Validation of a scale to measure the workload of midwives

Objective: To validate the design of a scale to measure the workload of the midwives based on Classification of Nursing Interventions (NIC), through their multicentric application in different delivery units. Methods: Quantitative, longitudinal, study multicentric character, conducted in three general university hospitals of the public system of health. The sample consisted of fifty midwives, who examined the validity of the construct of the designed scale, for a total of 370 births. Data collection began through the scale designed ad hoc by the research team, accounting for the time and average number of NIC interventions, performed at each birth. Results: The midwives of the study, are subject to an increase in their workload regarding the number and average time


Introduction
In the delivery service, prenatal, intrapartum, and postpartum care is provided with significant variations in the number of midwives, with respect to the number of interventions or activities performed by this staff. (1)Quantitative staffing of midwives within the delivery units it is of the utmost importance, to ensure the quality in the service provided and safety of the mother-child binomial.
(4)(5)(6) The Royal College of Obstetricians &amp; Gynecologist (RCOG) and the Royal College of Midwives (RCM), suggested that women in labor should receive individual attention by midwives.A midwife/pregnant ratio of 1:1 recommended, and for women with high-risk pregnancies, the ratio between midwives and women should be up to 1.2 -1.4:1 being the minimum ratio of midwives per women to be 1:2, -1.4:1 and, a ratio 1:2 for a safe level of care, to ensure the ability to achieve personalized care during labor.It is logical to assume that the gaps in the provision of experienced personnel in the daily practice could have a cumulative effect on patient satisfaction, clinical outcomes and even the health and morale of midwives. (5,7,8)he Midwives have an essential role during the birth process and experience.)(11) The United Nations places them at the center of the Millennium Development Goals, for their specific contribution to the normal physiological process in normal childbirth and its determined focus on the continuous care of the sexual-reproductive, maternal, and neonatal health. (3,10)The impact of the lack of midwives is major, resulting in a loss in their professional skills in certain areas, due to heavy workload or time constraints for make its functions effective. (1,12,13)This brings up the ethical dilemma of how to prioritize the attention. (14)The appropriate staffing of midwives depends on the burden of work.In general, the workload can be understood as all activities performed by a team of midwives in the attention process during a determined time frame.
These activities are related to direct attention (performed in the presence of the patient), and to indirect care (occurring outside the interaction with the patient).This workload is influenced by several factors, such as: patient characteristics (patient classification system), characteristics of the role of health personnel (competences, skills, and attitudes) and the number of patients they see.
Due to frequent schedule changes in the flow of patients, the workload of midwives within the delivery unit it is often difficult to predict, (4,14,15) so it is important to assess the burden of work of midwives within the hospital institution, more specifically in the delivery unit, to establish an effective link between the demand for care, the staffing and health outcomes. (9)sumen Objetivo: Validar la elaboración de una escala para medir la carga de trabajo de las parteras con base en la Clasificación de Intervenciones de Enfermería (NIC) a través de su aplicación multicéntrica en diferentes unidades de parto.
Conclusión: Los datos indican la validez de la escala elaborada ad hoc, ya que este instrumento refleja la real carga de trabajo que tienen las parteras del estudio.
Over the past few years, managers have faced the challenge of collecting data on the various dimensions of the workload to make decisions regarding staffing.With the increased use of health information technology in the hospital setting, the measurement of workload using these technologies would be ideal.A fundamental component of most technologies' health information is standardized terminology.
The Classification of Nursing Interventions (NIC) is a standardized comprehensive nursing terminology that has been used to systematically to classify nursing care in the clinical setting. (16)From this perspective, the use of NICs provides support to the planning and evaluation of personnel, identifying the workload of nursing, expressed in interventions, (17) including direct patient care, patient and family education, and counselling. (16)(18) The objective of this study was to validate the design of a scale to measure midwifery workloads based on interventions NIC, through its multicentric application in different delivery units.

Methods
Quantitative, longitudinal, multicentric study, conducted between months of October, November and December 2021, in three delivery units of three public hospitals in the Region of Murcia, Spain.These hospitals present significant differences in terms of their physical and organizational structure.Hospital A, is considered of first level of care, regional, its delivery unit is structured in 2 delivery rooms, 2 dilation rooms, 1 emergency room and 1 epidural room, with an annual care of 480 deliv-eries, with an endowment for a 12-hour day, (19) of two midwives in the day shift (from 8 to 20 hours) and a midwife in night shift (from 20 to 8 hours), for the attendance at normal childbirth, as well as maternal-neonatal-gynecological emergencies, care at the end of gestation and breastfeeding, among its multiple professional competences.Hospital B, of third level of care, is structured in 8 delivery rooms and 5 postpartum and recovery beds, with an annual care of 2522 deliveries, therefore counts with an endowment of four midwives in day and night shift.And finally, the hospital C, of third level of care, and of reference within the sanitary area of Murcia, Spain.It is structured in 18 birthing centers, with an annual attention of 6828 deliveries for a crew of 7 midwives in day-night shift.The participants of the study were the midwives who worked in the network of the 3 selected public hospitals from the region of Murcia, performing a probabilistic sampling and of convenience, establishing a series of inclusion and exclusion criteria: • Inclusion criteria: be over 18 years of age, have the qualification of nursing, as well as being a specialist in obstetrics -gynecology (midwife), and be in active service within the health field.• Exclusion criteria: Midwifery professionals who are under the residence regime EIR (Resident Internal Nurse).Achieving a total participation among the three hospitals of the study of fifty midwives.The sample of the size of deliveries studied was calculated according to the history of births attended by midwives, in the different units, in the year prior to the start of this study.A total of 370 births were established, to achieve statistical representativeness, assuming a ratio of 0.5 and an accuracy of 0.05.For a confidence level of 95% and a beta power of 0.8.Stratifying by hospitals, this sample was estimated at n=16 for hospital A, n=95 for hospital B and n=258 for hospital C.
The observation and accounting of the care activity itself by the midwives of the study, through a scale designed in standardized language (CIN), structured with correlation to the four functions of nursing (care, manager, coach, and researcher), and nursing care plans based on functional health pat-terns by Marjory Gordon.Which was designed ad hoc by the team researcher.In order to achieve this, semi-structured interviews were conducted between May-June 2020, in virtual format, to a representative sample of midwives, to list the various activities that they conduct in their daily work.
Subsequently, a mapping of these activities, to catalog them with their corresponding NIC intervention.Once the instrument was built in standardized language (NIC), it was qualitatively validated in content and construct by three focus groups of expert midwives, or their competencies in the matter recognized within the Spanish legal framework, (20) national, regional, and senior, during the month of May 2021, through a digital format, by zoom platform, verifying that the NIC interventions were suitable and enough to show the great variety in the clinical practice of this guild professional.What influenced the acceptance of the instrument and the application in this clinical research.
The scale consists of 24 items, each item contains one or more NIC nursing interventions associated with the same time of application.The time assigned to each item was established by comparing the actual time it takes to execute each intervention with the time agreed upon by the focus groups.
To verify the quantitative validation of the content of the scale, as well as its effectiveness, relevance, and representativeness in determining the workload of the midwives within the selected delivery units, the accounting of the time and number of NIC interventions, carried out in each birth attended by the group of midwives who make up the study.
To do this, a notebook of data collection was created in Excel format grouping the time and number of interventions conducted in rows, and the description of each of the variables to measure in the study in columns.The midwives participating in the study completed a new scale in every shift.They considered the number of patients attended in each work shift.
Piloting was conducted prior to the total collection of the data, which, in addition, supposes the validation of the tool for a sample of 30 births, checking reliability and comprehension by the midwives of the study, identifying the collection of the data in relevance.
The data was entered into a Microsoft Excel 97-2003 spreadsheet, and analyzed using the statistical package SPSS version 23.0, performing a descriptive analysis with calculation of frequencies, percentages, means, standard deviations and medium.An inferential analysis of the independent variables "delivery unit" and "shift" was carried out with variables: sociodemographic, workload for care, management, teaching and research activity, and that corresponding to each of the items on the scale.To evaluate the differences in measured times, we use the analysis of variances (ANOVA) and Tukey's subsequent test.It was set as the level of statistical significance 95%(p&lt;0.05).The study was conducted according to national and international ethical guidelines.
Prior to data collection, the study obtained initial evaluation and approval from the ethics research committees of the three hospitals participating in this study, following their protocol guidelines.Professionals who agreed to participate, received guidance on the purpose of the study and signed the free and informed consent form, always respecting the law 3/2018, of December 5, 2018, protection of personal data and guarantee of digital rights.

Results
Over a period of 3 months, a sample of 408 deliveries was recruited, distributed in the three hospitals that make up the study; 20 of these births correspond to Hospital A collected over a 1-month time period, 99 to Hospital B, collected for 2 months and 289 to Hospital C, collected for 3 months.In the set of the three hospitals and attending the work shift, a sample of 238 deliveries was collected in the day shift, 120 in the night shift, 38 in the day-night shift and 12 in the shift night-day.The most attended ethnic group during the birth process was the Spaniard (n=317), followed by Arabic (n=66) and South American (n=22), of which 188 they were nulliparous, 155 secondary and 65 multiparous.Hospital admission to the more repeated births were active birth (n=208), pregnancy in the process of prolongation (n=75) and premature rup- In addition, we measure the workload of midwives within the delivery unit, with regarding the work shift, finding important significant differences in terms of the shift.According to the items of the scale, a greater workload was obtained for the items corresponding to the care function, those that include the NICs of "fetal monitoring", "accompaniment", "emergencies".We also observe that the care load is greater in the day shift compared to the night shift (Table 1).Also, the workload of midwives was measured with respect to the sociodemographic variables studied (Table 2).
Stand out among the variables studied, those that imply a greater dedication, and, therefore, an increase in the function of care, such as: working in a hospital of great technification (hospital C), in day-night work shift (24 hours), attending women of South American ethnicity, nulliparous and with twin births, and attendance at childbirth with induced onset and ending in dystocia.For the statistical analysis and to determine the levels of significance, inferences were made between the average time dedicated to each of the variables investigated in the study.Finding statistically significant differences in the variables shown in the following table (Table 3).

Discussion
The results of the study, show us how midwives in hospitals, the focus of this study, is subject to an increase in its workload, regarding the number and average time spent carrying out NIC interventions.The NIC interventions studied, which bring a greater workload, both in day and night shift, are the fetal monitoring, companionship, and action in emergency situations.Findings consistent with other studies, (12,21) suggest that midwives have to constantly evaluate and redefine the mode of delivery of care, as the birth experience influences not only the woman, but her partner, the relationship with the child and the whole family.Therefore, the importance of the continuous presence of the midwife during the birthing process.In addition, the intended actions, and the improvement in the workflow, by this professional organization, reduce clinical risks for the mother and the newborn.But the results of this study show us how the presence and attention of the midwife, cannot be continuous, due to the increased pressure to which they are exposed.Well, the midwives of the study, must attend regularly and constantly to three women during their birth process, which it involves maintaining a midwife/surrogate ratio of 1:3.By studying the clinical practice of midwives, integrated by the four functions, it is evident how, the healthcare function implies a greater time of dedication both in the day shift and night, followed by the function of management, teaching and research.Total time means invested by midwives, with respect to the four functions in the care of a woman in the process of childbirth is 960.61 minutes (16 hours) for the day shift and 840.29 minutes (14 hours) for the night shift.This supposes, an excess in time dedicated to the execution of its functions, with respect to the duration of its working day labor (12 hours); and, therefore, affects the midwife/ surrogate ratio default.Data in line with other studies, (5,7,8) as it shows us how the ratio prefixed (1:2) of the study hospitals, it is not well established to lend those quality care, so demanded today.If, in addition, we take into account the results extracted, in terms of the relationship between the workload of the midwives during the care of a woman in childbirth (ratio1:1), with respect to the variables sociodemographic of the study, we found significant discrepancies in terms of type of hospital, work shift, ethnicity, parity, medical diagnosis, onset and completion of labor.
If we address the type of hospital, hospital C (third level of care, and reference), presents average times of midwives' workloads (1051.60 min -17.5 hours) older than, hospital B (1001.36 min -16.7 hours) and hospital A (945.40 min -15.7 hours).Results compatible with the literature, which indicates how the organizational structure, the size of the delivery units and the increase in the technification of the birth process, varies the frequency and number of interventions performed by midwives. (22)y exploring into the work shift and type of patient they are assisting, we find that during the day work shift, the workload increases significantly with respect to night shift.)(25) And second factor is depending on the type of patient assisted, such as: the Sub-American ethnicity, the nulliparous and the women who present medical-obstetric comorbidities.This increase in the burden of work observed is consistent with other studies findings (1,2,8,21,23) as we are currently facing an increase in attention to chronic processes, generated by the increase in twinhood, the increase in maternal age, preterm births, as well as the rise of assisted reproduction techniques.
If we evaluate the results with respect to, at the beginning and end of labor, the workload in induced labor (1035.94minutes -17.3 hours) is de-tected to be higher than the spontaneous delivery (1032.74minutes -17.2 hours), as exposed by certain studies (19) stating that the increase in the rate of induction of labor has led to an increased workload of midwives in maternity units, and the guide of the National Institute of Clinical Excellence (NICE), recognizes that the inductions of the childbirth, exert an increase in pressure on the delivery room than childbirth spontaneous onset.
And as for the completion of it, the average time for dystocia delivery (1104.41minutes -18.4 hours), eutocia delivery (1047.07minutes -17.45 hours) and caesarean section (955.42 minutes -16 hours).This difference in time observed is the result of the action and coordination of numerous professionals in the same care process.24)(25) Midwives are at the front line of services of births and must be perceived as such by the Nursing Departments and Directorates of hospitals.The standard 12-hour shifts set for midwives condense the care that should be performed, between an average of 2 hours and 6.5 more hours, outside that shift.
This translates into work overload, so the use of this scale by the supervisor in the Delivery Service in any moment allows to show the need to reinforce or increase the staff of the shift.This works for both shifts: the one in which it is measured, and for the next one.
The provision of human and material resources, including a good working environment, is essential to ensure the provision of quality services.Staffing should be an integrated process, incorporating a broad demographic, epidemiological, cultural, and social perspective, to meet the demand of the current society by health clinicians.
The evidence found by this research provides a valuable contribution to the analysis and evaluation in terms of staffing, workload of midwives and the risks to the safety of the mother-child binomial.It shows us how the ratio midwife/surrogate must be redefined to take charge of the current situation of overload.This research offers us objective data corroborating theoretical or alleged claims based on García LG, Valcarcer MD, Llor AM, Gil MF, Merino GR, Guerrero FJ, et al subjective experiences.By not finding studies to analyze the findings in the national literature and in the international context, new multicenter studies on the subject should be carried out in order to allow comparisons.Although, we may find studies that highlight the importance of implementing a tool for planning and staffing for nursing in certain units, they are not oriented for midwifery specifically.
We found a major limitation in not being able to compare this research with others.Given the scarcity of studies to measure burdens on midwives.This study could be the basis for developing later ones, applying this scale in other situations, and start the path towards a more objective management of midwifery workloads, so that their workforce is based on an accurate care demanded by women during their birth process.It is relevant to continue with this line of research in future studies, which would contemplate other hospital units where the midwives are integrated.

Conclusion
The results obtained indicate the validity of the scale designed to measure the workload of midwives, as this instrument reflects the workload experienced by the midwives of the study in the different hospitals included.Using a standardized, user-friendly, highly contributed language (NIC) for clinical practice, this scale allows quantifying the work done by the midwives in the provision of care to the woman, during the birthing process, shows the real working time, which needs a midwife in each type of delivery according to the context sanitary.Therefore, this scale allows an improvement of human resources management, adapting the care demands to the patients and guides the midwifery to satisfy this demand, guaranteeing the safety and quality of care.

Collaborations
García LG, Valcarcer MDR, Llor AM, Gil MFH, Merino GR, Guerrero FJN and Cano EDLI contributed equally to the present paper, namely to the conception and design, data collection or analysis, interpretation of data, writing of the article, and review of the intellectual content.Therefore, all authors approved the final version to be published.

Table 1 .
NIC interventions and time of implementation of such interventions and to the four functions by the midwives during attendance at the birthing process

Table 2 .
Average workload time based on the four functions of the midwives with respect to the sociodemographic variables of the study a. Total workload of midwives with respect to the 4 functions

Table 3 .
Comparisons of the multiple study variables with each other, with their level of significance .Sociodemographic variable 1; b.Sociodemographic variable 2; c.Total workload of midwives with respect to the 4 functions; d.Considering intergroup (comparisons between the same variable) and intragroup (comparisons between different variables) a