 So this is Julia, my language skills are absolutely atrocious, you can say it right yourself. And she's been a midwife for many years, both in Germany and in Australia, and her particular interest now is in birth trauma and its effect on midwives. So welcome Julia, and please take the floor. Yes, thank you Linda for the introduction and welcome everybody to this presentation. It's very exciting to see midwives from so many countries being interested in the topic. So I just start by giving you a just short background about the topic and also about the study I did. So as Linda introduced said in the introduction, I was interested in researching the effects of witnessing birth trauma. So about and one way to think about the effect is to think that midwives themselves actually become traumatized and develop what is referred to as post-traumatic stress. So just as a background here, so post-traumatic stress that has three classic symptoms that is re-experiencing avoidance and arousal symptoms. And if that is really bad, then it becomes a post-traumatic stress disorder. So there has been some research that shows that when midwives witness that sort of birth trauma that they can develop symptoms of post-traumatic stress. However, we do not know a lot about what constitutes risk factors, which what makes midwives more likely to develop that sort of stress. And maybe just on the just some info on the practical implications, just if you imagine the symptoms re-experiencing avoidance and arousal in clinical practice, just to explain the significance of the topic, it just makes your life as a midwife pretty much hard. If you have experienced, have witnessed the trauma and it does affect you and you are whilst you in the following days, weeks or for some years you are affected. You just have to re-experience that terrible event. You try to avoid maybe the place where it happened, maybe that special room where the birth took place. And whenever there is a little reminder, you get like your heart rate just speeds up. So that's how it looks in practice. It's very unpleasant. And yeah, if it goes on, it can really make you sick. So what I did, I just asked midwives about if they've ever witnessed trauma and then asked them about symptoms of post-traumatic stress. This is just so as a background to before I move on to talk about professional autonomy and traumatic stress. So what I found in my study which took place in Australia, in which I just did an online survey and asked midwives who are interested in the topic, midwives who are registered with the Australian College of Midwives and I had big response. So all the way through my research, I had the impression midwives are really interested in the topic of traumatic stress. And what I found in this sample is that quite a lot of midwives have symptoms of post-traumatic stress and then if we use like this working definition of probable PTSD, like also very likely to have that stress disorder, that in my study was up to 17% so that is significant. That's almost one-fifth of midwives. So is a topic that is relevant for midwives in their daily practice and just from this study and also from studies done in the UK and the USA, we know that there are many midwives out there practicing who are actually battling with symptoms of traumatic stress. So when I then investigated possible risk factors, of course I looked at what has been done in other related neighbouring disciplines, what are risk factors for post-traumatic stress in general and then maybe there's some research done with ambulance, people who work as ambulance personnel, so what is their risk when they watch terrible events, how does it, what risk factors make them more likely to develop post-traumatic stress. And I just, so this is still the background, just came up with this model, say that there's lots of reasons, there's lots of factors that also interact with each other, there's basically factors that have to do with the midwife herself, that's her own history, also her own personality. Then there is an important factor is things related to the birth trauma itself, what type of trauma did they witness, how was the immediate reaction to that and then there's factors that have to do with the wider environment. So that has to do with the way the work is organised there and this is this area, the wider environment and in particular the how work is organised, the job, what are the demands midwives are experiencing and how much control do they have over how they do their work, this is the area that this presentation will look into. So just like having these three, we know that these three factors are affecting the trauma risk and the environmental factor is something that is interesting in reference to professional autonomy in midwives. So I just want to stop here and just ask you, is there any questions so far to that? Anything you want to want to know a bit better before I can go on and talk about the job control and job demands in regards to traumatic stress? Okay, I just keep going then and you interrupt me if there's any questions in between. So the demand control model is a model that has been widely used to assess occupational stress. So it's been developed I think in the 1980s and it's been tested in a lot of occupations and it has been validated so there's definitely there is something to it. So we know that the psychosocial work environment influences the health of employees and we also know that how employees perceive the demands of the work they're doing and the extent they can make their own decisions that these two factors interact with each other and from just asking people about those two domains we can then predict how well do they cope with occupational stress and as you see when I talk about occupational stress so traumatic stress can just be considered as a form of occupational stress. It is a stress that midwives are confronted with as part of doing their job. So when we look at the model we see it assesses it's about two dimensions so it's about job control and I'll refer to this as decision authority later so job control how much control I have and what demands am I experiencing and as I said this you can apply to a variety of work situations. It has also it has been used in nursing quite a bit but so far I think midwives have not really worked with that model which I think is a shame because it has a lot to offer. So what we see here is if we have a job in general that gives us a low amount of control so here up here so low control but meanwhile has lots of demands and here more specifically we can talk about psychological demands then we'll end up in this part of the of the so in the in the high strain job quarter of the model so low control over what you're doing in your work low decision-making authority combined with lots of demands result in a job that is very stressful or in the model they call it a high strain job so that's that's important information and I think you know those of you who've worked across different areas they could probably if you look in your own experience here you can maybe relate to that. It doesn't always mean high demands in a job doesn't always mean that the job that you get high strain so when you experience high demands but you also have a lot of control over how you exactly manage these demands and you have a lot of say about how you do your job and what you do then you don't have a high strain job but you have what is referred to as an active job and active jobs are associated with positive outcomes with satisfaction with job satisfaction and positive health outcomes so since the demand side of midwifery we cannot change that much so midwifery is clearly a very demanding profession and particularly their psychological their psychological demands on midwives but the control side the other variable this is something that has to do with the models of care midwives are working in so there's models of care where midwives have very low job control then there's somewhere they have a bit of job control and then there's models of care where midwives have high job control and then this then combines with the demands determines whether the midwives is experiencing a high strain job or a rather an active job so that's the demand control model any questions is this okay I just keep going then talking about the keeping it I keep talking about the job control as I said you can use the the term workplace decision authority this is how it's measured in the questionnaire that is used the job content questionnaire and it basically as I said the influence over what to do and how to do it in midwives we can make the equation that job control is decision authority and that equals professional autonomy and then you could I guess we develop the model could say all these factors are really influenced by the model of care midwives are working in opposite sorry okay so so in my study I used the that questionnaire it's called the job content questionnaire and I used the decision authority subscale to find out how do midwives perceive their decision authority and the good thing about it is it's really quite short it's only three questions and now which just then when you analyze it so it gives you quite a valid and quite a reliable answer about the degree of decision authority so of professional autonomy people have so it's it's a quite a valid tool that has been has been tested and now I would really like it if that poll would come into and if actually you could just answer these three questions in regards to your current job so just don't think too much about it just just give a spontaneous answer is that possible Julia I yeah Julia I had to do the three questions as three different the three questions separately okay because there's no way to do all of those yeah so I'll do them in questions so and if you're not currently working as a midwife because they might be educators just think of the last job you're holding as a in clinical practice so in in your last job did your job allow you to make a lot of decisions on your arm so yeah and then goes through the anybody else going to answer this one you can do a no vote as well or no vote job everybody finish that one couple more okay I'm going to end that poll then the next one was in my job I had very little freedom there we go okie dokie any more just a few more still fabulous there's the rest of the 48 of you maybe you don't work as midwives that's always a possibility to anymore three two one that long enough Julia yep I think it's long enough yep no more coming in but so they're all trying to tell you the same concept really so so just the last one just different way of asking it but they're just just um please answer the last one for me I had a lot of say about what happened in my job so either your current job or in your in the last job you did you work as a midwife in clinical practice I had a lot of say you agree to that or did you rather not have a lot of say okay I think people are learning how to do polls just now it's good so this just gives you a bit of an idea you know what what is the concept of decision authority about and it's quite telling even though the questions are very general but you know from the answers you can normally tell um yeah how people how that area of people's work life looks like and um so I did I asked that the midwives in my study and I just show you what uh how they answered it doesn't want to do it this keeps flipping away let's try one more time sometimes um adobe will not um allow something on top of the original slides you know the the transitions don't work very well so maybe do you have it in front of you you can tell us what the the the yeah it's there no you should see you should see it now you should see the slide oh i'm sorry decision authority in in australia midwives it should be there now um so what what you see is um you know obviously so a low score is um low levels of decision authority in the highest scores high levels of decision authority and this how it was distributed just in my sample so so the medium um so the highest what you could get was 12 I don't know why this is showing 2.5 and 12.5 so just ignore just move it a bit to the left so it's two now it goes so so yeah it's the highest is 12 really um but what it shows us the medium here is um around a 7.5 and um but there is a bit of edge there's quite there's quite a few midwives who really have very low decision authority who answer these questions really like saying look I don't have a lot of say about what happened in my job um I um uh this is you know this is in general so they're just really indicated this is um not decision authority is not that uh big in in my current practice and there's a few who have lots of it so that is interesting um okay so as I said um I used this job this job control model and was interested in decision authority because I said look witnessing trauma is like just something that happens so often because we now know that I think it's like at least one third of women in you know in in any country who says they experience their own birth as dramatic and then of those women in Australia we know it's about six percent who go on then and develop even post-traumatic stress disorder but these numbers just tell us that witnessing trauma is something that happens quite regular to midwives so it's definitely something that we need to conceptualize as a form of occupational stress and then it's good to um then the demand control model which explains occupational stress is is a good one to understand what puts midwives at risk so what I um my hypothesis was uh that midwives who have um so that that decision authority affects how midwives react to witnessing trauma and um it might even make them less so low decision authority would make them more likely to be uh to react with traumatic stress because as we saw in the model if you have low decision authority um but high psychological demands you just kind of develop more stress so and this is what I found in my study first thing very interesting um I asked the midwives in the first um when I inquired about uh birth trauma asked have you ever witnessed birth trauma and then I asked them to think of one specific traumatic event that stood out for them and then in relation to that they answered the question about trauma symptoms and also about what type of birth trauma it was so I made these categories um so obviously death you know like this the big these big dramatic ones death and then I had injury or threat of injury to mother and child uh one category was abusive care management and witnessing disrespect so what I was trying is to identify um interpersonal trauma that is trauma that has to do with what other people do to you and trauma that is non interpersonal it's a bit like um a destiny so if you don't think of birth but and other trauma research is like natural catastrophes they are non interpersonal but then uh violence and abuse that's interpersonal trauma so I try to kind of think okay what constitutes interpersonal trauma for um in birth and then of course abusive care management so okay so this is how I came up with the categories of birth trauma interesting is that I found associations between what type of birth trauma the midwives witnessed and their decision authority at the time of the traumatic event because that's how I asked the question how much so I asked them to answer these questions um about their how much say they had how much say they had in their working environment and so on um in with reference to the uh birth to the time when they were experiencing the birth trauma so at the time of a traumatic event how much um say did you have over your job and so on and so on so um so on the right hand side here you see the odd ratios so that's just um an indication of um how much more likely is the occurrence of an event and that's here of uh having lower high decision authority um when the birth trauma included uh death injury or abusive care or interpersonal disrespect so I just um so what it what it tells us is that um midwives who witnessed um a traumatic event that included abusive care or management they were um um now sorry the other way around midwives who um had lower decision authority were two two point six times more likely to have witnessed um a traumatic event that included abusive care or management midwives that had lower decision authority were one point eight times more likely to witness a traumatic event that included their personal disrespect and one point six times more likely to witness injury midwives of lower decision authority um there was no relationships in regard to um death so um so death is clearly a non interpersonal um traumatic event it's more like has to do with destiny not that much with what uh is what is what sort of care the women is getting what interventions are um are happening uh with the women so um it's interesting to see that the category death uh witnessing death um that midwives remembered that that didn't really matter in regards to low and high decision authority so this is I want to ask you how do you have any questions do you understand what I want to say with this um why this this matter this analysis so I'm gonna move on um to it so so basically what it shows is that um when I ask midwives just remember one event that really you know stood out for you that was that was bad that affected you um midwives who had lower decision authority or midwives who remembered an event that uh a really bad event of abusive care and management they also had lower decision authority uh at that time so you can then argue that having lower decision authority makes it more likely that you witness for example um abusive care management or in general that you witness interpersonal trauma okay maybe it becomes more clear when I talk about um the relationship between decision authority and traumatic stress that's so so but yeah there's also so this was interesting there is a relationship um decision authority and what type of birth trauma trauma midwives um recall as particular distressing interesting also um the um paratraumatic emotions um they were so the paratraumatic emotions that's how you what you feel immediately um after the trauma so and that's a risk factor for traumatic stress um fear horror helplessness that's are the classic ones that are asked when you make when you diagnose a post-traumatic stress disorder but um I also um asked about anger powerlessness in guilt because in other studies about post-traumatic stress uh that has been identified as um affecting or that has been shown that midwives who witness trauma they often get very angry and also they experience powerlessness and they sometimes feel guilty um so what we see in this um what these results show us is that um midwives who um recall horror reacting with horror so being absolutely horrified by what they watched and being deeply affected with this horror they were much more likely uh to have um low to have had low decision authority at the time of the traumatic event so but you know again I I um I've expressed that in odds race odds ratios or risk relative risk so the relative risk um for um horror there was a 2.68 times times more again interesting too um so anger was more midwives who witnessed um who had low decision authority had more anger and more powerless feeling more sense of powerlessness when they witnessed trauma um and very interesting is that midwives with lower decision authority also had significantly they had more feelings of responsibility and I thought this is really odd because as you notice by the questions per se um the concept of of decision authority expresses that you actually don't have that much say about what happens into the woman whilst you whilst uh providing care because you're working in a model of care where you're not allowed to make too many decisions uh autonomously because your professional autonomy as a midwife is reduced so interesting is so even midwives or particular when they have low decision authority they still feel responsible for what happened to the woman and that's uh yeah that is interesting I think my interpretation for me was that even if midwives work in settings where they are really um do not have a lot of say about how they do their work and settings that are probably not women centers they still have like a very strong sense um that their job is to be with the woman and to um get the best outcome for the women so even though this is not possible and it's not the midwives fault that it's not possible um she would still feel responsible for the outcome it kind of shows how midwives and women are connected very deeply how much midwives care about the women they they are providing care during labor and birth too but um I thought it also uh is a bit pro it shows also how um um it must um be emotionally distressing for midwives for a midwife to be in a setting where you actually can't make some major decisions but you still feel such a sense of responsibility for the overall outcome so that does um yeah it just does does seem stressful there do you have any thoughts about um that relationship here between so so so basically midwives who have low decision authority don't have a lot of say about what's happening in the birth um in the birth management but they still feel a strong sense of responsibility when they when there is a traumatic event do you um does anybody want to comment on that or does that ring true for you for your own experiences maybe certainly rings true from every experience I've ever had but can I also give you a five-minute warning um Julia oh okay sure sure so yeah that's I think that is just something really interesting for midwives to think about so that you know they even yeah they just they just feel responsible for what happens to to the women and when something traumatic happens so that it just affects them that's because the midwife considers the patient to be her woman whatever happens doesn't she yeah so there's always an additional um connection there I think well in any good midwife anyway yeah that is right so so the final thing so what I was looking then was so the the amount of post-traumatic stress so that's what I measured with the um just the scale just the normal trauma scale for for assessing post-traumatic stress symptoms and decision authority and the similar results are reflected midwives who had low decision authority they um had a higher risk of developing post-traumatic stress disorder compared to midwives of um high decision authority so if you want in a small scale these findings confirm that the um job demand the the control demand model uh does also work for midwives because we see midwives can deal with can deal with stresses better when they have more decision authority and with the stress of witnessing birth trauma they can uh deal much better when they have more decision authority important here so also you can also choose another angle to that you could say okay maybe midwives who have high decision authority maybe they just in the first place do not witness that much uh cruel some traumatic events because as a result of them being able to manage the birth and to really um uh orchestrate the care and the way they want maybe that is actually protects women from trauma and when women are perfected when women are experiencing uh no birth trauma of course the midwives is not witnessing it so I think it could be a two-way relationships that really um in the end it is certainly also good for women to have midwives who have lots of decision authority who kind of manage the birth and have this authority because it might actually also prevent uh traumatic um birth events uh from happening so particularly out of sort of trauma that has to do that um is related with um or that is man-made like uh traumas through um unsensitive vaginal examinations or traumas through just rough approaches by um obstetricians or maybe other um fellow midwives could be too so but when the midwife has really a lot of say about how she looks after that woman um that might really just make the whole birth um better for the women in in that sense of course where we know there's better outcomes associated with one-to-one midwifery care but also one one outcome might be that the woman really is less likely to experience birth trauma that's a very interesting um consideration I think in future when we look at models of care we should assess birth trauma too and say okay what is what is the birth trauma aspect um of this model of care does it affect how much uh the likelihood for women to be traumatized in birth okay so I have to rush through it now since I not have too much time but I already said so there might there's definitely research needs needs to be done about the exact relationship about professional autonomy and um occupational stress in midwives but I think my findings show that there is a relationship that midwives who have more professional autonomy I have are less likely to experience traumatic stress and um one way this might be affected is that midwives actually um with lower decision authority are more likely to witness care related birth trauma because they are not don't have the power to really um stop um let's say disrespectful care or abusive care and as a result of having to witness that sort of birth trauma they have more perigematic distress this is the emotions of horror anger feeling helplessness feeling responsible and we know that perigematic distress distress is just a very um important a risk factor for post traumatic stress disorder so as a result of this chain low professional autonomy midwives um leads to post traumatic stress symptoms okay so this is the end of this presentation as I said um important points that have uh that has have been uh shown um through the findings of my research are that professional autonomy influences midwives health and well-being um there is a chance through job redesign and that means just change in model of care to increase professional autonomy in midwives and um whilst this whilst we have lots of findings how this might really be advantages bring lots of advantages for women um job redesign to increase professional autonomy may also bring health benefits for midwives and it may reduce for example traumatic stress symptoms in midwives um a problem in this area is that uh professional autonomy has not been uh measured a lot and has not been uh and because we don't have really solid model to measure it um it's hard for us as midwives to discuss what means professional autonomy in different settings and my presentation is a step forward to really say okay there is the concept of decision authority it has been used in many other settings it gives us a clear indication about level of professional autonomy let's try and use that concept let's ask midwives about their decision authority and let's investigate how that affects birth outcomes in women and how it affects midwives okay so oopsie that is uh was a summary of my presentation and i would really be interested to hear some of your thoughts about that so in general whether it brings true that you see in your um when you in your professional life that you see that relationship between professional um between decision authority or professional autonomy and workplace you can that brings true for your mid mid for free work experiences and um yeah so so maybe start with that thank you Julia did you have another um poll that you wanted to run uh yeah there was uh one other poll that was um uh when i talked about the different forms of birth trauma maybe you can we can run that quickly so have you ever witnessed uh disrespectful and abusive care i think that was my uh i would just be interested in that because lots of what i've been talking about is um okay when midwives have lots of decision authority it's less likely that their witness uh disrespectful or abusive care um but before this is really important to see okay um isn't the common occurrence to midwives really witness witness that a lot so i have 14 people answering um maybe there's some more i would i would like to know i would like to know if there's anybody who has who said he's never never witnessed disrespectful care that would be really great to see i've added lots in the chat box because um my answer would be 100 and lots yeah yeah yeah it's interesting again that also needs more investigation i think that that's a hundred percent look even though we've only had 18 to date some people are not midwives of course so um yeah okay that makes sense yep anybody else want to add to it anybody going to put in a no only if it's true only that's true yet all 20 see the numbers are going up well people can ask people can actually ask their questions let's see what the chat box we've got uh five minutes only so what kind of questions have come up um somebody asked at one point where can i see the questions linda or it's in there in the chat box i'm just on a little look and some one person marquita has said can we interpret that the low da midwives are a bit on the side of the traumatized woman i think that answer would be yes um they are on the side of the traumatized women yeah would we would we be empathetic with the woman who's been traumatized and therefore um more would we be more empathetic with women who are traumatized if we don't have any decision-making authority i think your research um that's a good that's a interesting question um i think um also midwives who have high decision authority um would have would be empathetic with the women but maybe they would be more in a position to prevent certain certain forms of trauma so but so and yes if you can't prevent certain uh certain trauma like disrespectful care then certainly as a midwife with low decision authority you are very much with the woman you are you know you are you are um identifying with her even probably that's my interpretation of it and marquette has also commented that if a woman decides what she wants and the staff are trying to follow the women's wishes but this doesn't happen then the staff are likely to be more traumatized at least i think that's what she meant yeah can you can you repeat if the woman is at the bottom of marquette has said if a woman decides what she wants and then the staff following the women's decision um that it can't be uh the decision can't be followed for some reason then the staff are more likely to be traumatized because um they're not following the women's wishes yeah they might have feelings of guilt and um we know also that guilt the same way guilt and horror when so when you feel guilt and horror when the trauma occurs you are more likely then to develop symptoms of post-traumatic stress because yeah that's that's just a very established relationship so that's that's very likely to be true yeah marquette has put another good point actually um being a devil's advocate maybe the high da medwives who are experiencing less personal abuse because they may feel less sensitive i suppose are you saying marquette that um if a woman if a midwife has a lot of responsibility but she's become kind of hardened over time um with that responsibility she's less likely to be stressed if a woman is traumatized is that what you were saying yeah i would like to get a clarified too why so but why would midwives who have high decision authority why would they be less sensitive i too would personally think that was unlikely because people who have responsibility generally um have more um more invested in the whole interest but maybe i'm thinking of independent midwife type people rather than yeah that's what i'm thinking too what is my key what is my key thing can i see her it's it's the bottom of the chat box here the last few comments oh i can't see that so just above are you in the every one part of the chat box yes of course you are no i'm not uh now i am yes okay yeah see all those bits of bottom there yeah i see yeah yeah yeah so yeah if you don't identify with the woman that much so you don't get so you don't get hurt that much that's um i get that point but i think still um if you are having a lot of decision authority you can still identify with the women oh absolutely i agree with you there but there are a few midwives i'm sure we've all met them who have that responsibility in that decision-making ability but they um they are they are being hardened or they're different types of people um and actually they're the ones that often um administer some of that um disrespectful care yeah that's right i mean you know it's really a big topic i think disrespectful care in maternity and um i think you know uh there is lots of reasons for why it happens um but i also think that midwives in general have a very strong uh instinct i'll almost say to protect the women and if have if women have if midwife have um decision authority if they have professional autonomy to manage the birth i think uh per se they would manage the birth in a way that is not traumatizing the woman what would that they can only do when they have really um have that authority in decision-making in the model of care they are working so it's really about models of care i don't think we can do an awful lot about the hard and midwife that i was describing just now but what we can do probably is more to do with the ones who don't have that responsibility yeah we can um we can support those people and maybe give them more responsibility or ensure by protocols and disciplinaries and things that disrespectful care is what is stopped which is very hard to do i just read the comment from um Margaret you have it and yeah that's why the the model does the model of care um encourage or discourage a close relationship between midwife and women that's of course important too because i see what you mean you might have you have this midwife who's very much the manager type having maybe a lot of say but then really does not have that close relationship with the woman so um ideally we would have a model where we have one to one care and the midwife uh can afford to uh enter like a close relationship where she identifies with the woman but still she has uh decision-making authority about how the birth is managed yes i agree anyway we've run out of time now julia so if you wanted to give um everybody anybody your contact um details if you wish um so that they can continue this discussion elsewhere you are very welcome but meantime i'm afraid we will have to move on to the next session to allow time to change the room over so thank you very much indeed julia for um this very interesting study and we hope to hear more about it yes yes i will certainly get it out as soon as i've finished writing it up so thank you everybody very much for your attention i hope i hope i could give you some basic ideas about just the concept of decision authority and how it may affect how midwives react to trauma thank you thank you very much i'll just need to move on to the final slides facility to remember to turn off record i will do that just