannot be ruled out, due to possible differences between the midwives who are members of unions and those who are not. Recruiting midwives through the unions was an efficient way to reach the greatest number of Swedish midwives and still have control over who was included. Due to General Data Protection Regulation, we had to invite the midwives trough the union’s membership register. The unions sent out the invitations. Unfortunately, due to General Data Protection Regulation, we do not have any data on the non-responders. However, the gender distribution in our study is in line with the national statistics of midwives in Sweden. A sampling bias could be another possible limitation as there may be differences between the midwives who completed the survey and those who did not. We consider the response rate of 41% to be acceptable and have not found any discrepancy in the distribution of midwives in our sample compared to public statistics on midwives.
Another conceivable limitation in this study is that there were available participant characteristics in 1697 participant (2,9% less participants than the full analysis set) due to that these variables were at the end of the extensive survey and therefore had missing values. We chose to include all participants for whom we had available outcome data and with > 50% reported answers on included QOPSOC III scales in the regression analysis, to make use all reported data.
We aimed to give an overall perspective of midwives’ organisational and psychosocial work environment and kept the adjustment variables to age and years of work experience. Future studies are needed on specific groups of midwives (e.g. maternity ward vs gynaecological ward, part-time vs full-time, leadership vs not leadership). Selection bias as a reason for found differences with the benchmark population is considered less likely since the distribution of age and gender of midwives is in line with the national statistics, and since the found differences are in line with findings from other studies and our qualitative studies.
Further longitudinal research is needed to identify predictors of job satisfaction for midwives in Sweden by following the work situation over time to enable causal assumptions.