For decades, the United States has had higher infant and maternal mortality rates than other developed countries1,2 and faces a crisis of disparities across social groups.3,4 Mortality rates are highest for Black, and American Indian/Alaska Native mothers, at least twice the rate for White mothers and infants.5 Institutionalized racism, disinvestment in rural and other communities, and resulting social and economic inequities have contributed to the disparate outcomes.6-9 For perinatal health outcomes, these social determinants of health and resulting lack of access to high-quality healthcare are key mechanisms that perpetuate disparities across racialized and rural communities.
Maternal and infant health disparities are especially stark in Wisconsin, where maternal mortality rates for Black and Native American women are 4 times higher than for White women.10 In 1991, Wisconsin launched the Medicaid Prenatal Care Coordination (PNCC) aiming to address the psychosocial, environmental, and economic needs of pregnant people and reduce disparities. PNCC services are available to any Medicaid-covered pregnant person with at least 4 identified risk factors. PNCC uses the long-standing public health nursing model including home visiting and a case management approach11; it is often administered by local public health agencies but can also be delivered by independent agencies, health systems, and others.
Since the Affordable Care Act was passed, federal Title X funding has been designated to support maternal and child health home visiting programs of various types.12 Nurse-delivered care coordination roles have been shown to positively impact health outcomes when they involve frequent, in-person interactions and follow-up, and applied specific behavior change or learning theories.13-15 However, the effectiveness of less structured versions of home visiting interventions remains unclear.16-19
Despite growing evidence of a nursing workforce shortage and increasing burnout among nurses as a result of the COVID-19 pandemic,20 the experiences of community health and perinatal nurses have not been well studied.21,22 Community and public health nursing already faced serious staffing shortages before the pandemic.23 Heavy workload paired with inadequate organizational support can contribute to lost autonomy and depersonalization in these settings.20,24 Increasing awareness of stark health disparities and a perceived inability to address them may also contribute to burnout among public health nurses.25,26
In this qualitative study, we aimed to describe PNCC nurses' experiences working in perinatal community health with high-risk families, with a focus on risks for burnout. A larger parent study aimed to describe the overall implementation of PNCC using the Consolidated Framework for Implementation Research (CFIR).27 This article describes themes that emerged from CFIR constructs in the domains of "Characteristics of Individuals" and "Outer Setting."
METHODS
Using a qualitative descriptive approach,28 we conducted individual semistructured interviews (see the Appendix) and field observation with PNCC providers who were registered nurses (RNs) at 2 PNCC program sites. The study was approved by the institutional review board. The personal and professional positionalities of all study team members were discussed throughout the conceptualization, data collection, and analysis processes. The first author is a White, cisgender woman with a professional nursing background. All other study team members were White women: 2 with professional nursing backgrounds and 1 with a professional psychology background.
Sites and sample
Research sites were selected to capture variation in size, location, and population. The first site was a large local public health department in an urban area. This health department serves a racially diverse population across rural and urban environments, in which 36% of births are covered by Medicaid.29 At the time of data collection, there were 5 RNs and a nurse manager on the PNCC staff at this site. The second site was a tribal-affiliated clinic on a reservation in a rural area (70% of births to American Indian or Alaska Native people are covered by Medicaid in Wisconsin29). The PNCC program is a component of the clinic's community health services and is delivered by 1 RN in collaboration with other social service providers.
Data collection
The data collection process started with field observation of RNs at both sites. The first author conducted all observation and interviews. That researcher first observed PNCC providers, administrative staff, and managers engaged in PNCC work during team meetings, scheduling tasks, billing, planning for client visits, and documenting visits. She observed 1 full work week at the urban site, returned multiple times to observe client interactions with client's permission, and subsequently observed the rural site's team and client visits on the 2 monthly designated days for PNCC care. Finally, semistructured interviews took place at both sites with the broad aim of characterizing the PNCC implementation process and participant's experiences and expectations of PNCC implementation. All participants provided written informed consent. The interviews were audio-recorded and transcribed verbatim. A gift card of $100 was given to each site for use by the programs or other staff-supporting materials or activities.
Data analysis
We used the CFIR30 to complete a deductive thematic analysis process.31,32 The CFIR framework has been used to guide qualitative evaluation of factors that influence implementation and dissemination of many healthcare services and public health programs. The original CFIR framework includes 39 constructs across 5 domains: the intervention itself, internal setting for the intervention, external context, the individuals implementing the intervention, and the process of implementation. The framework has recently been revised to focus on the recipients of innovations and to incorporate equity and its determinants,33 but our analysis made use of the original CFIR framework's domains and concepts.
The initial codebook reflected all 39 CFIR constructs. Three study team members independently conducted multiple readings and line-by-line coded transcripts in NVivo software version 12 (2018). Discrepancies in coding were resolved through discussion. Study team members then read the coding reports, made note of the density or frequency of codes, and discussed thematic content within each domain. Theme development-with attention to consistency and variability within and between sites-was an iterative process led by the first author. Field notes from observations were consulted for programmatic context; this context was then used to "triangulate" themes generated from the interview data by confirming that the interpretation made sense based on what had been observed at the site. As themes related to nurses' work experience began to emerge, the research team noted that several were related to known risk factors for professional burnout.
RESULTS
Table 1 describes information about each site and the participating nurses. Several themes reflected the significant challenges with implementing PNCC and making a positive impact for their clients. Three specific themes reflected ways that PNCC nurses may be exposed to burnout risk: role strain related to scope of practice and training, discordant racial and socioeconomic identities leading to role conflict, and low control combined with high psychological demand (see Table 2).
Theme 1: Role strain
PNCC nurses are unable to practice to their full scope
Study participants described significant role strain that was a result of tension between the PNCC role and their full scope of expertise as RNs. Participants acknowledged the benefits of having a nursing education and clinical care experience to ground their understanding of perinatal health, health systems, goal setting, and coordinating care in a complex health system. However, the administrative rules for the PNCC benefit define the scope of PNCC as care coordination and specifically prohibit providers from performing "clinical care services" within the PNCC benefit. This meant that PNCC nurses could not measure a client's blood pressure or weigh a newborn. Although not all PNCC providers across the state are RNs, our participants were and thus have the clinical knowledge and expertise to perform such assessments. Participants continued to view themselves as clinicians and reported that patients perceived them as such and expected them to perform those typical nursing functions. Role strain emerged from being put in the awkward position of either explaining why they were unable to use their nursing expertise for clients' benefit or performing nursing care that was not sanctioned or compensated by the program. As one nurse explained, "I know that's not something we can bill for. It's not that we don't do it, but it's not something we can bill for as part of the program" (Urban site).
Role strain also emerged from nurses' inability to adjust plans of care and adapt interventions to the specific clinical and individual context using their nursing judgment. From efforts to standardize the services, there were expectations that nurses uniformly use specific assessment tools. One participant described how a particular screening question was judgmental and did not yield helpful information about her clients' needs: "There is a question, like, a state questionnaire about 'Have you skipped any meals in the last two weeks?' I'm thinking in my head, 'Yes. I'm a mom that's got a toddler. Of course I have!' You know? But it's like, if the question could just be phrased differently .... If you were to say more open ended, like 'How many meals a day do you eat?'" (Urban site). The competing expectations of being a nurse and providing a social service-focused intervention in a nonclinical environment were sources of conflict and role strain.
Limited training for the PNCC role
Role strain can emerge from an inability to perform one's expected role or function; PNCC nurses expressed that limited training and preparation for the PNCC role was a significant challenge. Their community-based, client-driven work differed from traditional hospital nursing that they felt better prepared for. PNCC requires an individualized, relational approach; providers do not have algorithms or protocols to guide their decisions. One provider reflected on specific training challenges around tailored, patient centered care: "Each program has an orientation checklist, right? So, things you're supposed to watch for or supposed to know, supposed to look up .... Your preceptor says, 'Did you look it up?' you say, 'Yep.' [...] But what's missing is the questions or the feedback we get from patients that you can't teach" (Urban site). Most participants felt that there was inadequate or incomplete training available for nurses new to PNCC or home visiting, given that they had been trained primarily to work in acute care settings: "I feel like I need more knowledge. I'm used to chronic illness in older adults. I need more knowledge about pregnancy issues and baby, newborn issues. And, I mean, all of my newborn experience is with newborns with sickness needing specific IVs" (Urban site). The training materials that did exist were also self-driven and not evaluated systematically. When asked about her training experience, 1 participant remembered: "I am pretty sure that I had this long document and had to, like, rate myself on confidence or competence on everything from, like, delivery, breast feeding, birth control ... I don't know that I ever sent it to anyone, or anyone asked for it. It was just supposed to be a reflective thing. No, so there's really no competency" (Urban site).
Many nurses described strategies they had developed independently to learn and improve skills on the job. At the urban research site, the relatively large team of providers was a resource for training and support. One nurse there recalled: "I really learned how to do this job from [a former colleague]." Another characterized teamwork as characteristic of public health nursing: "I believe public health nurses understand what it's like to be new, and we mentor each other." In contrast, the provider at the more rural site had had no direct peers. She reflected, "Coming into this position and pretty much creating it on my own without being trained or, kind of, shown the ropes was definitely an issue for me in the beginning."
Theme 2: Lack of racial and socioeconomic concordance with clients
Participants of all racial and socioeconomic identities at the urban site agreed that there were not enough PNCC staff members of color and not enough PNCC staff members who shared a socioeconomic background with clients. White providers acknowledged that lack of personal experience could compromise their effectiveness in a program like PNCC. One stated, "No matter how much I try to be understanding, be empathetic, I am not a Black teen living in [this city]. I have no idea what that world is like." That same provider reflected on a piece of advice that helped her to stay conscious of her potential biases:
I remember [...] a couple of weeks on the job as a public health nurse going out on a home visit with an experienced nurse. And she said, "I'm going to give you two pieces of wisdom" [...] Her first was kind of tongue in cheek [...], but her other words of wisdom were, "you never judge your clients by your middle-class values." And I hear her say that in my mind occasionally, you know? "You can't judge. If you want to be a public health nurse, you don't judge." (Urban site)
Participants recognized challenges of reconciling the dichotomy between their personal experiences and their clients' lives.
Participants who did share certain identities with clients reflected on the value of having that perspective. The provider at the rural site described the insight and trust she gained by being from the small Native American community herself. This was especially important when discussing stigmatized health concerns such as addiction. "A lot of the times I know history, which is a good thing about living in this small community, that I know history. So, sometimes I'll even just come out and ask and say, 'so, you know, are you using? Does your boyfriend use?' Like, 'where are you with that?' In a gentle way, I kind of ask, you know?" These "concordant" providers also expressed that more racial, ethnic, and socioeconomic concordance between PNCC clients and providers would benefit both clients and staff. The only African American provider at the urban site reflected:
This is a shame about public health that we don't have nurses of color. There are no nurses of color that can actually understand, from a different level, what some of the moms-many of our moms are African American that come through this program. [...] To be able to understand from that level, just the ability to empathize, not sympathize with families? I got that. I understand that. I actually have been through that. So, you're a white woman, you're going to see a Black family. You can see what they're going through. You can understand it. But the ability to say "I've been through that. I understand the racist glares that you get from some of the workers at WIC." Those are the kind of things.
The distinction between sympathy and empathy was critical in the eyes of this participant, and true empathy was facilitated by sharing some of the racialized experiences of her clients. The same participant mentioned specific instances in which other providers had perpetuated stereotypes or made covertly racist comments. This led her to advocate specifically for the targeted recruitment of other Black nurses:
I've talked to [our manager] about it, and I've told him we really need to be recruiting in other places. There are African American nurses who live in other areas of this state who would be willing to come and be able to do this job. I'm not the only one. [...] It doesn't mean every Black mom has to have a Black nurse. But, geez, we need a little bit more than what we have. And there are some nurses in this program who haven't a clue about [the impact of] what they say.
However, sharing certain identities with clients could also introduce role strain when interacting with medical providers, because it positioned their professional identities and social identities at odds. For example, a physician asked one PNCC provider to engage with Child Protective Services because of concern over a patient's first child being more independent than the physician thought appropriate:
I had a mom who like, was severely depressed, she had two girls, and the provider wanted me to call CPS [child protective services] because her 4-year-old was microwaving her own mac and cheese. And I was like... "Huh. Well at least she has mac and cheese to eat!" They're not making unsafe decisions for their children. It may not be what you think is quote-unquote "safe ...." (Urban site)
This participant discussed multiple instances of role conflict emerging when she interacted with physicians and other healthcare providers; she was White, so she did not share racialized experiences of many clients, but came from a low socioeconomic status and could relate to other experiences. She described herself as being "stuck" between the client and the providers, who had important information and services to offer but were unable to empathize or assess safety in a context very different from their own. The tension between being a healthcare professional and being a client advocate was complex and challenging.
Theme 3: Low control and high psychological demand
Participants were very clear that a low sense of control over their day-to-day work and the broader social context that put clients at risk contributed to emotional and professional exhaustion. Ultimately, this low control left providers psychologically exhausted and doubting their impact on client outcomes. Three subthemes represent the ways providers expressed their experiences with a sense of low control and high psychological demand: maintaining client contact, social system failures, and doubting impact.
Maintaining client contact
The providers were frustrated by how much time was spent on the practicalities of connecting with clients and setting up times to meet, for which they had no good solution. One nurse described:
I think it's challenging. It's frustrating sometimes when you want to be able to help somebody, and you're just failing for one reason or another at making literal contact with them. My homeless patient right now? It took a good month to actually physically get together with her because we would arrange a meeting and then she wouldn't show up because nobody came to watch her kids, or I'd try and reach out to her, and I wouldn't hear back because her phone didn't have minutes. And, I mean, that was nobody's fault. It's just situational. (Urban site)
Aside from time spent on getting and staying in touch with clients being nonreimbursable, providers felt that it could have been better spent using the full scope of their skills to help other clients. Simultaneously, losing touch with a client with high needs was also distressing and seemed to warrant extensive efforts to reestablish contact. One nurse recalled worrying over a patient struggling with postpartum depression:
[She] actually texted me to say, "Could we have a meeting?" It was about 6:30 or 7:00. I said, "fine," that we would talk at about 9:00. Never heard back from her. And then I worry, you know? And in some of those cases you worry, "Is this mom going to hurt herself?" [...] Sometimes we just drop by someone's place. That's something I hardly ever do, but in some of these cases, you don't know if you're saving a life. (Urban site)
The providers were emotionally torn and felt that they had little or no control over barriers to connect with clients that needed extensive support or resources.
Social system failures
All of our participants alluded to the symptoms of burnout (fatigue, anxiety, emotional detachment) in the context of discussions about the broader health and social service systems. Although they were often able to piece together some solutions for their clients, it required extraordinary efforts and often felt inadequate. Their experiences highlighted gaps in the social support network that limited their ability to accomplish client goals. One participant described feeling "overwhelmed" when she became "a person's main contact for any question or problem" instead of more appropriate, but unavailable, social service providers.
Participants discussed the distress they felt as they witnessed the impact of limited housing and transportation systems but were unable to find good solutions for clients. One provider, who had immigrated to the United States, characterized the social service system as "stacked, very stacked" against clients. She shared:
I mean, to me, it highlights some big systematic changes that are not within our power. Like, maybe some universal healthcare, you know? A better transportation system, you know? Some of these big, big things. It does amaze me that you can have this person that is in that situation: that is pregnant; is going to have newborn, vulnerable baby; that's got a three-year-old; and we still can't get her in some housing somewhere? It is alarming that that situation can exist, especially when there are kids involved. So, that's disheartening. (Urban site)
Seeing broader problems in policy and public services that were not being addressed by larger, upstream approaches could introduce ethical dilemmas for participants: "Thinking upstream does not happen in healthcare. We don't look at the root causes [...] If I know something's wrong but I know damn well Suzie doesn't have health insurance, how am I gonna recommend she go to the doctor? So those are like, difficult things, the social and ethical like, struggles that we all have" (Urban site). Another provider compared this experience with that of not being able to respond appropriately to a common hospital nursing issue: pressure ulcers.
You feel a little bit like, almost putting a Band-Aid on a decubitus ulcer. I feel so bad about that because I can't come and see you every day, I can't-if they have all these huge problems, like they don't have money, they don't have a house, they don't have a vehicle, they're taking the bus to get to Salvation Army in the winter to sleep on the floor, and it's cold .... You feel kind of helpless in a sense. (Urban site)
The burden of responsibility for clients and their well-being in the context of a limited social safety net caused providers to question their ability to provide meaningful, impactful care.
Doubting impact
As a result of their low control over important factors, participants described feeling uncertain of their impact and losing hope about the potential of the program. One reflected that the interview process itself was one of her only recent moments to stop and reflect on positive aspects of the work:
That gets challenging [to think of things that make me feel good]. That's hard [...] It actually does feel good when a patient finds their voice. And if they learned it here or somewhere along the way, yeah, that's a good-that's a positive. You're helping me find positives in this. You really are. Thank you, because some days I can't. It's hard for me to. It's stressful. (Rural site)
Several participants also discussed ambivalence about measures of "success" in the program:
In a sense, I don't think [measuring low birthweight] is equitable. We're doing that now, apparently; we just had a little data thing on Tuesday, and I left that meeting feeling really shitty. Because in my brain [...] if the mom is deprived of nutrients, she's not gonna have a healthy baby [...] because she doesn't have the means for adequate food! [...] So something like low birthweight or preterm birth-it's easy to measure, or we feel confident in that measure, and yet, what it means about the rest of everything that's going on is real questionable. (Urban site)
The lack of measurable impact from their work contributed to self-doubt and doubt in the program itself. Promoting and working toward health equity was important to several participants, and the realities of the availability of services and resources led to disillusionment. The rural site participant described a common situation in which her supervisor helped realign her perspective when she felt ineffective: "I tell my boss, 'I'm feeling like I'm not making a difference, and I'm really feeling stressed out about this,' and like, 'maybe you should find someone else who's more passionate' even. And [it's] not a threat, but just venting my feelings. Then he comes back with, 'Okay, well, we need you. The community needs you.'"
DISCUSSION
Findings from this study provide rich evidence that PNCC nurses are at significant risk for burnout due to role strain and conflict and high psychological burden with low control over outcomes. The resulting "low sense of personal accomplishment" is a known major contributing factor to emotional exhaustion, depersonalization, and burnout.34 Providers saw their care coordinator role as essential in their clients' lives, but the extent of client needs in the context of limited support systems contributed to hopelessness and disillusionment.
Our participants had developed informal strategies to process and debrief work experiences in an effort to reduce the psychological burden. These strategies acted as positive protection against compassion fatigue and despair. This form of processing and confirming knowledge is a critical component of developing one's nursing clinical judgment and should be supported by formal programmatic efforts to improve care and to protect against burnout.35 Incorporating reflective practice techniques has been shown to effectively reduce burnout for nurses in other community-based home visiting programs.36 Supporting reflective practice can also demonstrate value alignment between the organization and providers, which is essential for burnout prevention and resilience.24
Similarly, a lack of available mentors and true role training can cause stress that can lead to burnout.37 Wisconsin Medicaid initially partnered with the State Maternal and Child Health program to offer structural support to local PNCC providers. Resulting regional networks created an environment for professional support but did not fill the void of a standardized training.
Our findings reveal how nurses' commitment to health equity can be challenging for perinatal community health nurses when evidence of change is hard to find. However, that commitment to equity also has potential to be a source of resilience. Participants emphasized the emotional boost they experienced when they helped link a client to a good resource or when clients reported successfully reaching a goal. These "small wins" validated their work and its significance. Issues with racial and socioeconomic concordance among the staff were felt deeply. Concordance is an understudied aspect of burnout risk and consequences: some research suggests that burnout can exacerbate implicit and explicit racism.38 Organizations can cultivate burnout-protective belonging and empowerment among staff by maintaining diverse, equitable, and inclusive hiring practices to mirror the population distribution of the community.39 Practices such as mindfulness-based stress reduction may be able to reduce both burnout symptoms and implicit bias and warrant further investigation.40
Limitations
Although our approach of purposive site selection did effectively capture diverse professional experiences of PNCC nurses, our data do not represent the various PNCC provider and agency types across the state. In addition, though we made efforts to ensure that participation was voluntary and that was communicated clearly to potential participants, social desirability bias may have influenced participants and biased our findings. This is especially relevant for findings related to race concordance and issues of racism in maternal and infant health, given that our study team was entirely composed of White individuals. Data were collected in 2019 and early 2020 and thus do not reflect the well-documented increase in nursing burnout during and after the COVID-19 pandemic. Finally, we did not aim to comprehensively evaluate all known risks for burnout or components of burnout, so there may be more critical and related issues that did not emerge in our data. Future studies could take this systematic approach to evaluating burnout among nurses in community perinatal health. In addition, racially and socioeconomically diverse research teams could facilitate improved data collection on race and racism and add positionality and perspective in interpretation.
CONCLUSION
Nurses have been widely recognized as the most trusted health professionals for more than 2 decades and are uniquely skilled to provide relationship-based care.41 This study adds to evidence that burnout among public health in perinatal care coordination is a significant problem that may compromise those skills. Risks may center around role strain and conflict, high psychological burden, and low control over an inadequate social safety net. Nurses working in the community can not only experience the benefit of deep connections with clients but also face despair and disillusionment due to encountering numerous social issues and health inequities. Future research that explores the development and implementation of protective efforts in public health nursing is needed to guide workforce development efforts.
References