Introduction
The number of registered nurses (RNs) around the world is dramatically increasing, and RNs now account for the largest portion of the healthcare workforce [1]. The nursing profession remains dominated by women [2, 3]. By the end of 2021, the number of RNs in China had reached 5.02 million [4], with most of the nursing workforce being female (97.7%) and of childbearing age (60.3%) [5]. In addition, spurred by changes in China’s population policy, the nursing profession has witnessed a boom in second and third children [6]. As a result, the number of nurses returning to work after childbirth has increased significantly.
The nursing profession is a high-risk occupation associated with a high degree of stress and physical and mental exhaustion [7, 8]. Almost 78% of clinical nurses reported high work stress, and the work stress of female nurses was much higher than that of men [9, 10]. Evidence shows that the nursing work environment has imposed great challenges for nurses, including heavy clinical work, irregular daily routines, tense nurse–patient relationships, colleague-related issues and occupational exposure risks [11, 12]. Furthermore, demanding job requirements and increasingly fierce competition for jobs have brought greater work stress and insecurity to clinical nurses [10, 13, 14]. Consequently, the nursing profession is particularly vulnerable to work-related health challenges both physically and psychologically. A high prevalence of musculoskeletal complaints and back pain among nursing staff was reported to be in the range of 44.1–82.7% [15, 16]. In addition, fatigue, sleep deprivation and night shifts all negatively affect their general health [17]. A survey of 138,279 nurses from 30 provinces in China revealed that the prevalence of burnout, depression and anxiety was 34,0%, 55.5% and 41.8%, respectively [18]. Overall, nurses, as an essential component of the healthcare workforce, are under enormous pressure and more prone to adverse physical and mental consequences.
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Professional women, including nurses who return to work after maternity leave, are a group that requires great attention as returning to work can be a stressful time for new mothers. Because of the special nature and low flexibility of clinical nursing work, nurses returning to work after childbirth face substantial stressors, interruptions in work continuity and prominent role conflicts. Nurses who return to work after childbirth are still in a transitional period physically and psychologically, with unpredictable hormone levels, and they are prone to negative emotions such as depression, distress and anxiety [5, 19]. Many mothers continue to report significant health concerns regarding childbirth, such as struggling physical recovery and fatigue associated with caring for children, at one year postpartum and beyond [20, 21]. Additionally, postpartum nurses have experienced interruptions in work continuity after taking lengthy maternity leave, which may result in substantial work stress due to the heavy workload, difficult clinical work and great medical risk. When they return to work after a long period of absence, they need to be resocialized [22]. and adapt to new changes both in work and life, including re-familiarizing with clinical nursing work, taking care of children and adjusting sleep habits [23]. In addition to the complex work stress they have encountered in the past, postpartum nurses also face greater challenges in the form of role conflicts [24]. Specifically, work–family conflict becomes one of the greatest stressors for nurses returning to work after childbirth [25, 26]. Moreover, highly educated nurses with a strong need for personal development are more likely to find career planning stressful when they return to work after childbirth [27]. Above all, the work stress of postpartum nurses is at a moderate to high level, and they exhibit poor adaptation after returning to work [28].
Work adaptation refers to the process in which individuals gradually adapt to work requirements through continuous learning and self-change [29]. Previous studies indicated that nurses’ work adaptation is a prominent factor influencing their personal well-being, work performance, patient care quality and the healthcare system [30, 31]. However, the poor adaptation of nurses returning to work after childbirth not only heighten the risk of physical conditions and mental problems such as chronic pain, depression and burnout [32], but also contribute to absenteeism, presenteeism, intention to leave and elevated turnover rates in the workplace [33], thus reducing the quality of clinical care. Within one year after delivery, postpartum nurses often suffer from physical fatigue, loss of energy and lack of concentration due to their role as mothers [34, 35]. At the same time, high postpartum work stress and lack of social support may lead to poor mental health [36]. The long-term loss of physical and mental health makes nurses who return to work after childbirth a high-risk group for adverse clinical nursing events, which undermines the stable development of the nursing team and inevitably reduces the quality of nursing care [10, 37]. Therefore, alleviating work stress and promoting work adaptation among nurses returning to work after childbirth is key to improving their physical and mental health and improving the quality of nursing care.
To our knowledge, there have been few studies of nurses returning to work after childbirth. One cross-sectional study explored the current situation of postpartum nurses returning to work and the factors influencing their work stress [5], and one qualitative study analysed nurses’ experiences of working while pregnant [24]; however, the experiences of adaptation among postpartum nurses returning to work are still little understood, which is not conducive to developing measures designed to help them. The present study addresses these gaps in the literature by identifying the problems and further needs of postpartum nurses’ work adaptation through qualitative interviews. Therefore, this study explores the adaptation experiences of nurses returning to work after childbirth. The results can be utilised to provide guidance for hospital managers to design targeted interventions to promote the adaptation of postpartum nurses returning to work and ultimately improve the quality of nursing care.
Methods
Design
A qualitative study was conducted using a descriptive phenomenological approach. Descriptive phenomenology is the optimal approach when the research aims to uncover shared aspects of lived experience, providing a genuine understanding of the essence of the phenomenon under investigation [38]. Therefore, descriptive phenomenology was used to gain an understanding of the adaptation experiences of postpartum nurses returning to work by exploring their feelings, experiences and perceptions. This study was designed and reported according to the Standards for Reporting Qualitative Research (SRQR) checklist (see Additional file 1) [39].
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Sampling and recruitment of participants
The study was conducted in four tertiary hospitals (three university-affiliated general hospitals and a provincial hospital) in Changsha, Hunan Province, mainland China, which were selected using convenience sampling. Purposive sampling was used to recruit RNs working in these hospitals between March and May 2023. The inclusion criteria were individuals (1) licensed as an RN, (2) returning to work within one year after their maternity leave, and (3) taking a position providing direct patient care when they returned to work after childbirth. The inclusion criteria of returning to work within one year was based on their ability to recall their adaptation experience after childbirth and changes in the healthcare environment that may present occupational challenges [5]. RNs diagnosed with depression or cognitive impairment before or after childbirth were excluded. To obtain a diversity of experiences from different perspectives, maximum variation sampling was also utilised to purposefully select a heterogeneous sample of postpartum nurses by observing their ages, educational backgrounds, professional titles, years of professional experience, nursing units, number of deliveries and time since returning to work.
The participants were recruited via posts on WeChat. WeChat, the most popular social media application and instant messaging platform with face-to-face communication in China, has a low cost and high speed and shows great value in forwarding information and recruiting participants [40]. The posts invited potential participants to view the study information and inclusion criteria and asked for their contact details if they were eligible and interested in participating. The researchers then contacted potential participants by phone to schedule a time and place for the interview. The researchers did not know any of the participants, and their only contact prior to the interview was a phone call to discuss times they were available.
Data collection
Semi-structured in-depth interviews with postpartum nurses were performed on a one-on-one basis. Before the interviews, the researchers drew up a preliminary outline based on policy interpretation, literature review and pre-interviews to fulfil the aim of the study. The interview outline was formulated through a process of joint discussion and repeated revisions by relevant experts, including one professor-level expert with qualitative research experience in the field of women’s health research and three associate clinical experts at the senior level or above who were engaged in nursing management. Open-ended questions and probing questions were both used; the key questions included in the interviews are listed in Table 1. Additionally, the demographic information and work-related characteristics of the participants were collected after each interview. The interview outline was piloted with three participants in a tertiary hospital in Changsha, mainland China, in March 2023 to refine the collection plan, and the three nurses stated that they had no difficulty understanding the questions included in the interview outline. The pilot test indicated that there was no need for further changes and the outline was in line with the aim; thus, the data from the pilot test were included in the analysis.
Table 1
Outline of the semi-structured in-depth interview
Number | Main focus |
|---|---|
1 | What are your feelings about returning to work after delivery? |
2 | What changes have occurred in your work since you returned to work after delivery compared with the past? |
3 | What difficulties or problems have you encountered since you returned to work after delivery? How did you cope with these problems? |
4 | In which aspects do you think you have adapted well since you returned to work after delivery? Can you share your experiences and insights in these areas? |
5 | What is your development plan for the nursing profession after returning to work after delivery? Is there any difference from prenatal? |
6 | Have you received help and support from any people or organisations since you returned to work after delivery? |
7 | What kind of help and support do you think nurses returning to work after delivery still need? |
Two main researchers (TJZ and XLD) conducted all of the interviews to ensure consistency; both of them have qualitative research experience and have undergone unified training. All of the interviews were conducted face-to-face at a prearranged time in a place of the participant’s choice, such as a doctor’s office or counselling room. The settings were independent, quiet and private, and nurses were free to discuss their experiences. Before the formal interview, the researcher gave a brief self-introduction and explained the purpose of the interview to the participants. Each individual interview lasted approximately 30–45 min and was audio-recorded with the participant’s consent. Field notes were taken during (to record the interviewees’ nonverbal actions) and immediately after each interview (to record the interviewers’ feelings and reflections). As a qualitative approach was used in this study, data collection for nurses continued until data saturation; that is, collection was terminated when the data collected would not generate new information or enable further coding [41]. Finally, 16 postpartum nurses returning to work were included in this study.
Data analysis
After each interview, the two researchers (TJZ and XLD) transcribed the audio recordings of the interviews into Chinese verbatim within 24 h. NVivo 12 software (2018; QSR International, Melbourne, Australia) was used to manage the data [42]. We analysed the transcripts systematically using Colaizzi’s descriptive analysis framework [38], divided into the following seven analytical steps: (1) Reading the interview transcripts repeatedly to reach a complete understanding of the participants’ experiences and become immersed in the data; (2) Identifying significant words and sentences related to the adaptation experience of postpartum nurses; (3) Formulating meaningful units for extracted statements through team discussion; (4) Clustering all identified meaningful units into potential subthemes and themes; (5) Integrating emergent ideas into an exhaustive description of work adaptation; (6) Closely linking themes to synthesise the fundamental structure of work adaptation; and (7) Validating the fundamental structure by providing feedback on the results to participants. An expert qualitative researcher (JC) examined the whole analysis process, and disagreements were resolved through discussion.
Trustworthiness
The study’s trustworthiness was ensured by focusing on the criteria of credibility, dependability, confirmability and transferability [43]. First, credibility was achieved through in-depth interviews with participants followed by analysis triangulation. A pilot interview of three nurses was thus performed to ensure credibility in data collection. The researchers immersed themselves in the qualitative data and engaged with the audio recordings. In addition, two of the main researchers independently analysed the qualitative data under the supervision of an expert in qualitative studies, and disagreements in interpretation were discussed by the research team. Member checking was also performed by returning the transcripts of the interviews to the nurses to ensure the authenticity of the data. Second, to ensure dependability, an audit trail was created to record the detailed research process, which enabled evaluation by peer researchers and transparency throughout the process. Third, to enhance confirmability, the researchers bracketed their potential preconceptions and implement reflexive weekly meetings during the analysis process to focus on the experiences of the nurses as impartially as possible. A description and rationale for the decisions made based on the findings were also provided. Finally, transferability was achieved by providing detailed information within the methodological section, including the study setting, sampling approach, data saturation and techniques of data collection and analysis. Exhaustive descriptions and contextual information of participants’ experiences were also furnished to enable readers to use the findings of our study in other contexts.
Ethical considerations
This study was approved by the Institutional Review Board of Xiangya School of Nursing, Central South University (Ref: E2023144). The objective and procedure, as well as the voluntary nature of the study, were made clear to the participants, who were informed of their right to withdraw from the study at any time without reprisal. RNs voluntarily participated with the assurance that their participation would not impact their career pathway or pose harm to them. Prior to the interviews, written informed consent and recording permission were obtained from all participants. To protect the anonymity of participants, numbers are assigned to participants and employed in presenting the findings. Confidentiality was guaranteed by not revealing their personal information, and only the researchers had access to the audio recordings and transcripts. All data were exclusively used for academic purposes.
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Findings
The researchers contacted 29 potential participants via phone or email. Eight of them refused because of their busy schedules and five did not return our phone calls. Ultimately, the study included a sample of 16 RNs who participated in the interviews. Among the participants, 8 experienced only one delivery, 7 experienced twice and 1 experienced three times. All included nurses were aged between 26 and 36 years and had a nursing tenure as an RN of 3–13 years. Most were bachelor’s degree-educated RNs with a primary title or a medium-grade professional title. They were employed in diverse nursing units, including the intensive care unit, operating room and general ward, and had returned to work for an average of 6.4 months. Table 2 provides an overview of the participants’ characteristics.
Table 2
Participant information at the time of the interview
Characteristics | Nurses (N = 16) |
|---|---|
Age (years) | |
Mean ± SD (range) | 30.4 ± 3.2 (26–36) |
25–29 | 7 |
30–34 | 7 |
≥ 35 | 2 |
Educational background | |
Junior college and below | 2 |
Undergraduate course | 9 |
Master’s degree or above | 5 |
Professional title | |
Primary title | 7 |
Medium-grade professional title | 8 |
Senior professional title | 1 |
Years of professional experience | |
Mean ± SD (range) | 7.6 ± 3.1 (3–13) |
≤5 | 6 |
6–10 | 6 |
> 10 | 4 |
Nursing units | |
Internal medicine | 3 |
Surgery | 3 |
Paediatrics | 2 |
Intensive care unit | 7 |
Operating room | 1 |
Number of deliveries | |
Mean ± SD (range) | 1.6 ± 0.6 (1–3) |
1 | 8 |
2 | 7 |
3 | 1 |
Times since returning to work (months) | |
Mean ± SD (range) | 6.4 ± 3.1 (1–11) |
≤1 | 2 |
1–6 | 6 |
7–12 | 8 |
By analysing the interviews, we obtained 13 subthemes, which were grouped into three major themes: changes and challenges of multiple roles, self-coping and social support, and further needs after returning to work. As one nurse stated, returning to work after delivery is a constant process of ‘breakdown and healing’, a phrase that reveals the core experiences of work adaptation. The first theme (changes and challenges of multiple roles) and the second theme (self-coping and social support) demonstrate the mutual relation of ‘breakdown’ and ‘healing’. The third theme, further needs after returning to work, focuses on ongoing demands and unsolved problems generated by the stress and coping process of ‘breakdown and healing’. Figure 1 illustrates the main themes, subthemes and potential relationships between them. The quotations below are aimed at achieving maximum illustrative clarity and have been contextualised, interpreted and integrated into the text [44].
Fig. 1
Schematic diagram of the study’s themes, sub-themes and the relationships among them
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Changes and challenges of multiple roles
Physical and mental exhaustion
Women usually encounter numerous physical and mental problems after giving birth. Nurses returning to work may experience joint pain, endocrine hormone disorders and slowed metabolism [45]. The lack of rest and relaxation time as well as emotional ups and downs affect the working status of nurses after returning to work.
‘My baby was premature, and I didn’t have much breast milk, so my kid has been drinking cow’s milk since he was born. I blamed myself, and I felt like I didn’t bring him into the world in a healthy way. After I returned to work, I just cried all day, thinking about how my child might have a bad ending.’ (Nurse 6).‘Since I returned to work, I get fatigued easily and suffer from inexplicable aches and pains. Because the work is very tiring, there will definitely be some bad emotions that will be brought into the family. These bad emotions last until I go to work the next day, and I feel like it is a vicious circle.’ (Nurse 7).
Breastfeeding and separation anxiety
Breastfeeding is one of the biggest obstacles to work adaptation for postpartum nurses returning to work. Even if nurses know enough about breastfeeding, few of them are able to exclusively breastfeed. After they return to work, it is not possible for them to breastfeed regularly, and their habits are broken. At the same time, the lack of time for pumping and a quiet and private environment leads to engorgement and decreased milk production.
‘I often worry about whether I have time to pump because my work is so heavy. If I do not pump for a long time, my breasts become engorged.’ (Nurse 3).‘After returning to work, the rhythm of breastfeeding was suddenly disrupted. The baby didn’t wake up when I went to work in the morning, and I was at the hospital when the baby should have been breastfeeding.’ (Nurse 4).
When postpartum nurses return to work, they often worry about their babies at home and suffer from separation anxiety, which is exacerbated by their babies’ illnesses. For nurses with more than one child, lack of energy is also a major problem for nurses returning to work. Worries and concerns about children may directly or indirectly affect the quality of nursing.
‘When I initially returned to work, the separation anxiety as a mother was even greater than that of the baby. I felt that he might not eat or sleep well if I was not with him, so I would sometimes get distracted when I was at work.’ (Nurse 7).
Disagreements within the family
It is common for grandparents to assist with childcare for postpartum nurses returning to work, which may lead to disagreements concerning parenting styles. In addition, the focus of the family shifts to care for the baby, overriding the emotional connection between family members, and thus changing the original family structure and family relationship.
‘We have some conflicts and disagreements with our parents-in-law in terms of childcare, as they adopt traditional and practical methods while we emphasize scientific and healthy ways. We often quarrel and fall out with each other.’ (Nurse 10).‘My husband’s work stress is also relatively high, and most of my attention tends to be devoted to the baby. It seems like everyone in my family gives absolute priority to the baby, and sometimes we may ignore each other’s feelings.’ (Nurse 8).
Disconnection from work
When postpartum nurses return to work, they may face a series of changes that occurred in their absence, such as changes in department layout, equipment updates, interpersonal environment and optimisation of job responsibilities and processes. Moreover, the high intensity, fast pace and strict standards of clinical nursing work make it a great challenge for most of them. At the same time, being busy with childcare may cause postpartum nurses who return to work to miss opportunities for further education and promotion.
‘I’m not very familiar with some of the new equipment in the department, such as hemofiltration machines. In addition, our department has been newly renovated, and I may not be able to quickly find where things are located. There are also many new colleagues in the department, and I don’t even know them yet. I come off like a new nurse who just joined the job and doesn’t understand anything.’ (Nurse 1).‘It’s also because of breastfeeding, which makes it more difficult for me to participate in many department activities. If there are opportunities for further training and learning, the leaders will not give me priority.’ (Nurse 8).
Changes in career planning
Nurses returning to work have refocused their energy and entered a different phase of life after giving birth, and their career planning has also changed accordingly. Some nurses with better self-efficacy maintained a desire for self-improvement, so they quickly adjusted their career planning goals and pace after returning to work; other nurses placed more value on their babies and family life, thus slowing down their career planning and personal development.
‘After having a baby, I still want to keep progressing. On the one hand, I want to do my best to improve my baby’s living standards, and on the other hand, I want to set an example for him. Therefore, I have been applying for projects and writing papers after returning to work.’ (Nurse 11).‘I was more ambitious before having this baby. My previous plan was to run for the position of head nurse or nursing management. But I cannot think about such possibilities now that I have a baby, and I am less motivated than before. It may be that my energy has become scattered, and the focus is now on my family and taking care of my baby.’ (Nurse 9).
Self-coping and social support
Positive self-management
Positive self-management of postpartum nurses includes the resilience to monitor their own conditions and adapt cognitive, behavioral, and emotional responses to maintain a satisfactory quality of life as well as work-family balance. Through this ongoing and dynamic self-regulation process, postpartum nurses may adopt problem-oriented coping strategies, and actively adjust to and manage the strain resulting from having multiple roles. They focus on postpartum recovery and staying healthy, regulate their emotions and mindset, and review and consolidate their professional knowledge and work skills in advance to adapt to the busy pace of clinical nursing work.
‘I found that exercise is very important, especially outdoor activities. Before my baby was half a year old, I seldom went out, but after returning to work, I had more chances to go outside with my colleagues to get in touch with nature, which made me feel much more relaxed. In addition, I enjoy doing exercises that facilitate postpartum recovery, such as yoga.’ (Nurse 8).‘After returning to work, I familiarised myself with the position I would return to, the new information and how to use the new instruments. I paid close attention to all kinds of information in the department even though I was resting at home. If there was any training or lecture, I would participate in it as much as possible.’ (Nurse 6).
Spousal coordination
Spousal coordination can relieve the tension and anxiety of postpartum nurses in the face of childcare and returning to work. It is an important support for postpartum nurses that reduces work pressure and promotes work adaptation. The spouse’s willingness to assume the roles of husband and father will promote the subjective and objective adaptation of multiple roles of postpartum nurses returning to work.
‘When my baby was sick, my husband told me to go to work without worrying and he would stay at home to take care of the baby. He stayed up all night monitoring the baby’s temperature.’ (Nurse 3).‘My husband has tolerated my negative emotions resulting from my work, and he listened to me patiently when I was in a bad mood. He looked at the problem from my point of view and gave me a lot of help when I needed it most. I think he gave me a sense of security, so I am very grateful to him now.’ (Nurse 6).
Family support
A strong family support system can help postpartum nurses returning to work, and the reasonable distribution of tasks within the family can reduce the stress on family members. Relatives and other family members can alleviate the burden of caring for the baby, leading to a more balanced and harmonious family life.
‘My parents are now here to help me take care of the baby’s daily needs. Now I have more free time, and I don’t have as much work stress as before.’ (Nurse 16).‘My mother is in charge of our family meals; my mother-in-law is in charge of the baby and housework; my husband plays with the baby after work and bathes him; and I take the baby to bed at night. The division of labour among our family members is relatively clear, and no one is tired out.’ (Nurse 2).
Peer support
For postpartum nurses, peer support refers to considerate care and humane assistance from supervisors and colleagues. Nursing managers’ implementation of humane management policies can improve the work enthusiasm of clinical nurses. Measures such as job transition (from auxiliary positions to primary positions) and suspension of night shifts not only reduce the work intensity of postpartum nurses returning to work but also provide them with emotional support. At the same time, supportive colleagues create a positive atmosphere that can help nurses to reintegrate into the department and adapt to work.
‘The head nurse takes good care of me. When taking care of the patients, she will assign the patients with milder conditions to me. If there is any difficulty at home, she will try her best to support me.’ (Nurse 15).‘When I go to work, I meet with my colleagues every day. They convey positive thoughts to me, and they always give me some advice on breastfeeding or dealing with family conflicts.’ (Nurse 6).
Further needs after returning to work
Flexible working arrangements
When the postpartum nurses first returned to work, family affairs and the needs of the baby inevitably affected their working status. Considering the differences in adaptability and individual needs of different nurses, it is necessary to set flexible times for returning to work, scheduling, training and assessment.
‘If some nurses don’t want to be bothered by family chores and want to return to work early, I think the nursing managers should support them and not deduct their maternity allowance. I hope that the managers could offer more flexibility in choosing the time to return to work.’ (Nurse 16).‘As far as examinations and training are concerned, nursing managers could give a little more consideration to us. It would be better if we could be allowed to participate online and not have mandatory deadlines for assessments.’ (Nurse 4).
Proactive care from supervisors and colleagues
Most postpartum nurses who return to work had positive emotions about the challenges of multiple roles and could seek emotional support from relatives and friends in a timely manner. There were also some nurses who had difficulties in psychological adjustment and weak social support, and their supervisors and colleagues needed to provide timely and proactive care.
‘I think the hospital trade union or other departments can do more to take the initiative to understand the emotional state of postpartum nurses and provide psychological counselling and help.’ (Nurse 8).‘The nursing managers may need to be more careful and pay more attention to us mothers and understand what difficulties we have. If our supervisors and colleagues cared more about us, we wouldn’t have to struggle so hard by ourselves, and we might be able to get through these few months happily.’ (Nurse 7).
Equitable policy for experiencing multiple deliveries
Given China’s new population policy, the work experience and practical needs of nurses returning to work after giving birth to their second or third child deserve further attention. Hospitals and departments should avoid differences in the management and deployment of nurses who experienced one delivery versus more than one delivery because of factors such as staff shortages, and nurses with more than one delivery should enjoy the same care and policies as nurses with only one.
‘I hope that when I give birth to my second child, I will not have to work the night shift until the baby is one year old. Because of the lack of staff, some mothers are required to work the night shift just one month after returning to work.’ (Nurse 11).‘In the past, my colleagues who returned to work after the birth of their first child were able to work in an auxiliary position for half a year. However, there are more colleagues who have had their second child currently, and we must take care of patients directly when we come back, which is physically and psychologically demanding.’ (Nurse 3).
Well-established mother–baby facilities
More and more nurses returning to work after childbirth are pursuing a higher quality of life and social support and making demands. To improve mother–baby facilities, hospitals and nursing managers may further build supporting facilities such as nurseries and centres for information and recuperation.
‘We almost always pump in the nurses’ duty room, but it’s inconvenient with a lot of colleagues, and there’s no way to ensure privacy. There are a lot of female nurses, and I think there is a need for a private space in the department to be used as a mother-and-baby room.’ (Nurse 1).‘Currently, I am more in need of a decompression centre where employees, including postpartum mothers, can destress.’ (Nurse 12).‘In the long run, it is difficult to find a suitable nanny, especially for dual-career or multi-child families like us. If the hospital could organize a childcare centre, we would all be willing to pay for it and would feel more relaxed.’ (Nurse 6).
Discussion
This study explored the adaptation experiences of postpartum nurses returning to work. The participants described 13 subthemes falling into three interrelated themes: the changes and challenges of multiple roles; self-coping and social support; and further needs after returning to work. To the best of our knowledge, this descriptive phenomenological study is the first to focus on the adaptation experiences of nurses returning to work after childbirth. The findings of this study demonstrate the complexity of the work adaptation process and provide deep insight into the problems, coping and needs of postpartum nurses when they return to work. Three interrelated themes were described, and their interrelationships were summarised by a quotation from one subject, ‘breakdown and healing’. ‘Breakdown’ indicates changes and challenges of multiple roles that are presented to postpartum nurses. These problems will lead to the coping process of postpartum nurses through positive self-management and social support, which can be presented by ‘healing’. Postpartum nurses’ further needs after returning to work were identified based on their problems and coping process; that is, the constant process of ‘breakdown and healing’. Therefore, the themes and the quotation reflect the dynamic and ongoing process of postpartum nurses’ work adaptation.
The changes and challenges brought about by multiple roles make postpartum nurses feel they are going through a ‘breakdown’, leaving them at a loss. Faced with the complex nursing environment and a strong workload, postpartum nurses have long been subject to physiological, psychological, work and family pressures, and thus are prone to maladaptive phenomena [21, 46]. Evidence shows that professional women who return to work after maternity leave have difficulty reintegrating into society and work [47]. Sousa’s study indicated that the main difficulties for returning to work after childbirth were reducing the time allocated to family, resuming daily and work rhythms and the unfriendly work environment [22], which aligns with the overarching findings of this study. Empirical studies have proven that nurses returning to work after childbirth are a high-risk group for adverse nursing events [27, 48]. When nurses return to clinical positions after childbirth, they may encounter problems such as physical and mental exhaustion, concerns about breastfeeding and separation, work–family conflicts, changes in career planning and disconnection from their work. The returning nurses’ overlapping roles as mothers, wives and nurses lead to a low level of work adaptation. This finding is consistent with the results of Chen et al. [5], who found that the score for ‘mother’s role commitment’ was the highest among all dimensions of work stress for nurses returning to work after childbirth. The intricate interplay of personal and professional dimensions highlights the need for targeted support and interventions to facilitate a smoother transition for nurses returning to clinical roles after childbirth. Overall, nurses returning to work after childbirth should be a priority group for nursing managers, and it is worth exploring the stressors that cause them to experience maladaptation to work.
Although new problems and issues repeatedly arise, most of the nurses who return to work after childbirth can slowly move towards ‘healing’ through self-coping and social support so as to find their own pace of work. Our findings that postpartum nurses felt they returned to work with improved soft skills, resilience and self-efficacy gained through motherhood is consistent with previous studies [49, 50]. When they returned to work, postpartum nurses demonstrated resilience through positive self-management and viewed support from their partners, families, supervisors and colleagues as key to their work adaptation. Help from their partners and families can help postpartum nurses better cope with daily life and vastly reduce family–work conflicts. Moreover, peer support is essential for the health and well-being of nurses, especially when they return to work [24, 51], both in terms of switching assignments as well as emotional support. Previous studies also showed that navigating the adaptation period of returning to work requires not only postpartum nurses themselves to make positive adjustments, but also colleagues and nursing managers to help them overcome the difficulties of returning to work [50, 52]. Therefore, the significance of positive self-management, such as actively engaging in learning and applying emotional regulation, time management and energy allocation, emerges as a crucial factor in enhancing postpartum nurses’ self-efficacy. Fostering a supportive social environment is also instrumental in aiding postpartum nurses as they reintegrate into the workforce.
Through the process of ‘breakdown and healing’, postpartum nurses strive to solve new problems and meet new practical needs. At its core, this study explores how to help postpartum nurses returning to work protect their rights and interests and have a more comfortable experience so that they can go through the ‘breakdown and healing’ period more easily. Based on participant responses in this study, further needs for nurses returning to work after childbirth were identified, including flexible working arrangements, equitable policies for multiple deliveries, proactive care from supervisors and colleagues, and convenient mother–baby facilities. Challenging workplaces and unfriendly work environments deplete nurses’ psychological reserves, threaten their resilience and are detrimental to their work adaptation [53, 54]. Therefore, nursing managers and workplaces should be incentivised to make the changes necessary to protect nurses returning to work after childbirth.
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In recent years, nursing managers have strengthened the standardisation and supervision of nursing work. Strict requirements for shift attendance and high-frequency training and assessment have placed heavy workloads on nurses who return to work after childbirth [55, 56]. Within a reasonable scope, nursing managers should allow postpartum nurses to return to work early or late according to their own needs, arrange for postpartum nurses to transition from auxiliary to primary positions [57], and combine online and offline methods of training and assessment [58]. If flexible work arrangements are adopted, postpartum nurses will not have to immediately embark on high-intensity, complex clinical tasks when they return to work. Therefore, consideration should be given to establishing a non-frontline department rotation model and implementing a short-term part-time work schedule, aiming to address the special problems faced by postpartum nurses during this particular period. A systematic review also suggested that workplace interventions, including flexible breaks and work arrangement options (teleworking or working part-time), were the most common strategies to support working mothers after childbirth and improve their well-being [59]. In addition, nursing managers should try to avoid situations where nurses with multiple deliveries cannot enjoy the same care, which will affect the nurses’ willingness to have a child. After a second or third child, nurses have to face issues such as the education of the eldest children and the care of the younger children, in which case they usually have higher stress [27]. Hence, managers should fully consider the actual family situation of nurses with multiple deliveries rather than shortening their adaptation period because they have previously had children.
The findings also suggest that proactive care from supervisors and colleagues can greatly reduce the negative emotions of postpartum nurses, reduce their sense of alienation from workplace and social relationships, and help those who are trapped in complicated family chores feel valued [60]. The needs of postpartum nurses for mother–baby rooms, stress relief, psychological counselling and nurseries reveal their deep-seated difficulties. This aligns with Hill et al. [33], who identified sources of stress for emergency nurses returning to work after parental leave, including lactation and childcare. Previous studies also found that nurses urgently need a workplace that supports breastfeeding, such as private lactation rooms and equipment to store breast milk [52, 59]. Moreover, the inability to talk about psychological privacy with relatives and friends, as well as childcare issues in dual-income families, are tough problems that some postpartum nurses have difficulty solving on their own. Nursing managers can establish counseling teams comprising staff members with qualifications in psychological counseling or nurses who share similar experiences. This initiative aims to provide postpartum nurses with a platform for open communication and seeking assistance, thereby alleviating stress.
Recommendations
Recognising how postpartum nurses returning to work perceive adaptation experience is essential for nursing managers, who could use the findings from the study to support them. First, relevant hospital departments and nursing managers should understand their physical and emotional changes, pay prompt attention to the working status of nurses returning to work after childbirth and clarify their problems and needs. Second, nursing managers are recommended to adopt flexible working arrangements and provide fair, continuous and extended care and support, which can not only meet the needs of the department’s workforce but also meet the breastfeeding needs of postpartum nurses. Nursing managers should arrange for postpartum nurses to transition from auxiliary to primary positions and allow for flexible breaks according to postpartum nurses’ physical and mental conditions. Third, developing personalized return-to-work training content and conducting training targeting new technologies, new theories and new systems introduced during maternity leave can reduce postpartum nurses’ work pressure and uneasiness. Education resources such as prenatal classes, postpartum lactation counseling and postpartum recovery support are also needed for postpartum nurses. These measures can avoid interruptions in nursing work and the occurrence of nursing errors, and eventually improve the quality of nursing care for patients. Furthermore, nursing managers can assist nurses returning to work after childbirth in re-planning their lives and careers. By making targeted recommendations and adjustments to the work content and skill specialisation, nursing managers can help postpartum nurses regain their sense of self-worth and career accomplishment, thereby maintaining the stability of the nursing workforce. Finally, it is strongly advocated that hospitals provide postpartum nurses with well-established breastfeeding rooms, milk storage facilities, counseling centers. In the long run, supporting new mothers’ lactation and childcare needs is not costly and has long-term benefits in terms of helping to recruit and retain nurses.
Limitations
This study has several limitations. First, we recruited a relatively small sample size of RNs from only four tertiary hospitals in mainland China. The findings may not be representative of other postpartum nurses who do not share these characteristics, thus limiting the transferability and generalisability of our findings. Second, we did not measure the work adaptation level of the participants included in this study and made judgements about their adaptation through interviews and data analysis. However, they may not represent the part of this population with more severe work adaptation problems. Third, to control for recall bias, only postpartum nurses returning to work within one year were recruited, which is not conducive to understanding their long-term adaptation experiences and changes over time. Fourth, this study was conducted in China and was therefore situated in a particular cultural context, such as China’s ‘three-child policy’ [61], notwithstanding the fact that the work adaptation of postpartum nurses returning to work is an international phenomenon. Moreover, the study did not include partners’ or nursing managers’ perspectives, which limited a more comprehensive picture of the maternity and adaptation experience of postpartum nurses. Finally, descriptive phenomenology was appropriate for this study of a phenomenon where little is known; however, this method did not allow for causal conclusions about the relationships between work adaptation, coping styles and social support identified in this study. Future studies should use a larger sample size and recruit postpartum nurses from different cultural backgrounds to further explore the coping strategies and practical needs of work adaptation. In addition, the concepts developed in this study should be further explored quantitatively and in longitudinal studies to gain a deeper understanding.
Conclusion
Returning to work after childbirth is a challenging endeavour that every postpartum nurse will experience. Most postpartum nurses experienced great changes and challenges from their multiple roles, and they managed these stressors through self-coping and social support. Additionally, they identified further needs after returning to work through the constant process of ‘breakdown and healing’. Nursing managers are highly recommended to understand postpartum nurses’ physical and emotional changes and develop personalized return-to-work training before they return to work. There is also a critical need for flexible working arrangements, a welcoming workplace, support from collogues, and well-established maternal facilities and services to shorten postpartum nurses’ maladaptation period after returning to work and improve their work adaptation. Furthermore, maternity leave policies, breastfeeding strategies, and equity in multiple deliveries should be further refined to create a supportive work environment. Future studies should develop and implement tailored interventions to address further needs raised by these postpartum nurses. Longitudinal studies are also encouraged to track the trajectory of postpartum nurses’ mental and occupational well-being after returning to work, which may contribute to a better understanding of their work adaptation and future intervention efforts.
Acknowledgements
We are grateful for the assistance of the nursing departments of the hospitals during data collection and wish to extend special thanks to all of the postpartum nurses who kindly shared their stories. We would like to thank the professional English language editing support provided by AsiaEdit.
Declarations
Ethics approval and consent to participate
The study was conducted in accordance with the Declaration of Helsinki, and approved, and approved by the Institutional Review Board of Xiangya School of Nursing, Central South University (Ref: E2023144). Prior to the interviews, written informed consent and recording permission were obtained from all participants.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
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