Enhancing maternity healthcare workers' wellbeing using Insider Participatory Action Research

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While urgently needing evidence-based wellbeing strategies, participatory interventions using positive psychology have been under-investigated. We aimed to develop a caring, collegial NHS labour ward environment wherein maternity HCWs created paths to enhancing individual and collective workplace wellbeing. Methods A social constructionist, pragmatic approach was adopted, applying positive psychology within Insider Participatory Action Research (IPAR). All clinical and non-clinical HCWs on a consultant-led labour ward in the East Midlands, England, UK were invited to identify current sources of workplace wellbeing on which to collectively construct future ways of working. Qualitative data from several methods (below) were inductively thematically analysed. Results Between October 2018 and July 2020, data derived from 83 paper and 13 online questionnaires; 59 interviews; 16 comments on data displays; three emails; three action groups; and six peer participant reviewers. Three themes represented sources of workplace wellbeing: emotional, professional, and physical nourishment. Culture shifted to be more compassionate and inclusive, and morale, positivity, and atmosphere improved. Ways of working changed: colleagues more proactively cared for each other; worked well together in teams; expressed thanks and feedback; and instigated interventions for colleagues’ and women’s welfare. Participants proposed that IPAR activities prompted change including: the researcher being considered an accessible colleague wellbeing resource; raised awareness of the importance of HCW wellbeing; and strengthened HCW relationships. The HEARS wellbeing intervention model ( H CW driven; E veryone involved; A sk what makes a person feel good at work; R esponses displayed; S teps taken) was developed to frame processes by which HCW participation catalysed impact towards workplace wellbeing. Conclusions This is the first study to use IPAR towards enhancing HCW wellbeing. Colleagues from diverse occupational groups improved individual and collective wellbeing through self-determined action. The use of participatory methodology and positive psychology encouraged a more compassionate and inclusive culture. Subject to implementation research evaluating these strategies’ impact in different settings, we propose the HEARS wellbeing intervention model and workplace-based Colleague Support Volunteers as actions towards wellbeing and retention in healthcare organisations. Health personnel Wellbeing Intervention Action Research Maternity Figures Figure 1 Figure 2 Figure 3 Terminology The terms woman and women include childbearing people whose gender identity may differ from that at birth, and those who identify as non-binary. Background The United Kingdom (UK) National Health Service (NHS) urgently needs to act on national guidance equating the importance of healthcare worker (HCW) wellbeing to patient wellbeing [1]. Workplace conditions need to improve in order to sustain those individuals who continue to work despite present pressures, and to encourage their retention to meet service demands. Prior to the Covid-19 pandemic, longstanding knowledge about correlations between HCW welfare and improved patient experience and outcomes [2] had triggered a range of stress-reduction interventions in the UK and overseas [3-5]. Specifically, maternity services in the UK had been affected by persistent poor workplace wellbeing. Workforce shortages had resulted from midwives abandoning their profession [6], citing poor staffing levels and high workloads compromising quality of care [7]. Over two-thirds of almost 2000 midwives reported work-related burnout in a 2017 survey [8]. In parallel, obstetricians had been suffering burnout [9], and retiring early due to heavy workloads [10]. Obstetric and gynaecology trainee numbers had fallen by 6.8% between 2012 and 2018 [11]. In 2020, the pandemic exposed the lived experiences of NHS HCWs with unprecedented intensity. Acute workforce shortages exacerbating chronic shortfalls laid bare the fragility of service provision. Passive acknowledgement of links between HCW and patient welfare was replaced by multiple health promotion initiatives attempting to maintain services by fortifying HCW wellbeing. Post pandemic, poor HCW wellbeing and retention remain core problems. Maternity practitioners’ burnout levels are high and rising [12,13]. A fifth of doctors plan to retire early and the same proportion to leave medicine completely [14], and over half of midwives responding to a 2021 survey were considering leaving the role [15]. England carries a minimum deficit of 496 obstetricians and 1932 midwives, with total workforce shortfalls estimated to reach 231,280 of 1,465,716 anticipated NHS posts in 2025 [14]. This paper presents a HCW wellbeing intervention in one NHS labour ward (LW) in the East Midlands, England, UK, and follows two previous publications of preliminary findings [16, 17]. At the time of the study, I, CW, was a practising clinical midwife in the setting and considered all occupational groups’ wellbeing to be deteriorating. Colleagues regularly cried at work, left their professions, or sought alternative HCW roles. Few supportive interventions existed [18]. The final catalyst for action was my discussing the personal impact of emotionally demanding work experiences as a recruit in a research study [19]. For the first time in over 30 years’ service, I perceived an institutionalised expectation that HCWs continue practising unwaveringly after all but the most serious of clinical incidents. With the national and international situation demanding action, the aim of this study was to develop a caring collegial environment within a NHS LW in which maternity HCWs created paths to enhancing their individual and collective wellbeing. Interventions for employee wellbeing Although definitions of wellbeing overlap and interrelate, employment is considered to positively contribute to wellbeing [20,21]. If given autonomy and control, people enjoy not only income but the challenge of mastering a role, and the related social interaction [21]. A virtuous cycle perpetuates wherein good working conditions improve individual wellbeing, and individuals’ wellbeing improvement effects good working conditions [21]. For study purposes, this paper’s authors positioned HCW workplace wellbeing as: Feeling emotionally buoyed in performing roles, and psychologically content with the ability to contribute to and be accepted within a socially supportive work community. We found in our initial literature search that employee wellbeing interventions do not consistently show positive impact. Most focus on problem-identification and solution development and report small to moderate positive effect on mental health, stress, burnout, social/working conditions, performance, and absenteeism [18,22-27]. Others find no, or mixed, benefit [28–31]. Rather than generic recommendations, the plethora of different healthcare environments require methodologies which prompt locally impactful strategies. New approaches are indicated. Interventions are classified as organisational, individual, or a combination. Organisational, or primary, interventions aim to be preventative, encompassing employees’ workplace conditions [32]. Work systems and/or job designs are modified, rationalising that in complex systems such as workplaces, the interaction of multiple components influences wellbeing more than change in specific, isolated elements [3,23-25,27,31]. Individual interventions are classified as either secondary or tertiary. Secondary interventions aim to ameliorate adverse workplace impact through self-care training (for example in stress, sleep), or through physical and psychological activity (for example in yoga, mindfulness). Tertiary interventions apply to those taking sickness-absence and were not investigated within this workplace-based enquiry. Combined approaches use secondary interventions within organisational interventions [26]. Defined, small-group, individual intervention programmes are moderately stress-reducing [26] and potentially more economically and operationally feasible than the large-scale engagement required for organisational interventions [27,31]. Individual interventions nevertheless risk employees feeling accountable for their poor wellbeing, rather than a responsibility for organisations to address [18,31]. Unchanged workplace stressors also threaten ongoing maintenance of any related individual improvement [27]. Combining organisational and individual interventions is proposed to enhance outcomes [25-27,31] and prolong effect [26]. Additionally, by incorporating participatory study design within the combination, employee engagement is fostered [3,26,31]. Participatory Action Research (PAR) methodology offers those potentially affected by interventions to co-create changes for local benefit. Shared ownership of the enquiry enables participants to form action groups (AGs) to collectively agree research questions, review data, plan action, generate data, take action, evaluate outcomes, and modify future plans in a continuing dynamic [33]. As few wellbeing interventions adopt participatory methodologies [26], we further scrutinised the literature by critically reviewing specifically the effectiveness of PAR in enhancing HCW psychosocial wellbeing [34]. Firstly, the review analysed the methodological elements related to reported effect and secondly, the review identified processes potentially modifiable to increase effect. Findings indicated significant improvements in psychological status, social support, effort-reward balance, decision-making, burnout, job satisfaction, and absenteeism. We nevertheless anticipated even greater impact by enabling bottom-up, HCW-initiated projects; including all HCW groups; applying positive psychology; increasing frontline HCW decision-making; and generating qualitative participant process/evaluation data. As I, CW, planned to initiate the study, this constituted Insider PAR (IPAR), wherein an employee undertakes research within their workplace [35]. As an IPAR researcher (IPARr), I intermittently use first person voice to acknowledge the subjectivity of IPAR practice. Study question and objectives The study question indicated that progress towards individual and collective wellbeing depended on, and aimed for, colleagues’ active contribution, and took an intersubjective approach whereby I positioned myself alongside my colleagues in the collective we : How can we as maternity healthcare workers enhance our individual and collective wellbeing? The study objectives applied a positive psychology approach as the authors’ review findings had indicated. Focussing on what made HCWs feel good at work was anticipated to buoy affect and maintain whatever feelings drove HCWs to persevere in demanding roles. This premise was therefore applied to the first two study objectives. The core of the intervention constituted HCWs using current sources of LW wellbeing as foundations for building further avenues going forward: Objective 1 - To collate factors identified as encouraging wellbeing Objective 2 - To collectively construct future ways of working. In line with PAR, a hypothesis was not proposed, and the direction of research activities was guided by participant data. The authors plan to address the final and third objective of evaluating IPAR’s role in outcomes in a forthcoming paper. Methods Patient and public involvement Since this study focused on HCW wellbeing at work, patient and public involvement was not considered to be directly applicable. Research design The study’s philosophical perspective was based on social constructionism, whereby individual minds in specific social and historical contexts constitute reality [36]. The theoretical perspective was pragmatism, putting theory to practical use [36]. Both align with PAR’s aim to achieve social impact through community with others [37], and also accords with all LW HCWs being involved in co-creating knowledge to build desired futures [33]. Thematic analysis techniques were used to support participatory principles by inviting members of different occupational groups, anticipated to have varying degrees of research experience, in data review [38]. Research setting Approximately 5000 births occurred annually in the setting’s consultant-led LW which included 13 birthrooms; two theatres; and high dependency, induction, and assessment units. Women’s care depended on the dynamic of different teams’ interaction, and HCW team members constantly changed shift to shift. For each shift, a senior midwife, the coordinator, liaised with medical colleagues to organise the work of approximately 20 HCWs. Activity was typically high and regularly required interdisciplinary teams to rapidly attend the operating theatre for emergency caesarean sections and other obstetric procedures. Participants Posters were used to invite participation to the Wellbeing Project (WbP), as the study was termed. All HCWs were eligible and, in order of highest numbers, occupational groups included midwives, obstetricians, operating theatre practitioners, anaesthetists, health care assistants (HCA), receptionists, housekeepers, and domestic personnel. Study documents and related online links were emailed to HCWs by groups’ administration leads, and paper copies were also made available. The IPARr presented information on study processes at shift changeovers; in management, research, and operating theatre meetings; and to new-starter HCWs. Data generation methods Six data generation methods were planned. Questionnaire - paper, online Individual/group interviews - qualitative, semi-structured Online consultation group - closed, asynchronous (not real-time) on social networking site Comments added to data displays Action groups Peer participant review (PPR) of data The first five methods were employed from the study start date 23 October 2018 to 30 April 2020. Posters were used from early September 2019 to invite all LW HCWs to act as PPRs in reviewing data until 31 July 2020. Questionnaires comprised two questions: Can you say something about an experience, working on Labour Ward, which made you feel good within yourself? What was happening at the time to make it possible? Interviews similarly exploring positive experiences were formal and pre-planned, in participants’ chosen location, or informal, arising spontaneously. See Prompt guide wellbeing interview: Supplementary information Additional file 1. Notes were taken if participants declined consent for audio-recording. Posters were used to invite HCWs to join AGs, act as PPRs, and/or add comments to data displays. In anticipation of discussions developing from data generated from objective 1, no questions were prescribed for AGs. Following verbal information on thematic analysis processes, the PPR role involved reviewing data transcripts for comparison to other PPR/IPARr interpretations. Further detail is given under Data Analysis and Results. Data were transcribed by the IPARr apart from those of longer pre-planned interviews which, to economise on time, were sent in an encrypted file to a transcription service. Evaluations of the intervention were actively sought in March and April 2020 using the same study questionnaire. A noticeboard posted a request for HCWs to document any learning over the past 18 months related to what made them/the team feel good, and any perceived study-related changes. These evaluations were requested in addition to evaluations already spontaneously given in questionnaires and interviews. To facilitate data generation, I attended the LW up to four times a week from 23 October 2018 to 30 April 2020 (approximately 900 hours total), aiming to be unobtrusively accessible. When LW activity precluded data generation, I regularly took tea-trolleys into the clinical area and delivered drinks and snacks to colleagues unable to leave work tasks. To differentiate my midwifery and IPARr roles, I wore uniform only when working clinically. Data analysis Transcripts were inductively thematically analysed by repeatedly reading data line by line, collating initial codes, categorising codes into themes, and producing a narrative synthesis. I started these processes when data were first generated. Later, PPRs and I together compared our interpretations and created codes and themes until these were all agreed. Peer review intended to avoid the risk of my personal assumptions, beliefs, and worldviews blinding me to new insights. I also undertook continual reflexive self-evaluation of the impact of my presuppositions on study processes, data collection, and data interpretation [33]. Regarding my presuppositions, I was white British, around retirement age, had good working relationships with colleagues from all occupational groups, and was unaware of personal characteristics likely to hinder research interactions. I felt I unremarkably fitted in as a well-known middle-grade practitioner usually supporting women on LW. Although comfortable inviting colleagues to participate, unusually combining PhD studentship/IPARr and clinical midwifery roles, I felt pressure to be a positive role model for my profession. Reflexively, I aimed to appear confident and approachable to inspire participation. Ethical considerations The concepts of dependability, credibility, and transferability support this study’s qualitative trustworthiness. Details of study processes and contexts upheld dependability by illustrating coherence with knowledge claims. Credibility of interpretations met international PAR criteria requiring participants to actively engage in ethical processes towards social change [33]. Transferability was met by illustrating sensitising concepts for other investigators [39]. To reduce triggering personal issues, participants were advised they could stop/pause participation at any time. Plans were also made for senior midwives to meet any upset participants, and study documents featured Trust wellbeing resources. To avoid participation out of friendship or perceived obligation, HCWs’ participation was not in the first instance pursued by the IPARr but volunteered by HCWs through contacting the IPARr after reading study documents. Consent process Written consent was required for interview, AG, and PPR. Consent was considered as given for those completing questionnaires, requesting membership of an online consultation group, and adding comments to displays. As participatory methodologies support public recognition of participant contributions towards publications [33], two different consent forms offered participants to optionally include role descriptor and/or self-identify by name. See below: Declarations, Consent for Publication. Results Data were generated from 83 paper questionnaires; 13 online questionnaires; 51 individual interviews; eight group interviews; 16 comments added to displays; three emails; three AGs; and six PPRs’ responses to the first 40 interview transcripts. Data initially included narratives of positive work experiences related to objective 1, whilst participants later more frequently added comments evaluating WbP changes related to objective 2. Throughout the study period, data quotes were exhibited for all HCWs to view. Colourful excerpts were widely posted on a full display wall as demonstrated in figure 1, and on noticeboards and posters in training, rest, office, changing, and theatre areas, and updated at least monthly. Table 1 demonstrates the range of occupational groups which took part, as exemplified in interview activity. Healthcare workers who only worked on the LW participated in higher numbers than those who rotated around the different maternity wards. Over half of interviewees self-identified by first or full name. Interview data varied from one-hour sessions away from clinical areas to short comments captured from exchanges with the IPARr on LW. Questionnaire data similarly spanned from one sentence to a packed A4 page. It was not possible to gauge self-identification levels in questionnaires as in March 2020 a group of midwives independently duplicated questionnaires to distribute at shift changes, and omitted the optional role/name section, affecting 21 submitted forms. Table 1 Number and occupational group of interviewees Occupational group Number of practitioners in group (estimate) Number participating in individual or group interview Midwife 150 32 (21%) Obstetric doctor 60 5 (8%) Theatre practitioner 45 5 (11%) Anaesthetic doctor 21 4 (19%) Healthcare assistant 20 10 (50%) Housekeeping, domestic, receptionist 13 5 (38%) Totals 319 64 (19%) Coordinator, Theatre, and HCA AGs were respectively established in response to reports of how coordinators’ behaviours impacted HCW wellbeing; the role of HCAs; and HCW experiences in operating theatres. See Action group activity: Supplementary information Additional file 2 for AG activity, and figure 2 for timing of AGs within the study period. One online consultation group began for HCAs but as it was largely used to arrange AG meetings, new data were not generated. From March to July 2020, impact from the pandemic impaired generating, sharing, and participants reviewing data. Planned WbP events, including a large social outing and the first maternity interdisciplinary Schwartz round (40), were cancelled. In the following findings section, excerpts of participants’ verbatim documentation and role/name entries are presented. Acronyms are used to identify the data source: AG = Action group: Anon = Anonymous; Int = Interview; Q = Questionnaire; OQ = Online questionnaire. Some participants chose to shorten their names, omit roles, and/or include unconventional role descriptors. Data related to the study’s aim and objectives are initially presented, including the how, the mechanisms, of study outcomes as proposed by participants. The section concludes with a wellbeing intervention model named HEARS which was developed to reflect how IPAR study processes were applied. Findings related to study aim The study aimed to develop a caring collegial environment on LW in which HCWs created paths to enhancing individual and collective wellbeing. Box 1 provides evaluation data indicating change in a positive direction. Although difficult to separate into discrete categories, as impacts were often interrelated, 28 individuals provided 38 comments on improved culture, morale, positivity, and atmosphere. No participant recorded a negative study effect. Box 1 Wellbeing Project evaluations ‘For the first time in many years I am eager...to work on LW...My colleagues are genuinely caring, compassionate and supportive no matter what role. We pull together...especially in the current situation [pandemic]. The project has made a huge difference to the general mood and morale.’(Anon, role omitted Q49) ‘I...had sick leave for workplace stress...I felt broken, and it’s taken six months, and your study really helped because I felt somebody was saying we were important, because I didn’t feel important, loved, or needed.’(Anon, Senior Clinical Midwife Int48) Findings related to study objectives Objective 1 sought to collate the factors identified as encouraging HCW wellbeing. Three themes were established from the data: Emotional, Professional, and Physical nourishment. Emotional nourishment included 286 comments from 98 individuals and, respectively, Professional nourishment 81 from 69, and Physical nourishment 47 from 47. Table 2 presents the related themes, sub-themes, and illustrative quotes. Table 2 Themes, sub-themes, and illustrative quotes related to factors encouraging healthcare worker wellbeing Theme Sub-theme Illustrative quotes Emotional nourishment Colleagues caring 103 comments [Felt unwell, sat, and cried. Colleague stayed and] ‘...brought me toast and a drink, and it made me feel looked after and comforted.’(Anon, Midwife Int15) [Midwives noticed participant wasn’t themself and asked if they were ok] ‘I liked it but didn’t want to share it. I liked it.’ (Anon, Doctor Int37) Appreciative communication 62 comments [Felt good] ‘Receiving a thank you card from a midwifery colleague for the support I had given her as the registrar on call.’(Mark, SpR [Specialist Registrar] in O&G [Obstetrics and Gynaecology]) ‘She'll say [LW manager] “you're really coming into your own”...just a passing comment on the corridor, but she puts a little spring in your step…that's important…our...perception of ourself is we're rubbish.’(Sophie Nabbs, Registered Preceptorship Midwife, PMW, [ newly qualified midwife in programme transitioning from student to accountable midwife] Band 5 Int39) Welcoming behaviours 43 comments ‘I feel welcome [to LW]. All the people, midwives, everybody, welcome to me. I don’t feel odd here...if it’s a doctor or a midwife, I feel the same...When a room needs doing [cleaning]...I have good feedback...housekeepers, HCAs, midwives, everybody.’(Anon, role omitted Int12) [Felt good] ‘...being known by my name not just my job title.’(Anon, role omitted Q69) Positive environment 32 comments ‘Bit of fun goes a long way. I like it when the music’s on...everyone’s humming...there’s a good vibe and a different energy. It changes the whole atmosphere.’(Anon, role omitted Int40) Belonging 24 comments [After a colleague helpfully intervened in a challenging situation] ‘...made me feel part of something...now I never feel on my own...I can feel the supportive team around me all the time.’(Anon, Preceptorship Midwife Q47) Joy in work 22 comments ‘I love my job. I love coming to work...we're very privileged to have such a wonderful job.’(Anon, Senior Clinical Midwife Int27) Professional nourishment Teamworking for good outcome 52 comments ‘ The case...this morning ...in theatre...was a very difficult, complicated case and you wouldn't have known that there was any difference between theatre staff and midwifery staff...The whole team was amazing...We kept in tune with each other the whole time. Communication was brilliant. We had a good hug at the end and said, “Well done” to each other. It couldn't have gone better.’(Lucille Griffiths, Senior Operating Department Practitioner Int42) [Teamworking] ‘...makes it a failsafe mechanism…a critical situation when has a good outcome, it makes you feel good to think that you have made a difference as a team.’(Anon, role omitted OQ13) Satisfaction of individual motivators 29 comments [Bereavement care episode] ‘ ... to me represented true midwifery care - being wholeheartedly with woman, treating her at all times with kindness, dignity and compassion...I hope that I will always remember feeling proud of the care that I have provided.’ (Anon, Preceptorship Midwife Q12) ‘I take pride in cleaning a room. I find it a privilege that a baby is going to be born there…it’s the first place the baby will be.’(Jodie Allsop, HCA Int59) Physical nourishment Rest and refreshment 47 comments ‘We don’t have structured breaks. [Tea-trolley] Is a good recognition of this.’(Anon, Doctor in training Int5) [Feels good] ‘...When toast is made on nights.’ (Anon, Registrar in Obstetrics and Gynaecology Int1) Emotional nourishment Data related to emotional nourishment were connected to colleagues showing caring gestures; to appreciative communication; welcoming behaviours; a positive environment; a sense of belonging; and to feeling joy in work. Participants referred to feeling good by both experiencing and witnessing caring actions within and between occupational groups, and in seniors’ role-modelling of such behaviours. Appreciative communication related to enjoying both giving and receiving positive feedback and gratitude. These were conveyed in verbal exchanges, emails, texts, cards, and social media, and reportedly provided HCWs with reassurance. Being welcomed to LW by greetings, smiles, being shown respect, and being addressed by one’s name similarly appeared in data as encouraging wellbeing, as did camaraderie, banter, humour, and an upbeat atmosphere. A number of participants connected their good feelings with being part of LW family/team. Related data were initially categorised as Teamworking but during PPR Rosie (Core Midwife, Birth Centre) stated: ‘Shared experience is more than just teamwork. It’s bonding. The tea-trolley bonds. We are held together. Teamwork is just working together for an effective outcome.’ These comments showed the importance of personal relatedness beyond purely professional connections, and how tea-trolleys provided more than simply physical sustenance. Being gathered at the tea-trolley was frequently cited as the environment where HCWs could break from tasks to talk, learn, and relate. Teamworking continued as a sub-theme, but earlier data interpretations were reviewed for potential recategorisation to a Belonging sub-theme. Slightly different to this deeper interpersonal connection, other participants expressed how everyday interactions with colleagues and practising their role made them joyful. Barriers to emotional nourishment nevertheless existed. New-starters’ befriending attempts were reportedly challenged by working with numerous different colleagues and by perceived unyielding established friendship groups. Being physically isolated in specific work areas away from most colleagues (for instance, in the reception area) was reportedly similarly disconnecting: ‘Everyone goes, “we're all in it together”, but we're also not, we're just there on our own.’(Tim Gray, Clerical Legend Int34) Professional nourishment Teamworking for good outcomes, and satisfaction of individual motivators, comprised the sub-themes of professional nourishment. The former related to collective wellbeing, and the latter to individual wellbeing. Participants reported that teamworking raised wellbeing through communication and learning, and through ‘ professional bonding ‘ (Anon, Midwife Int55). Many expressed how colleagues, regardless of role and hierarchy, willingly offered practical support in a collective effort to provide optimum care to women and babies. Data, however, also indicated participants perceived self-worth in striving to perform as individuals. Reported achievements towards these individual motivators included practising high quality care, contributing to potentially saving a life, learning, teaching, and acting autonomously. Physical nourishment The sub-theme Rest and refreshment reflected the many HCW references to how opportunities for food and drink improved their wellbeing. Tea-trolleys with snacks were regularly cited as a means of refuelling to ‘ keep going’ (Senior Clinical Midwife, Int27) . Although drinking and eating were reportedly physically sustaining, many related references also included emotional overtones as offering refreshments was linked to HCWs caring for each other. Objective 2 focussed on collectively constructing future ways of working. This section confirms the occurrence of changes in ways of working by providing related HCW data reports. These reports are followed by factors participants suggested as instrumental to these changes. New ways of working New and improved ways of working were described around four main topics: the care colleagues offered each other (25 comments); teamworking (12 comments); expressions of gratitude and feedback (10 comments); and HCW initiation of interventions for women’s and colleagues’ benefit (eight comments). Regarding colleagues offering each other care, participants noted an increase in compassionate gestures, including proactive offers of clinical support and provision of refreshments, and deeper enquiries into others’ welfare. ‘It [WbP] has made a difference. [HCAs] wanting to help. There’s less, “That’s not my job...” The tea trolleys more frequently. More confident to go and make trolleys. Before it was more strict.’(Charlotte, Midwife Int45) Data related to improved teamworking were both described specifically in relation to the multidisciplinary team and to general teamworking. ‘Big change in the atmosphere...very much more positive - with the multi-disciplinary team working much more effectively together and having a positive appreciation of each other.’(Anon, senior clinical midwife Q37) Colleagues also commented on more frequently giving and receiving thanks and positive feedback. ‘Coordinators [say at end of shift]... “Thank you for your hard work”. It has made a big difference that way...before...you'd just go home.’(Anon, HCA Int36) ‘I have been noticing and receiving more feedback from the midwifery team when we do a procedure.’(Anon, role omitted Q72) The last principal change in ways of working referred to HCWs autonomously initiating several interventions for women’s and colleagues’ benefit. These included housekeeping and HCA colleagues independently fundraising for refurbishment of HCW and women’s sitting rooms/bathroom, and reorganising dining areas to offer women more social interaction. ‘Haven’t known the enthusiasm. We’re just as tired now, just as busy, but we’re putting in the extra mile now for the patients.’(Karen Battelle, Housekeeper Int44) Factors instrumental to changes in ways of working Participants spontaneously suggested several factors which contributed to changes in ways of working. These included: exposure to IPAR/r activity; raised awareness of the importance of enhancing HCW wellbeing; and strengthened HCW relationships. The first factor, exposure to IPAR/r activity, was reported to originate from both the IPARr’s individual action and from action associated with IPAR practice. In relation to the former, one participant suggested: ‘[The IPARr] has rubbed off on people.’ (Anon, role omitted Q61) Simply seeing the IPARr in the setting was reported to remind participants to be alert to others’ wellbeing and, similarly, the IPARr providing drinks for others was described as ‘ role-modelling ’ and having a ‘ cascading effect ’ (Anon, role omitted Q22) . ‘Like drip-feeding, nurturing...like an aura...in the background.’(Anon, Midwife Int54) Participants also expressed how IPARr actions held personal significance for how they felt at work. ‘Made a difference...made us...feel valued that you - somebody's interested in how we feel.’(Anon, Midwife Int33) A further unanticipated phenomenon also developed from the start of the WbP. C olleagues from all occupational groups and seniority levels confided personal homelife and workplace concerns with the IPARr, often in lengthy exchanges. These included families’ relationships and health, adolescent behaviours, personal anxiety, and many more, with several such exchanges occurring daily. Few had knowledge of, or had accessed, formal Trust wellbeing resources and several referred to these conversations as offloading feelings rather than seeking advice. ‘Changes I’ve seen...improvement in staff mental wellbeing by having [IPARr] available for chat and debrief...having someone in a permanent role...would be a massive asset as [IPARr] has demonstrated what a difference it can make.’(Anon, role omitted Q43) The potential for this IPARr activity to have influenced ways of working is suggested in one evaluation: ‘The [WbP] has certainly helped me to...engage in more conversations about how you’re actually feeling, instead of the generic answer “yeah, are you?” when asked if you’re ok”.’(Jodie Allsop, HCA Int34) Regarding IPAR practice of sharing data, participants stated that data displays had prompted them to consider others’ wellbeing and had encouraged individual change in ways of working: ‘[WbP] made me think about doing things differently. You are more aware of the impact you have on someone else. You do reflect on things you read on the [display] wall.’(Carol Greasley, Housekeeper Int29) The second factor frequently suggested to prompt new individual and collective behaviours was raised awareness of the importance of enhancing HCW wellbeing, both to benefit HCWs’ and women’s experiences. ‘I'm...more aware of what I say or the way...I say it...a little more measured...I’ve had greater awareness that the medical staff also feel vulnerable.’ (Kate, Senior Midwife Int62) ‘Recognition that it’s important - this stuff saves lives.’(Anon, role omitted Q35) Potentially related to raised awareness, the involvement of all HCWs in the intervention was considered impactful. ‘[Including all HCWs]...is paramount if we are all working together. From receptionists and HCA’s to co-ordinating band 7’s. We are all just a little bit kinder.’(Anon, role omitted Q30) The third factor proposed as influential to improved ways of working was the strengthening of relationships between HCWs: ‘The atmosphere...has...improved and friendships have blossomed.’(Anon, role omitted Q51) Participants described more open communication between different occupational groups and offering more compassionate gestures. ‘Communication of feelings, needs & appreciation between the MDTs [Multidisciplinary Teams] is improved. Instead of...moaning...concerns are being shared.’(Anon, role omitted Q68) Action groups apparently similarly fostered these HCW relationships. One Theatre AG participant described: ‘Trying to become one team, not them and us.’(Louise Humphries, Senior Operating Department Practitioner, AG meeting) Another suggested that new understanding of each other’s positions was instrumental to change. ‘I have witnessed big changes as a result of [Theatre AG]...the reasons for this are that we were able to discuss our roles with each other, and gain an understanding and appreciation of each other's roles.’(Anon, Senior Clinical Midwife Q83) Following findings related to the first two objectives, the HEARS wellbeing intervention model is presented. The HEARS wellbeing intervention model We developed the HEARS model in figure 3 to demonstrate how IPAR processes were practically applied during the study. The model implies active listening and mirrors LW HCWs’ ready participation and agency within the WbP. Its development was intended to facilitate similar wellbeing initiatives in other settings. Discussion This first IPAR intervention for HCW wellbeing grew from a bottom-up approach rooted in NHS clinical workplace experiences. An overarching organisational approach encompassed all HCWs’ workplace conditions while enabling individual interventions to develop according to local need. Despite conditions and workforce numbers remaining unchanged, participants reported improved culture, morale, positivity, and atmosphere. Evidence continues to support the effectiveness of participatory approaches in fitting individual workplace needs [ 41 ], yet leaders struggle to formulate creative strategies [ 42 ]. Unlike conventional top-down approaches, the WbP met the current preferred strategy of influencing wellbeing through cultural change [ 1 ]. Individual, prescriptive, generic interventions may be insufficiently tailored for the complex needs of diverse healthcare environments [ 41 ]. Examples of such top-down interventions include programmes’ contents mismatching employee needs [ 43 ], lunchtime walking initiatives in the absence of lunchtimes [ 44 ], and wellbeing resources inaccessibly situated [ 45 ]. The study processes, implemented from the findings of our critical review of PAR’s effectiveness in enhancing HCW wellbeing (see Background) [ 34 ], are considered to have been effective towards progressing the study aim. The bottom-up approach included all HCW groups and, despite medical colleagues’ engagement being particularly rare in wellbeing interventions [ 46 ], members of all occupational groups participated. Sharing the qualitative data, generated by several methods, illuminated good workplace experiences and increased HCWs’ decision-making towards change in ways of working. Positive psychology, applied to amplify conditions making life worth living [ 47 ] and encourage individual thriving [ 48 ], avoided the employee disillusionment which interventions focussing on workplace deficit and challenges may risk provoking [ 49 ]. Study objectives sought to identify factors encouraging wellbeing and to construct future ways of working. In objective 1, the Emotional, Professional , and Physical nourishment themes represented sources of LW HCW wellbeing. The themes’ data fit the three core needs considered fundamental to securing wellbeing and flourishing in healthcare work [ 50 ]. These comprise autonomy, belonging, and contribution. Autonomy reflects the need for control of one’s working life, and contribution refers to working effectively for desired outcomes. Within the Professional nourishment theme, both elements were illustrated by LW HCW narratives of competently fulfilling personal work ambitions and offering valuable interventions in teamworking scenarios. To belong in a workplace, a person needs to be allied with colleagues, feel cared for and valued, and be able to care for others [ 50 ]. Emotional nourishment data suggested this element was fuelled for LW HCWs by welcoming gestures, and reciprocal caring and appreciation. Parallel findings for all three themes were found in the literature. Examples include: for Emotional nourishment , UK and New Zealand midwives describing mutual acts of compassion sustaining them at work [ 51 ]; for Professional nourishment , early career UK midwives’ individual motivators being satisfied by facilitating natural births and taking leadership roles [ 44 ]; and for Physical nourishment , confirmation of the importance of refreshment breaks, yet the normalisation of their scarcity [ 52 ]. In objective 2, data demonstrated how IPAR activities catalysed a shift towards a more compassionate, inclusive, and positive LW culture. Healthcare workers’ ways of working reportedly changed. Colleagues cared for each other more proactively, expressed thanks and positive feedback more frequently, worked better together in teams, and autonomously initiated beneficial interventions for colleagues and women. Participants proposed mechanisms for these changes as exposure to IPAR activity; raised awareness of the importance of enhancing HCW wellbeing; and strengthening of relationships between colleagues. Theory supports these three mechanisms concurrently interacting towards the cultural shift, as detailed below. Participants stated that feeling valued by IPAR/r activities, and reading colleagues’ data describing how their wellbeing was enhanced, raised mindfulness around workplace wellbeing and stimulated caring actions towards others. Caring, compassionate behaviours elevate mood, positive emotion [ 53 ], and a sense of wellbeing [ 54 ], and also consolidate social connections [ 54 ] and feelings of belonging [ 55 ]. Feelings of belonging in workplaces further nourish compassionate behaviours, prompting a self-perpetuating cycle [ 55 ].This is important in terms of retention as experiencing and witnessing workplace compassion encourages employees’ commitment to organisations [ 53 ]. Additionally, although compassionate behaviours are most commonly directed to those who are known or liked [ 53 ], in our study LW HCWs’ raised awareness of the importance of enhancing HCW wellbeing may potentially have extended attention to less familiar colleagues, accounting for data related to both caring behaviours and to strengthening colleague relationships and team working. Broaden and build theory suggests that experiencing positive emotions primes the non-conscious mind for similarly uplifting experiences and encourages continuation of these ways of working in an upward spiral known as positive potentiation [ 48 ]. Emotional contagion, the transfer of moods between people [ 56 ], may have intensified this effect such that the LW HCW body sought to reproduce positive emotions by more proactively caring for colleagues, thereby shifting group norms to a more compassionate and inclusive LW culture. In sum, a theoretical basis supports HCW rationales for reported changes in ways of working. Considering objective 1 findings, HCWs’ changed ways of working may be viewed as an extension of the need to belong, and while no data were generated rationalising HCWs’ increased initiatives for women’s and colleagues’ welfare, it is conceivable that these behaviours reflected HCW needs for further autonomy and contribution. Although enhancing LW HCW wellbeing and strengthening colleague relationships is important for HCWs, it is crucial for patient safety. The latest of numerous maternity reports illustrate how poor HCW relationships lead to women’s and babies’ mortality and morbidity [ 57 , 58 ]. Poor HCW wellbeing diminishes compassion and makes patients vulnerable to psychological trauma [ 59 ]. By contrast, collective wellbeing correlates with improved role performance [60 ] by encouraging psychological safety, the group relationship in which members respect, review, and act on others’ workplace safety concerns [ 61 ]. The improved HCW relationships reported in our study therefore promise to support ongoing patient safety. Extending the value of the Wellbeing Project To extend the value of study findings, we propose testing a combination of two routes in a range of settings: applying the HEARS wellbeing intervention model (HEARS) and establishing Colleague Support Volunteer roles. HEARS The HEARS model provides a new, simple, low-cost, and readily implementable strategy for workplace wellbeing. Advisory documents direct managers towards positive culture change but fail to position power and control within the larger body of frontline workers [ 62 ]. Cultures continually transform and caring cultures cannot be implemented on demand [ 63 ] but instead depend on ongoing supportive group behaviours [ 61 ]. Applying HEARS could meet these cultural challenges, as in the WbP, by enabling colleagues to generate positive preferred behaviours and cultural norms as demonstrated in the WbP and supported in theory [ 48 , 56 ] Colleague Support Volunteer roles Struggling HCWs need effortless access to wellbeing support. Organisations need HCWs to feel sufficiently valued to stay. Even after traumatic events [ 64 ], many HCWs neglect self-care and hide emotional distress [ 8 ]. In the current study, LW HCWs reported feeling valued and purposefully engaged with the IPARr as an accessible person with a self-declared interest in colleague wellbeing. Refreshments and a listening ear were easily obtainable. Translating what HCWs considered beneficial into a formal Trust Colleague Support Volunteer (CSV) role offers the potential for embedding a source of physical and emotional nourishment in workplaces. Establishing CSV networks, provided by retired or part-time HCWs with relevant previous work experience, accords with recent calls for Trusts to strategically operationalise volunteers [ 65 ]. Placed within organisations’ Health and Wellbeing Teams, CSVs trained as Wellbeing Champions could additionally signpost HCWs to local and national wellbeing resources. Limitations The WbP was specific to one English NHS LW. The attitudes and responses of the setting’s clinical HCWs and those of local and senior management, the setting’s readiness for the intervention, the culture towards colleague wellbeing, clinical activity levels, existing teamworking, all influenced study processes and outcomes. The IPARr’s personal characteristics and behaviours would also be expected to affect participant engagement and commitment. While these factors challenge generalisation of the resulting impact on HCW wellbeing, the HEARS model distils IPAR processes for potential application in other settings. Unusually, HCWs from many different occupational groups participated in study activities but, as data were often anonymous, related proportions cannot be quantified. Existing time restraints from high clinical activity limited participant engagement, and were exacerbated by the pandemic, yet reflect the realities of undertaking research in current UK healthcare environments. Conclusions The WbP was the first study known to use IPAR to enhance HCW wellbeing. Colleagues from diverse occupational groups participated and reported improved culture, inclusivity, morale, positivity, and atmosphere. Methodological processes prompting increased awareness of the importance of HCW wellbeing strengthened HCW relationships and shifted culture to be more compassionate and inclusive. The authors developed the HEARS wellbeing intervention model to reflect IPAR processes and enable application in other healthcare settings. Subject to implementation research, we propose that in addition to establishing CSV roles, HEARS provides positive, participatory, practical, and economic steps that organisations could take towards improving HCW wellbeing and retention. Abbreviations AG Action group CSV Colleague support volunteer HCA Healthcare assistant HCW Healthcare worker IPARr Insider participatory action research researcher LW Labour ward PPR Peer participant reviewer PMW Preceptorship midwife WbP Wellbeing Project Declarations Acknowledgements We are deeply grateful for the support of participants and colleagues without whose commitment the research would not have been possible. Authors’ contributions CW designed and conducted all study processes as part of a Doctor of Philosophy degree and compiled the first draft of the manuscript. MC and JEM acted as PhD supervisors, agreed final themes, and contributed critical revisions before approving the final manuscript submitted for publication. Funding CW would like to thank the Royal College of Midwives for the Ruth Davies Research Bursary 2017/8 and the Faculty of Health, Social Care and Education, Kingston University, London and St George’s, University of London for a Student PhD Fellowship. Availability of data and materials The datasets used and/or analysed during the current study are available from the authors on reasonable request. Ethics approval and consent to participate The study was conducted according to the Declaration of Helsinki. Health Research Authority and Health and Care Research Wales granted ethical approval 19/HRA/0334. Informed consent to participate was obtained from participants. Consent for publication Written informed consent for publication was obtained from participants whose personal details are included in this publication. Competing interests The authors declare that they have no competing interests. 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Supplementary Files Additionalfile1.Promptguidewellbeinginterview.docx Additional file 1. Prompt guide wellbeing interview Additionalfile2.Actiongroupactivity.docx Additional file 2. Action group activity Cite Share Download PDF Status: Published Journal Publication published 31 Jan, 2025 Read the published version in BMC Health Services Research → Version 1 posted Editorial decision: Revision requested 15 Nov, 2024 Reviews received at journal 13 Nov, 2024 Reviews received at journal 01 Nov, 2024 Reviewers agreed at journal 31 Oct, 2024 Reviewers agreed at journal 17 Oct, 2024 Reviewers agreed at journal 11 Sep, 2024 Reviewers invited by journal 21 May, 2024 Editor assigned by journal 15 May, 2024 Submission checks completed at journal 15 May, 2024 First submitted to journal 12 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4408146","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":305760186,"identity":"b776642a-f52a-4f44-9a65-eb20a0fe6503","order_by":0,"name":"Claire Margaret Wood","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYDACdgaGA1CmwQGJCoYEwlqYEVoMD1icgWo5gEM1TAsMGB+obCNCC38z88PDFRUMif3szRsO3Jx3J0++gffg4w94tEgcZjM4eOYMQ+LMnmMFB2due1ZscIAv2QCfLQbMDAYHG9sYcjfcyDE4LLntcOIGBh4zCfxa2D8cbPwH1fJ3zuHE+Q085j/wa+EB2tIA0XJAsuFwYsMBHjO83pc4zFNwsOGYRD3ILwckjgEddpjHWOIMHi387e2bPzbU2Bjzszdv/iBRA3RYe4/hhwo8WmCWIbGZcaoaBaNgFIyCUUAsAACw3FgJ+V+fuQAAAABJRU5ErkJggg==","orcid":"","institution":"University Hospitals of Derby and Burton NHS Foundation Trust","correspondingAuthor":true,"prefix":"","firstName":"Claire","middleName":"Margaret","lastName":"Wood","suffix":""},{"id":305760187,"identity":"0acea35a-7de5-4d52-8cc5-135d53964ada","order_by":1,"name":"Mary Chambers","email":"","orcid":"","institution":"Kingston University","correspondingAuthor":false,"prefix":"","firstName":"Mary","middleName":"","lastName":"Chambers","suffix":""},{"id":305760188,"identity":"b1c500d4-b95e-48ed-9603-9cee59fabc26","order_by":2,"name":"Jayne E Marshall","email":"","orcid":"","institution":"University of Leicester","correspondingAuthor":false,"prefix":"","firstName":"Jayne","middleName":"E","lastName":"Marshall","suffix":""}],"badges":[],"createdAt":"2024-05-12 10:38:21","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4408146/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4408146/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12913-025-12331-6","type":"published","date":"2025-01-31T15:58:12+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":57435822,"identity":"a8f1ec24-c6dd-4faa-b2aa-a8078af060b1","added_by":"auto","created_at":"2024-05-30 16:03:56","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1064750,"visible":true,"origin":"","legend":"\u003cp\u003eParticipant data display wall\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-4408146/v1/dfb54d0506dae54e1d44f95c.png"},{"id":57435826,"identity":"d269bbb8-0623-4a0b-b650-23ae78d4529f","added_by":"auto","created_at":"2024-05-30 16:03:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":21321,"visible":true,"origin":"","legend":"\u003cp\u003eTiming of action groups within study context\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-4408146/v1/5c241717e246afb8a3774f9f.png"},{"id":57436256,"identity":"53e7440b-ae41-42fe-a06f-555b98d509ae","added_by":"auto","created_at":"2024-05-30 16:11:56","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":43181,"visible":true,"origin":"","legend":"\u003cp\u003eHEARS wellbeing intervention model\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-4408146/v1/5b81317186f1328afb0db1c5.png"},{"id":75351371,"identity":"04e7021e-3d3f-476e-a229-d2f743acd4c1","added_by":"auto","created_at":"2025-02-03 16:10:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2253457,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4408146/v1/ad425110-de48-45eb-995f-7bd1223ac8ef.pdf"},{"id":57436255,"identity":"fdbce79e-e5b4-44e7-b0af-af86b808fa35","added_by":"auto","created_at":"2024-05-30 16:11:56","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":114133,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 1. Prompt guide wellbeing interview\u003c/p\u003e","description":"","filename":"Additionalfile1.Promptguidewellbeinginterview.docx","url":"https://assets-eu.researchsquare.com/files/rs-4408146/v1/409b74ccfece1ae71c38bf6e.docx"},{"id":57435824,"identity":"a213164f-baee-44b6-878a-996424e7b55d","added_by":"auto","created_at":"2024-05-30 16:03:56","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20117,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional file 2. Action group activity\u003c/p\u003e","description":"","filename":"Additionalfile2.Actiongroupactivity.docx","url":"https://assets-eu.researchsquare.com/files/rs-4408146/v1/829637f3821861a3aefde3cc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Enhancing maternity healthcare workers' wellbeing using Insider Participatory Action Research","fulltext":[{"header":"Terminology","content":"\u003cp\u003eThe terms \u003cem\u003ewoman\u003c/em\u003e and \u003cem\u003ewomen\u003c/em\u003e include childbearing people whose gender identity may differ from that at birth, and those who identify as non-binary.\u0026nbsp;\u003c/p\u003e"},{"header":"Background","content":"\u003cp\u003eThe United Kingdom (UK) National Health Service (NHS) urgently needs to act on national guidance equating the importance of healthcare worker (HCW) wellbeing to patient wellbeing [1]. Workplace conditions need to improve in order to sustain those individuals who continue to work despite present pressures, and to encourage their retention to meet service demands. Prior to the Covid-19 pandemic, longstanding knowledge about correlations between HCW welfare and improved patient experience and outcomes [2] had triggered a range of stress-reduction interventions in the UK and overseas [3-5]. Specifically, maternity services in the UK had been affected by persistent poor workplace wellbeing. Workforce shortages had resulted from midwives abandoning their profession [6], citing poor staffing levels and high workloads compromising quality of care [7]. Over two-thirds of almost 2000 midwives reported work-related burnout in a 2017 survey [8]. In parallel, obstetricians had been suffering burnout [9], and retiring early due to heavy workloads [10]. Obstetric and gynaecology trainee numbers had fallen by 6.8% between 2012 and 2018 [11]. In 2020, the pandemic exposed the lived experiences of NHS HCWs with unprecedented intensity. Acute workforce shortages exacerbating chronic shortfalls laid bare the fragility of service provision. Passive acknowledgement of links between HCW and patient welfare was replaced by multiple health promotion initiatives attempting to maintain services by fortifying HCW wellbeing. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePost pandemic, poor HCW wellbeing and retention remain core problems. Maternity practitioners\u0026rsquo; burnout levels are high and rising [12,13]. A fifth of doctors plan to retire early and the same proportion to leave medicine completely [14], and over half of midwives responding to a 2021 survey were considering leaving the role [15]. England carries a minimum deficit of 496 obstetricians and 1932 midwives, with total workforce shortfalls estimated to reach 231,280 of 1,465,716 anticipated NHS posts in 2025 [14]. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis paper presents a HCW wellbeing intervention in one NHS labour ward (LW) in the East Midlands, England, UK, and follows two previous publications of preliminary findings [16, 17]. At the time of the study, I, CW, was a practising clinical midwife in the setting and considered all occupational groups\u0026rsquo; wellbeing to be deteriorating. Colleagues regularly cried at work, left their professions, or sought alternative HCW roles. Few supportive interventions existed [18]. The final catalyst for action was my discussing the personal impact of emotionally demanding work experiences as a recruit in a research study [19]. For the first time in over 30 years\u0026rsquo; service, I perceived an institutionalised expectation that HCWs continue practising unwaveringly after all but the most serious of clinical incidents. With the national and international situation demanding action, the aim of this study was to develop a caring collegial environment within a NHS LW in which maternity HCWs created paths to enhancing their individual and collective wellbeing.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eInterventions for employee wellbeing\u003c/h3\u003e\n\u003cp\u003eAlthough definitions of wellbeing overlap and interrelate, employment is considered to positively contribute to wellbeing [20,21]. If given autonomy and control, people enjoy not only income but the challenge of mastering a role, and the related social interaction [21]. A virtuous cycle perpetuates wherein good working conditions improve individual wellbeing, and individuals\u0026rsquo; wellbeing improvement effects good working conditions [21]. For study purposes, this paper\u0026rsquo;s authors positioned HCW workplace wellbeing as:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFeeling emotionally buoyed in performing roles, and psychologically content with the ability to contribute to and be accepted within a socially supportive work community.\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eWe found in our initial literature search that employee wellbeing interventions do not consistently show positive impact. Most focus on problem-identification and solution development and report small to moderate positive effect on mental health, stress, burnout, social/working conditions, performance, and absenteeism [18,22-27]. Others find no, or mixed, benefit [28\u0026ndash;31]. Rather than generic recommendations, the plethora of different healthcare environments require methodologies which prompt locally impactful strategies. New approaches are indicated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterventions are classified as organisational, individual, or a combination. Organisational, or primary, interventions aim to be preventative, encompassing employees\u0026rsquo; workplace conditions [32]. Work systems and/or job designs are modified, rationalising that in complex systems such as workplaces, the interaction of multiple components influences wellbeing more than change in specific, isolated elements [3,23-25,27,31]. Individual interventions are classified as either secondary or tertiary. Secondary interventions aim to ameliorate adverse workplace impact through self-care training (for example in stress, sleep), or through physical and psychological activity (for example in yoga, mindfulness). Tertiary interventions apply to those taking sickness-absence and were not investigated within this workplace-based enquiry. Combined approaches use secondary interventions within organisational interventions [26].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDefined, small-group, individual intervention programmes are moderately stress-reducing [26] and potentially more economically and operationally feasible than the large-scale engagement required for organisational interventions [27,31]. Individual interventions nevertheless risk employees feeling accountable for their poor wellbeing, rather than a responsibility for organisations to address [18,31]. Unchanged workplace stressors also threaten ongoing maintenance of any related individual improvement [27]. Combining organisational and individual interventions is proposed to enhance outcomes [25-27,31] and prolong effect [26]. Additionally, by incorporating participatory study design within the combination, employee engagement is fostered [3,26,31]. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipatory Action Research (PAR) methodology offers those potentially affected by interventions to co-create changes for local benefit. Shared ownership of the enquiry enables participants to form action groups (AGs) to collectively agree research questions, review data, plan action, generate data, take action, evaluate outcomes, and modify future plans in a continuing dynamic [33]. As few wellbeing interventions adopt participatory methodologies [26], we further scrutinised the literature by critically reviewing specifically the effectiveness of PAR in enhancing HCW psychosocial wellbeing [34]. Firstly, the review analysed the methodological elements related to reported effect and secondly, the review identified processes potentially modifiable to increase effect. Findings indicated significant improvements in psychological status, social support, effort-reward balance, decision-making, burnout, job satisfaction, and absenteeism. We nevertheless anticipated even greater impact by enabling bottom-up, HCW-initiated projects; including all HCW groups; applying positive psychology; increasing frontline HCW decision-making; and generating qualitative participant process/evaluation data. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs I, CW, planned to initiate the study, this constituted Insider PAR (IPAR), wherein an employee undertakes research within their workplace [35]. As an IPAR researcher (IPARr), I intermittently use first person voice to acknowledge the subjectivity of IPAR practice.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003eStudy question and objectives\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe study question indicated that progress towards individual and collective wellbeing depended on, and aimed for, colleagues\u0026rsquo; active contribution, and took an intersubjective approach whereby I positioned myself alongside my colleagues in the collective \u003cem\u003ewe\u003c/em\u003e :\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eHow can we as maternity healthcare workers enhance our individual and collective wellbeing?\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eThe study objectives applied a positive psychology approach as the authors\u0026rsquo; review findings had indicated. Focussing on what made HCWs feel good at work was anticipated to buoy affect and maintain whatever feelings drove HCWs to persevere in demanding roles. This premise was therefore applied to the first two study objectives. The core of the intervention constituted HCWs using current sources of LW wellbeing as foundations for building further avenues going forward:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eObjective 1 - To collate factors identified as encouraging wellbeing\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eObjective 2 - To collectively construct future ways of working.\u003c/em\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn line with PAR, a hypothesis was not proposed, and the direction of research activities was guided by participant data. The authors plan to address the final and third objective of evaluating IPAR\u0026rsquo;s role in outcomes in a forthcoming paper.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003ePatient and public involvement\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eSince this study focused on HCW wellbeing at work, patient and public involvement was not considered to be directly applicable. \u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eResearch design\u003c/h3\u003e\n\u003cp\u003eThe study\u0026rsquo;s philosophical perspective was based on social constructionism, whereby individual minds in specific social and historical contexts constitute reality [36]. The theoretical perspective was pragmatism, putting theory to practical use [36]. Both align with PAR\u0026rsquo;s aim to achieve social impact through community with others [37], and also accords with all LW HCWs being involved in co-creating knowledge to build desired futures [33]. Thematic analysis techniques were used to support participatory principles by inviting members of different occupational groups, anticipated to have varying degrees of research experience, in data review [38]. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eResearch setting \u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eApproximately 5000 births occurred annually in the setting\u0026rsquo;s consultant-led LW which included 13 birthrooms; two theatres; and high dependency, induction, and assessment units. Women\u0026rsquo;s care depended on the dynamic of different teams\u0026rsquo; interaction, and HCW team members constantly changed shift to shift. For each shift, a senior midwife, the coordinator, liaised with medical colleagues to organise the work of approximately 20 HCWs. Activity was typically high and regularly required interdisciplinary teams to rapidly attend the operating theatre for emergency caesarean sections and other obstetric procedures. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eParticipants\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003ePosters were used to invite participation to the Wellbeing Project (WbP), as the study was termed. All HCWs were eligible and, in order of highest numbers, occupational groups included midwives, obstetricians, operating theatre practitioners, anaesthetists, health care assistants (HCA), receptionists, housekeepers, and domestic personnel. Study documents and related online links were emailed to HCWs by groups\u0026rsquo; administration leads, and paper copies were also made available. The IPARr presented information on study processes at shift changeovers; in management, research, and operating theatre meetings; and to new-starter HCWs. \u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData generation methods\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eSix data generation methods were planned. \u0026nbsp;\u003c/p\u003e\n\u003col\u003e\n \u003cli\u003eQuestionnaire - paper, online\u003c/li\u003e\n \u003cli\u003eIndividual/group interviews - qualitative, semi-structured\u003c/li\u003e\n \u003cli\u003eOnline consultation group - closed, asynchronous (not real-time) on social networking site\u003c/li\u003e\n \u003cli\u003eComments added to data displays\u003c/li\u003e\n \u003cli\u003eAction groups\u003c/li\u003e\n \u003cli\u003ePeer participant review (PPR) of data\u0026nbsp;\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe first five methods were employed from the study start date 23\u003csup\u003e\u0026nbsp;\u003c/sup\u003eOctober 2018 to 30 April 2020. Posters were used from early September 2019 to invite all LW HCWs to act as PPRs in reviewing data until 31 July 2020. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQuestionnaires comprised two questions: \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ch4\u003eCan you say something about an experience, working on Labour Ward, which made you feel good within yourself? \u0026nbsp; \u0026nbsp;\u003c/h4\u003e\n\u003ch4\u003eWhat was happening at the time to make it possible? \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/h4\u003e\n\u003cp\u003eInterviews similarly exploring positive experiences were formal and pre-planned, in participants\u0026rsquo; chosen location, or informal, arising spontaneously. See Prompt guide wellbeing interview: Supplementary information Additional file 1. Notes were taken if participants declined consent for audio-recording. Posters were used to invite HCWs to join AGs, act as PPRs, and/or add comments to data displays. In anticipation of discussions developing from data generated from objective 1, no questions were prescribed for AGs. Following verbal information on thematic analysis processes, the PPR role involved reviewing data transcripts for comparison to other PPR/IPARr interpretations. Further detail is given under Data Analysis and Results. Data were transcribed by the IPARr apart from those of longer pre-planned interviews which, to economise on time, were sent in an encrypted file to a transcription service. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEvaluations of the intervention were actively sought in March and April 2020 using the same study questionnaire. A noticeboard posted a request for HCWs to document any learning over the past 18 months related to what made them/the team feel good, and any perceived study-related changes. These evaluations were requested in addition to evaluations already spontaneously given in questionnaires and interviews. To facilitate data generation, I attended the LW up to four times a week from 23 October 2018 to 30 April 2020 (approximately 900 hours total), aiming to be unobtrusively accessible. When LW activity precluded data generation, I regularly took tea-trolleys into the clinical area and delivered drinks and snacks to colleagues unable to leave work tasks. To differentiate my midwifery and IPARr roles, I wore uniform only when working clinically. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eData analysis\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eTranscripts were inductively thematically analysed by repeatedly reading data line by line, collating initial codes, categorising codes into themes, and producing a narrative synthesis. I started these processes when data were first generated. Later, PPRs and I together compared our interpretations and created codes and themes until these were all agreed. Peer review intended to avoid the risk of my personal assumptions, beliefs, and worldviews blinding me to new insights. I also undertook continual reflexive self-evaluation of the impact of my presuppositions on study processes, data collection, and data interpretation [33]. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding my presuppositions, I was white British, around retirement age, had good working relationships with colleagues from all occupational groups, and was unaware of personal characteristics likely to hinder research interactions. I felt I unremarkably \u003cem\u003efitted in\u003c/em\u003e as a well-known middle-grade practitioner usually supporting women on LW. Although comfortable inviting colleagues to participate, unusually combining PhD studentship/IPARr and clinical midwifery roles, I felt pressure to be a positive role model for my profession. Reflexively, I aimed to appear confident and approachable to inspire participation.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eEthical considerations\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eThe concepts of dependability, credibility, and transferability support this study\u0026rsquo;s qualitative \u0026nbsp; trustworthiness. Details of study processes and contexts upheld dependability by illustrating coherence with knowledge claims. Credibility of interpretations met international PAR criteria requiring participants to actively engage in ethical processes towards social change [33]. Transferability was met by illustrating sensitising concepts for other investigators [39]. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo reduce triggering personal issues, participants were advised they could stop/pause participation at any time. Plans were also made for senior midwives to meet any upset participants, and study documents featured Trust wellbeing resources. To avoid participation out of friendship or perceived obligation, HCWs\u0026rsquo; participation was not in the first instance pursued by the IPARr but volunteered by HCWs through contacting the IPARr after reading study documents. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eConsent process\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003eWritten consent was required for interview, AG, and PPR. Consent was considered as given for those completing questionnaires, requesting membership of an online consultation group, and adding comments to displays. As participatory methodologies support public recognition of participant contributions towards publications [33], two different consent forms offered participants to optionally include role descriptor and/or self-identify by name. See below: Declarations, Consent for Publication.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eData were generated from 83 paper questionnaires; 13 online questionnaires; 51 individual interviews; eight group interviews; 16 comments added to displays; three emails; three AGs; and six PPRs\u0026rsquo; responses to the first 40 interview transcripts. Data initially included narratives of positive work experiences related to objective 1, whilst participants later more frequently added comments evaluating WbP changes related to objective 2. Throughout the study period, data quotes were exhibited for all HCWs to view. Colourful excerpts were widely posted on a full display wall as demonstrated in figure 1, and on noticeboards and posters in training, rest, office, changing, and theatre areas, and updated at least monthly.\u003c/p\u003e\n\u003cp\u003eTable 1 demonstrates the range of occupational groups which took part, as exemplified in interview activity. Healthcare workers who only worked on the LW participated in higher numbers than those who rotated around the different maternity wards. Over half of interviewees self-identified by first or full name. Interview data varied from one-hour sessions away from clinical areas to short comments captured from exchanges with the IPARr on LW. Questionnaire data similarly spanned from one sentence to a packed A4 page. It was not possible to gauge self-identification levels in questionnaires as in March 2020 a group of midwives independently duplicated questionnaires to distribute at shift changes, and omitted the optional role/name section, affecting 21 submitted forms.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e Number and occupational group of interviewees\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"570\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.64912280701754%\"\u003e\u003cstrong\u003eOccupational group\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.24561403508772%\"\u003e\u003cstrong\u003eNumber of practitioners in group (estimate)\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"32.10526315789474%\"\u003e\u003cstrong\u003eNumber participating in individual or group interview\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.64912280701754%\"\u003eMidwife\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.24561403508772%\"\u003e150\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"32.10526315789474%\"\u003e32 (21%)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.64912280701754%\"\u003eObstetric doctor\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.24561403508772%\"\u003e60\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"32.10526315789474%\"\u003e5 (8%)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.64912280701754%\"\u003eTheatre practitioner\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.24561403508772%\"\u003e45\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"32.10526315789474%\"\u003e5 (11%)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.64912280701754%\"\u003eAnaesthetic doctor\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.24561403508772%\"\u003e21\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"32.10526315789474%\"\u003e4 (19%)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.64912280701754%\"\u003eHealthcare assistant\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.24561403508772%\"\u003e20\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"32.10526315789474%\"\u003e10 (50%)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.64912280701754%\"\u003eHousekeeping, domestic, receptionist\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.24561403508772%\"\u003e13\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"32.10526315789474%\"\u003e5 (38%)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.64912280701754%\"\u003e\u003cstrong\u003eTotals\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"28.24561403508772%\"\u003e\u003cstrong\u003e319\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"32.10526315789474%\"\u003e\u003cstrong\u003e64 (19%)\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eCoordinator, Theatre, and HCA AGs were respectively established in response to reports of how coordinators\u0026rsquo; behaviours impacted HCW wellbeing; the role of HCAs; and HCW experiences in operating theatres. See Action group activity: Supplementary information Additional file 2\u0026nbsp;for AG activity, and figure 2 for timing of AGs within the study period.\u0026nbsp;One online consultation group began for HCAs but as it was largely used to arrange AG meetings, new data were not generated. From March to July 2020, impact from the pandemic impaired generating, sharing, and participants reviewing data. Planned WbP events, including a large social outing and the first maternity interdisciplinary Schwartz round (40), were cancelled.\u003c/p\u003e\n\u003cp\u003eIn the following findings section, excerpts of participants\u0026rsquo; \u003cem\u003everbatim documentation\u003c/em\u003e and role/name entries are presented. Acronyms are used to identify the data source: AG = Action group: Anon = Anonymous; Int = Interview; Q = Questionnaire; OQ = Online questionnaire.\u003cem\u003e\u0026nbsp;Some participants chose to shorten their names, omit roles, and/or include unconventional role descriptors.\u003c/em\u003e Data related to the study\u0026rsquo;s aim and objectives are initially presented, including the \u003cem\u003ehow,\u0026nbsp;\u003c/em\u003ethe\u003cem\u003e\u0026nbsp;\u003c/em\u003emechanisms, of study outcomes as proposed by participants. The section concludes with a wellbeing intervention model named HEARS which was developed to reflect how IPAR study processes were applied.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFindings related to study aim\u003c/p\u003e\n\u003cp\u003eThe study aimed to develop a caring collegial environment on LW in which HCWs created paths to enhancing individual and collective wellbeing. Box 1 provides evaluation data indicating change in a positive direction. Although difficult to separate into discrete categories, as impacts were often interrelated, 28 individuals provided 38 comments on improved culture, morale, positivity, and atmosphere. No participant recorded a negative study effect.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003eBox 1 Wellbeing Project evaluations\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"100%\" valign=\"top\"\u003e\u0026nbsp;\u0026lsquo;For the first time in many years I am eager...to work on LW...My colleagues are genuinely caring, compassionate and supportive no matter what role. We pull together...especially in the current situation [pandemic]. The project has made a huge difference to the general mood and morale.\u0026rsquo;(Anon, role omitted Q49)\u003cbr\u003e\u0026nbsp;\u0026lsquo;I...had sick leave for workplace stress...I felt broken, and it\u0026rsquo;s taken six months, and your study really helped because I felt somebody was saying we were important, because I didn\u0026rsquo;t feel important, loved, or needed.\u0026rsquo;(Anon, Senior Clinical Midwife Int48)\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eFindings related to study objectives\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective 1\u003c/strong\u003e sought to collate the factors identified as encouraging HCW wellbeing. Three themes were established from the data: \u003cem\u003eEmotional, Professional,\u0026nbsp;\u003c/em\u003eand \u003cem\u003ePhysical nourishment. Emotional nourishment\u003c/em\u003e included 286 comments from 98 individuals and, respectively, \u003cem\u003eProfessional nourishment\u003c/em\u003e 81 from 69, and \u003cem\u003ePhysical nourishment\u003c/em\u003e 47 from 47. Table 2 presents the related themes, sub-themes, and illustrative quotes.\u003c/p\u003e\n\u003cp\u003eTable 2 Themes, sub-themes, and illustrative quotes related to factors encouraging healthcare worker wellbeing\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.21505376344086%\" valign=\"top\"\u003e\u003cstrong\u003eTheme\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.150537634408602%\" valign=\"top\"\u003e\u003cstrong\u003eSub-theme\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"77.63440860215054%\" valign=\"top\"\u003e\u003cstrong\u003eIllustrative quotes\u003c/strong\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.21505376344086%\" valign=\"top\"\u003eEmotional nourishment\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.150537634408602%\" valign=\"top\"\u003eColleagues caring\u003cbr\u003e\u003cem\u003e103 comments\u003c/em\u003e\u003cbr\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"77.63440860215054%\" valign=\"top\"\u003e\u003cem\u003e[Felt unwell, sat, and cried. Colleague stayed and] \u0026lsquo;...brought me toast and a drink, and it made me feel looked after and comforted.\u0026rsquo;(Anon, Midwife Int15)\u003c/em\u003e\u003cbr\u003e\u003cem\u003e[Midwives noticed participant wasn\u0026rsquo;t themself and asked if they were ok] \u0026lsquo;I liked it but didn\u0026rsquo;t want to share it. I liked it.\u0026rsquo;\u003c/em\u003e\u003cem\u003e(Anon, Doctor Int37)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.21505376344086%\" valign=\"top\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.150537634408602%\" valign=\"top\"\u003eAppreciative communication\u003cbr\u003e\u003cem\u003e62 comments\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"77.63440860215054%\" valign=\"top\"\u003e\u003cem\u003e[Felt good] \u0026lsquo;Receiving a thank you card from a midwifery colleague for the support I had given her as the registrar on call.\u0026rsquo;(Mark, SpR [Specialist Registrar] in O\u0026amp;G [Obstetrics and Gynaecology])\u003c/em\u003e\u003cbr\u003e\u003cem\u003e\u0026lsquo;She\u0026apos;ll say [LW manager] \u0026ldquo;you\u0026apos;re really coming into your own\u0026rdquo;...just a passing comment on the corridor, but she puts a little spring in your step\u0026hellip;that\u0026apos;s important\u0026hellip;our...perception of ourself is we\u0026apos;re rubbish.\u0026rsquo;(Sophie Nabbs, Registered Preceptorship Midwife, PMW, [\u003c/em\u003e\u003cem\u003enewly qualified midwife in programme transitioning from student to accountable midwife]\u0026nbsp;Band 5 Int39)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.21505376344086%\" valign=\"top\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.150537634408602%\" valign=\"top\"\u003eWelcoming behaviours\u003cbr\u003e\u003cem\u003e43 comments\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"77.63440860215054%\" valign=\"top\"\u003e\u003cem\u003e\u0026lsquo;I feel welcome [to LW]. All the people, midwives, everybody, welcome to me. I don\u0026rsquo;t feel odd here...if it\u0026rsquo;s a doctor or a midwife, I feel the same...When a room needs doing [cleaning]...I have good feedback...housekeepers, HCAs, midwives, everybody.\u0026rsquo;(Anon, role omitted Int12)\u003c/em\u003e\u003cbr\u003e\u003cem\u003e[Felt good] \u0026lsquo;...being known by my name not just my job title.\u0026rsquo;(Anon, role omitted Q69)\u0026nbsp;\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.21505376344086%\" valign=\"top\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.150537634408602%\" valign=\"top\"\u003ePositive environment\u003cbr\u003e\u003cem\u003e32 comments\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"77.63440860215054%\" valign=\"top\"\u003e\u003cem\u003e\u0026lsquo;Bit of fun goes a long way. I like it when the music\u0026rsquo;s on...everyone\u0026rsquo;s humming...there\u0026rsquo;s a good vibe and a different energy. It changes the whole atmosphere.\u0026rsquo;(Anon, role omitted Int40)\u003c/em\u003e\u003cbr\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.21505376344086%\" valign=\"top\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.150537634408602%\" valign=\"top\"\u003eBelonging\u003cbr\u003e\u003cem\u003e24 comments\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"77.63440860215054%\" valign=\"top\"\u003e\u003cem\u003e[After a colleague helpfully intervened in a challenging situation] \u0026lsquo;...made me feel part of something...now I never feel on my own...I can feel the supportive team around me all the time.\u0026rsquo;(Anon, Preceptorship Midwife Q47)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.21505376344086%\" valign=\"top\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.150537634408602%\" valign=\"top\"\u003eJoy in work\u003cbr\u003e\u003cem\u003e22 comments\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"77.63440860215054%\" valign=\"top\"\u003e\u003cem\u003e\u0026lsquo;I love my job. I love coming to work...we\u0026apos;re very privileged to have such a wonderful job.\u0026rsquo;(Anon, Senior Clinical Midwife Int27)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.21505376344086%\" valign=\"top\"\u003eProfessional nourishment\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.150537634408602%\" valign=\"top\"\u003eTeamworking for good outcome\u003cbr\u003e\u003cem\u003e52 comments\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"77.63440860215054%\" valign=\"top\"\u003e\u003cem\u003e\u0026lsquo;\u003c/em\u003e\u003cem\u003eThe case...this morning ...in theatre...was a very difficult, complicated case and you wouldn\u0026apos;t have known that there was any difference between theatre staff and midwifery staff...The whole team was amazing...We kept in tune with each other the whole time. Communication was brilliant. We had a good hug at the end and said, \u0026ldquo;Well done\u0026rdquo; to each other. It couldn\u0026apos;t have gone better.\u0026rsquo;(Lucille Griffiths, Senior Operating Department Practitioner Int42)\u003c/em\u003e\u003cbr\u003e\u003cem\u003e[Teamworking] \u0026lsquo;...makes it a failsafe mechanism\u0026hellip;a critical situation when has a good outcome, it makes you feel good to think that you have made a difference as a team.\u0026rsquo;(Anon, role omitted OQ13)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.21505376344086%\" valign=\"top\"\u003e\u0026nbsp;\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.150537634408602%\" valign=\"top\"\u003eSatisfaction of individual motivators\u003cbr\u003e\u003cem\u003e29 comments\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"77.63440860215054%\" valign=\"top\"\u003e\u003cem\u003e[Bereavement care episode] \u0026lsquo;\u003c/em\u003e...\u003cem\u003eto me represented true midwifery care - being wholeheartedly with woman, treating her at all times with kindness, dignity and compassion...I hope that I will always remember feeling proud of the care that I have provided.\u0026rsquo;\u003c/em\u003e\u003cem\u003e(Anon, Preceptorship Midwife Q12)\u003c/em\u003e\u003cbr\u003e\u003cem\u003e\u0026lsquo;I take pride in cleaning a room. I find it a privilege that a baby is going to be born there\u0026hellip;it\u0026rsquo;s the first place the baby will be.\u0026rsquo;(Jodie Allsop, HCA Int59)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"10.21505376344086%\" valign=\"top\"\u003ePhysical nourishment\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"12.150537634408602%\" valign=\"top\"\u003eRest and refreshment\u003cbr\u003e\u003cem\u003e47 comments\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd width=\"77.63440860215054%\" valign=\"top\"\u003e\u003cem\u003e\u0026lsquo;We don\u0026rsquo;t have structured breaks. [Tea-trolley] Is a good recognition of this.\u0026rsquo;(Anon, Doctor in training Int5)\u003c/em\u003e\u003cbr\u003e\u003cem\u003e[Feels good] \u0026lsquo;...When toast is made on nights.\u0026rsquo; (Anon, Registrar in Obstetrics and Gynaecology Int1)\u003c/em\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eEmotional nourishment\u003c/p\u003e\n\u003cp\u003eData related to emotional nourishment were connected to colleagues showing caring gestures; to appreciative communication; welcoming behaviours; a positive environment; a sense of belonging; and to feeling joy in work. Participants referred to feeling good by both experiencing and witnessing caring actions within and between occupational groups, and in seniors\u0026rsquo; role-modelling of such behaviours. Appreciative communication related to enjoying both giving and receiving positive feedback and gratitude. These were conveyed in verbal exchanges, emails, texts, cards, and social media, and reportedly provided HCWs with reassurance. Being welcomed to LW by greetings, smiles, being shown respect, and being addressed by one\u0026rsquo;s name similarly appeared in data as encouraging wellbeing, as did camaraderie, banter, humour, and an upbeat atmosphere. A number of participants connected their good feelings with being part of LW family/team. Related data were initially categorised as \u003cem\u003eTeamworking\u003c/em\u003e but during PPR Rosie (Core Midwife, Birth Centre) stated: \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Shared experience is more than just teamwork. It\u0026rsquo;s bonding. The tea-trolley bonds. We are held together. Teamwork is just working together for an effective outcome.\u0026rsquo; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThese comments showed the importance of personal relatedness beyond purely professional connections, and how tea-trolleys provided more than simply physical sustenance. Being gathered at the tea-trolley was frequently cited as the environment where HCWs could break from tasks to talk, learn, and relate. \u003cem\u003eTeamworking\u0026nbsp;\u003c/em\u003econtinued as a sub-theme, but earlier data interpretations were reviewed for potential recategorisation to a\u003cem\u003e\u0026nbsp;Belonging\u003c/em\u003e sub-theme. Slightly different to this deeper interpersonal connection, other participants expressed how everyday interactions with colleagues and practising their role made them joyful.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBarriers to emotional nourishment nevertheless existed. New-starters\u0026rsquo; befriending attempts were reportedly challenged by working with numerous different colleagues and by perceived unyielding established friendship groups. Being physically isolated in specific work areas away from most colleagues (for instance, in the reception area) was reportedly similarly disconnecting:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Everyone goes, \u0026ldquo;we\u0026apos;re all in it together\u0026rdquo;, but we\u0026apos;re also not, we\u0026apos;re just there on our own.\u0026rsquo;(Tim Gray, Clerical Legend Int34)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eProfessional nourishment\u003c/p\u003e\n\u003cp\u003eTeamworking for good outcomes, and satisfaction of individual motivators, comprised the sub-themes of professional nourishment. The former related to collective wellbeing, and the latter to individual wellbeing. Participants reported that teamworking raised wellbeing through communication and learning, and through \u0026lsquo;\u003cem\u003eprofessional bonding\u003c/em\u003e \u0026lsquo;\u003cem\u003e(Anon, Midwife Int55).\u003c/em\u003e Many expressed how colleagues, regardless of role and hierarchy, willingly offered practical support in a collective effort to provide optimum care to women and babies. Data, however, also indicated participants perceived self-worth in striving to perform as individuals. Reported achievements towards these individual motivators included practising high quality care, contributing to potentially saving a life, learning, teaching, and acting autonomously.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePhysical nourishment\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe sub-theme \u003cem\u003eRest and refreshment\u003c/em\u003e reflected the many HCW references to how opportunities for food and drink improved their wellbeing. Tea-trolleys with snacks were regularly cited as a means of refuelling to \u0026lsquo;\u003cem\u003ekeep going\u0026rsquo;\u003c/em\u003e \u003cem\u003e(Senior Clinical Midwife, Int27)\u003c/em\u003e. Although drinking and eating were reportedly physically sustaining, many related references also included emotional overtones as offering refreshments was linked to HCWs caring for each other. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective 2\u003c/strong\u003e focussed on collectively constructing future ways of working. This section confirms the occurrence of changes in ways of working by providing related HCW data reports. These reports are followed by factors participants suggested as instrumental to these changes. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNew ways of working\u003c/p\u003e\n\u003cp\u003eNew and improved ways of working were described around four main topics: the care colleagues offered each other (25 comments); teamworking (12 comments); expressions of gratitude and feedback (10 comments); and HCW initiation of interventions for women\u0026rsquo;s and colleagues\u0026rsquo; benefit (eight comments). \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding colleagues offering each other care, participants noted an increase in compassionate gestures, including proactive offers of clinical support and provision of refreshments, and deeper enquiries into others\u0026rsquo; welfare.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;It [WbP] \u003cstrong\u003ehas\u003c/strong\u003e made a difference. [HCAs] wanting to help. There\u0026rsquo;s less, \u0026ldquo;That\u0026rsquo;s not my job...\u0026rdquo; The tea trolleys more frequently. More confident to go and make trolleys. Before it was more strict.\u0026rsquo;(Charlotte, Midwife Int45) \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData related to improved teamworking were both described specifically in relation to the multidisciplinary team and to general teamworking.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Big change in the atmosphere...very much more positive - with the multi-disciplinary team working much more effectively together and having a positive appreciation of each other.\u0026rsquo;(Anon, senior clinical midwife Q37)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eColleagues also commented on more frequently giving and receiving thanks and positive feedback.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Coordinators [say at end of shift]... \u0026ldquo;Thank you for your hard work\u0026rdquo;. It has made a big difference that way...before...you\u0026apos;d just go home.\u0026rsquo;(Anon, HCA Int36)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;I have been noticing and receiving more feedback from the midwifery team when we do a procedure.\u0026rsquo;(Anon, role omitted Q72)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe last principal change in ways of working referred to HCWs autonomously initiating several interventions for women\u0026rsquo;s and colleagues\u0026rsquo; benefit. These included housekeeping and HCA colleagues independently fundraising for refurbishment of HCW and women\u0026rsquo;s sitting rooms/bathroom, and reorganising dining areas to offer women more social interaction.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Haven\u0026rsquo;t known the enthusiasm. We\u0026rsquo;re just as tired now, just as busy, but we\u0026rsquo;re putting in the extra mile now for the patients.\u0026rsquo;(Karen Battelle, Housekeeper Int44)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFactors instrumental to changes in ways of working\u003c/p\u003e\n\u003cp\u003eParticipants spontaneously suggested several factors which contributed to changes in ways of working. These included: exposure to IPAR/r activity; raised awareness of the importance of enhancing HCW wellbeing; and strengthened HCW relationships. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe first factor, exposure to IPAR/r activity, was reported to originate from both the IPARr\u0026rsquo;s individual action and from action associated with IPAR practice. \u003cstrong\u003eIn relation to the former, one participant suggested:\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026lsquo;[The IPARr] has rubbed off on people.\u0026rsquo;\u003c/strong\u003e(Anon, role omitted Q61)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSimply seeing the IPARr in the setting was reported to remind participants to be alert to others\u0026rsquo; wellbeing and, similarly, the IPARr providing drinks for others was described as \u0026lsquo;\u003cem\u003erole-modelling\u003c/em\u003e\u0026rsquo; and having a \u0026lsquo;\u003cem\u003ecascading effect\u003c/em\u003e\u0026rsquo; \u003cem\u003e(Anon, role omitted Q22)\u003c/em\u003e.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Like drip-feeding, nurturing...like an aura...in the background.\u0026rsquo;(Anon, Midwife Int54)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParticipants also expressed how IPARr actions held personal significance for how they felt at work.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Made a difference...made us...feel valued that you - somebody\u0026apos;s interested in how we feel.\u0026rsquo;(Anon, Midwife Int33)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA further unanticipated phenomenon also developed from the start of the WbP. C\u003c/strong\u003eolleagues from all occupational groups and seniority levels confided personal homelife and workplace concerns with the IPARr, often in lengthy exchanges. These included families\u0026rsquo; relationships and health, adolescent behaviours, personal anxiety, and many more, with several such exchanges occurring daily. Few had knowledge of, or had accessed, formal Trust wellbeing resources and several referred to these conversations as offloading feelings rather than seeking advice. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Changes I\u0026rsquo;ve seen...improvement in staff mental wellbeing by having [IPARr] available for chat and debrief...having someone in a permanent role...would be a massive asset as [IPARr] has demonstrated what a difference it can make.\u0026rsquo;(Anon, role omitted Q43)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe potential for this IPARr activity to have influenced ways of working is suggested in one evaluation:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;The [WbP] has certainly helped me to...engage in more conversations about how you\u0026rsquo;re actually feeling, instead of the generic answer \u0026ldquo;yeah, are you?\u0026rdquo; when asked if you\u0026rsquo;re ok\u0026rdquo;.\u0026rsquo;(Jodie Allsop, HCA Int34)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRegarding IPAR practice of sharing data, participants stated that data displays had prompted them to consider others\u0026rsquo; wellbeing and had encouraged individual change in ways of working:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;[WbP] made me think about doing things differently. You are more aware of the impact you have on someone else. You do reflect on things you read on the [display] wall.\u0026rsquo;(Carol Greasley, Housekeeper Int29)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe second factor frequently suggested to prompt new individual and collective behaviours was raised awareness of the importance of enhancing HCW wellbeing, both to benefit HCWs\u0026rsquo; and women\u0026rsquo;s experiences.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;I\u0026apos;m...more aware of what I say or the way...I say it...a little more measured...I\u0026rsquo;ve had greater awareness that the medical staff also feel vulnerable.\u0026rsquo;\u003cstrong\u003e(Kate, Senior Midwife Int62)\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Recognition that it\u0026rsquo;s important - this stuff saves lives.\u0026rsquo;(Anon, role omitted Q35)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePotentially related to raised awareness, the involvement of all HCWs in the intervention was considered impactful.\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;[Including all HCWs]...is paramount if we are all working together. From receptionists and HCA\u0026rsquo;s to co-ordinating band 7\u0026rsquo;s. We are all just a little bit kinder.\u0026rsquo;(Anon, role omitted Q30)\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe third factor proposed as influential to improved ways of working was the strengthening of relationships between HCWs:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;The atmosphere...has...improved and friendships have blossomed.\u0026rsquo;(Anon, role omitted Q51)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants described more open communication between different occupational groups and offering more compassionate gestures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Communication of feelings, needs \u0026amp; appreciation between the MDTs [Multidisciplinary Teams] is improved. Instead of...moaning...concerns are being shared.\u0026rsquo;(Anon, role omitted Q68)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAction groups apparently similarly fostered these HCW relationships. One Theatre AG participant described:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;Trying to become one team, not them and us.\u0026rsquo;(Louise Humphries, Senior Operating Department Practitioner, AG meeting)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAnother suggested that new understanding of each other\u0026rsquo;s positions was instrumental to change.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026lsquo;I have witnessed big changes as a result of [Theatre AG]...the reasons for this are that we were able to discuss our roles with each other, and gain an understanding and appreciation of each other\u0026apos;s roles.\u0026rsquo;(Anon, Senior Clinical Midwife Q83)\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFollowing findings related to the first two objectives, the HEARS wellbeing intervention model is presented. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe HEARS wellbeing intervention model\u003c/p\u003e\n\u003cp\u003eWe developed the HEARS model in figure 3 to demonstrate how IPAR processes were practically applied during the study. The model implies active listening and mirrors LW HCWs\u0026rsquo; ready participation and agency within the WbP. Its development was intended to facilitate similar wellbeing initiatives in other settings.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis first IPAR intervention for HCW wellbeing grew from a bottom-up approach rooted in NHS clinical workplace experiences. An overarching organisational approach encompassed all HCWs\u0026rsquo; workplace conditions while enabling individual interventions to develop according to local need. Despite conditions and workforce numbers remaining unchanged, participants reported improved culture, morale, positivity, and atmosphere.\u003c/p\u003e \u003cp\u003eEvidence continues to support the effectiveness of participatory approaches in fitting individual workplace needs [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e], yet leaders struggle to formulate creative strategies [\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Unlike conventional top-down approaches, the WbP met the current preferred strategy of influencing wellbeing through cultural change [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Individual, prescriptive, generic interventions may be insufficiently tailored for the complex needs of diverse healthcare environments [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Examples of such top-down interventions include programmes\u0026rsquo; contents mismatching employee needs [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], lunchtime walking initiatives in the absence of lunchtimes [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e], and wellbeing resources inaccessibly situated [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe study processes, implemented from the findings of our critical review of PAR\u0026rsquo;s effectiveness in enhancing HCW wellbeing (see Background) [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e], are considered to have been effective towards progressing the study aim. The bottom-up approach included all HCW groups and, despite medical colleagues\u0026rsquo; engagement being particularly rare in wellbeing interventions [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e], members of all occupational groups participated. Sharing the qualitative data, generated by several methods, illuminated good workplace experiences and increased HCWs\u0026rsquo; decision-making towards change in ways of working. Positive psychology, applied to amplify conditions making life worth living [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e] and encourage individual thriving [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e], avoided the employee disillusionment which interventions focussing on workplace deficit and challenges may risk provoking [\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStudy objectives sought to identify factors encouraging wellbeing and to construct future ways of working. In objective 1, the \u003cem\u003eEmotional, Professional\u003c/em\u003e, and \u003cem\u003ePhysical nourishment\u003c/em\u003e themes represented sources of LW HCW wellbeing. The themes\u0026rsquo; data fit the three core needs considered fundamental to securing wellbeing and flourishing in healthcare work [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. These comprise autonomy, belonging, and contribution. Autonomy reflects the need for control of one\u0026rsquo;s working life, and contribution refers to working effectively for desired outcomes. Within the \u003cem\u003eProfessional nourishment\u003c/em\u003e theme, both elements were illustrated by LW HCW narratives of competently fulfilling personal work ambitions and offering valuable interventions in teamworking scenarios. To belong in a workplace, a person needs to be allied with colleagues, feel cared for and valued, and be able to care for others [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e]. \u003cem\u003eEmotional nourishment\u003c/em\u003e data suggested this element was fuelled for LW HCWs by welcoming gestures, and reciprocal caring and appreciation. Parallel findings for all three themes were found in the literature. Examples include: for \u003cem\u003eEmotional nourishment\u003c/em\u003e, UK and New Zealand midwives describing mutual acts of compassion sustaining them at work [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]; for \u003cem\u003eProfessional nourishment\u003c/em\u003e, early career UK midwives\u0026rsquo; individual motivators being satisfied by facilitating natural births and taking leadership roles [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]; and for \u003cem\u003ePhysical nourishment\u003c/em\u003e, confirmation of the importance of refreshment breaks, yet the normalisation of their scarcity [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn objective 2, data demonstrated how IPAR activities catalysed a shift towards a more compassionate, inclusive, and positive LW culture. Healthcare workers\u0026rsquo; ways of working reportedly changed. Colleagues cared for each other more proactively, expressed thanks and positive feedback more frequently, worked better together in teams, and autonomously initiated beneficial interventions for colleagues and women. Participants proposed mechanisms for these changes as exposure to IPAR activity; raised awareness of the importance of enhancing HCW wellbeing; and strengthening of relationships between colleagues. Theory supports these three mechanisms concurrently interacting towards the cultural shift, as detailed below.\u003c/p\u003e \u003cp\u003e Participants stated that feeling valued by IPAR/r activities, and reading colleagues\u0026rsquo; data describing how their wellbeing was enhanced, raised mindfulness around workplace wellbeing and stimulated caring actions towards others. Caring, compassionate behaviours elevate mood, positive emotion [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], and a sense of wellbeing [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e], and also consolidate social connections [\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e] and feelings of belonging [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e]. Feelings of belonging in workplaces further nourish compassionate behaviours, prompting a self-perpetuating cycle [\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e].This is important in terms of retention as experiencing and witnessing workplace compassion encourages employees\u0026rsquo; commitment to organisations [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e]. Additionally, although compassionate behaviours are most commonly directed to those who are known or liked [\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e], in our study LW HCWs\u0026rsquo; raised awareness of the importance of enhancing HCW wellbeing may potentially have extended attention to less familiar colleagues, accounting for data related to both caring behaviours and to strengthening colleague relationships and team working. Broaden and build theory suggests that experiencing positive emotions primes the non-conscious mind for similarly uplifting experiences and encourages continuation of these ways of working in an upward spiral known as positive potentiation [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Emotional contagion, the transfer of moods between people [\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e], may have intensified this effect such that the LW HCW body sought to reproduce positive emotions by more proactively caring for colleagues, thereby shifting group norms to a more compassionate and inclusive LW culture. In sum, a theoretical basis supports HCW rationales for reported changes in ways of working. Considering objective 1 findings, HCWs\u0026rsquo; changed ways of working may be viewed as an extension of the need to belong, and while no data were generated rationalising HCWs\u0026rsquo; increased initiatives for women\u0026rsquo;s and colleagues\u0026rsquo; welfare, it is conceivable that these behaviours reflected HCW needs for further autonomy and contribution.\u003c/p\u003e \u003cp\u003eAlthough enhancing LW HCW wellbeing and strengthening colleague relationships is important for HCWs, it is crucial for patient safety. The latest of numerous maternity reports illustrate how poor HCW relationships lead to women\u0026rsquo;s and babies\u0026rsquo; mortality and morbidity [\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e]. Poor HCW wellbeing diminishes compassion and makes patients vulnerable to psychological trauma [\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e]. By contrast, collective wellbeing correlates with improved role performance [60 ] by encouraging psychological safety, the group relationship in which members respect, review, and act on others\u0026rsquo; workplace safety concerns [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. The improved HCW relationships reported in our study therefore promise to support ongoing patient safety.\u003c/p\u003e \u003cdiv id=\"Sec26\" class=\"Section2\"\u003e \u003ch2\u003eExtending the value of the Wellbeing Project\u003c/h2\u003e \u003cp\u003eTo extend the value of study findings, we propose testing a combination of two routes in a range of settings: applying the HEARS wellbeing intervention model (HEARS) and establishing Colleague Support Volunteer roles.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec27\" class=\"Section2\"\u003e \u003ch2\u003eHEARS\u003c/h2\u003e \u003cp\u003eThe HEARS model provides a new, simple, low-cost, and readily implementable strategy for workplace wellbeing. Advisory documents direct managers towards positive culture change but fail to position power and control within the larger body of frontline workers [\u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e]. Cultures continually transform and caring cultures cannot be implemented on demand [\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e] but instead depend on ongoing supportive group behaviours [\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e]. Applying HEARS could meet these cultural challenges, as in the WbP, by enabling colleagues to generate positive preferred behaviours and cultural norms as demonstrated in the WbP and supported in theory [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eColleague Support Volunteer roles\u003c/h2\u003e \u003cp\u003eStruggling HCWs need effortless access to wellbeing support. Organisations need HCWs to feel sufficiently valued to stay. Even after traumatic events [\u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e], many HCWs neglect self-care and hide emotional distress [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In the current study, LW HCWs reported feeling valued and purposefully engaged with the IPARr as an accessible person with a self-declared interest in colleague wellbeing. Refreshments and a listening ear were easily obtainable. Translating what HCWs considered beneficial into a formal Trust Colleague Support Volunteer (CSV) role offers the potential for embedding a source of physical and emotional nourishment in workplaces. Establishing CSV networks, provided by retired or part-time HCWs with relevant previous work experience, accords with recent calls for Trusts to strategically operationalise volunteers [\u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e65\u003c/span\u003e]. Placed within organisations\u0026rsquo; Health and Wellbeing Teams, CSVs trained as Wellbeing Champions could additionally signpost HCWs to local and national wellbeing resources.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe WbP was specific to one English NHS LW. The attitudes and responses of the setting\u0026rsquo;s clinical HCWs and those of local and senior management, the setting\u0026rsquo;s readiness for the intervention, the culture towards colleague wellbeing, clinical activity levels, existing teamworking, all influenced study processes and outcomes. The IPARr\u0026rsquo;s personal characteristics and behaviours would also be expected to affect participant engagement and commitment. While these factors challenge generalisation of the resulting impact on HCW wellbeing, the HEARS model distils IPAR processes for potential application in other settings. Unusually, HCWs from many different occupational groups participated in study activities but, as data were often anonymous, related proportions cannot be quantified. Existing time restraints from high clinical activity limited participant engagement, and were exacerbated by the pandemic, yet reflect the realities of undertaking research in current UK healthcare environments.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe WbP was the first study known to use IPAR to enhance HCW wellbeing. Colleagues from diverse occupational groups participated and reported improved culture, inclusivity, morale, positivity, and atmosphere. Methodological processes prompting increased awareness of the importance of HCW wellbeing strengthened HCW relationships and shifted culture to be more compassionate and inclusive. The authors developed the HEARS wellbeing intervention model to reflect IPAR processes and enable application in other healthcare settings. Subject to implementation research, we propose that in addition to establishing CSV roles, HEARS provides positive, participatory, practical, and economic steps that organisations could take towards improving HCW wellbeing and retention.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAG Action group\u003c/p\u003e\n\u003cp\u003eCSV Colleague support volunteer\u003c/p\u003e\n\u003cp\u003eHCA Healthcare assistant\u003c/p\u003e\n\u003cp\u003eHCW Healthcare worker\u003c/p\u003e\n\u003cp\u003eIPARr Insider participatory action research researcher\u003c/p\u003e\n\u003cp\u003eLW Labour ward\u003c/p\u003e\n\u003cp\u003ePPR Peer participant reviewer\u003c/p\u003e\n\u003cp\u003ePMW Preceptorship midwife \u003c/p\u003e\n\u003cp\u003eWbP Wellbeing Project\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are deeply grateful for the support of participants and colleagues without whose commitment the research would not have been possible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCW designed and conducted all study processes as part of a Doctor of Philosophy degree and compiled the first draft of the manuscript. MC and JEM acted as PhD supervisors, agreed final themes, and contributed critical revisions before approving the final manuscript submitted for publication. \u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCW would like to thank the Royal College of Midwives for the Ruth Davies Research Bursary 2017/8 and the Faculty of Health, Social Care and Education, Kingston University, London and St George\u0026rsquo;s, University of London for a Student PhD Fellowship. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the authors on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted according to the Declaration of Helsinki. Health Research Authority and Health and Care Research Wales granted ethical approval 19/HRA/0334. Informed consent to participate was obtained from participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent for publication was obtained from participants whose personal details are included in this publication. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor details\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003csup\u003e1\u003c/sup\u003e\u0026nbsp; University Hospitals of Derby and Burton NHS Foundation Trust, Labour Ward, Royal Derby Hospital, Derby, DE22 3NE, England, UK. \u003csup\u003e2\u003c/sup\u003e Faculty of Health, Science, Social Care and Education, Kingston University, Kingston upon Thames, London, KT1 2EE, England, UK. \u003csup\u003e3\u003c/sup\u003e School of Healthcare, University of Leicester, Leicester, LE1 7RH, England, UK.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNHS England. 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Midwifery. 2019;76:21\u0026ndash;35.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGarc\u0026iacute;a-Buades ME, Peir\u0026oacute; JM, Monta\u0026ntilde;ez-Juan MI et al. Happy-productive teams and work units: A systematic review of the \u0026lsquo;Happy-productive worker thesis\u0026rsquo;. Int J Environ Res Public Health. 2019;17(1):69.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEdmondson AC. The fearless organization: creating psychological safety in the workplace for learning, innovation, and growth. Hoboken, New Jersey: Wiley; 2019.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNHS Employers. Improving staff retention. A guide for line managers and employers. 2022. 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London, Department of Health. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.gov.uk/government/publications/berwick-review-into-patient-safety\u003c/span\u003e\u003cspan address=\"https://www.gov.uk/government/publications/berwick-review-into-patient-safety\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed 15th April 2024].\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSlade P, Balling K, Sheen K, et al. Work-related post‐traumatic stress symptoms in obstetricians and gynaecologists: findings from INDIGO, a mixed‐methods study with a cross‐sectional survey and in‐depth interviews. BJOG Int J Obstet Gynaecol. 2020;127(5):600\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGilburt H, Beech J. How can a strategic approach to volunteering in NHS Trusts add value? The King\u0026rsquo;s Fund, 2022. Available: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://pearsfoundation.org.uk/wp-content/uploads/How-can-a-strategic-approach-online-version.pdf\u003c/span\u003e\u003cspan address=\"https://pearsfoundation.org.uk/wp-content/uploads/How-can-a-strategic-approach-online-version.pdf\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e [Accessed 15th April 2024].\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Health personnel, Wellbeing, Intervention, Action Research, Maternity","lastPublishedDoi":"10.21203/rs.3.rs-4408146/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4408146/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cb\u003eBackground\u003c/b\u003e\u003c/p\u003e \u003cp\u003eGood healthcare worker (HCW) wellbeing positively impacts service user outcomes, yet the United Kingdom (UK) National Health Service (NHS) is suffering workforce burnout and retention issues. While urgently needing evidence-based wellbeing strategies, participatory interventions using positive psychology have been under-investigated. We aimed to develop a caring, collegial NHS labour ward environment wherein maternity HCWs created paths to enhancing individual and collective workplace wellbeing.\u003c/p\u003e\u003cp\u003e\u003cb\u003eMethods\u003c/b\u003e\u003c/p\u003e \u003cp\u003e A social constructionist, pragmatic approach was adopted, applying positive psychology within Insider Participatory Action Research (IPAR). All clinical and non-clinical HCWs on a consultant-led labour ward in the East Midlands, England, UK were invited to identify current sources of workplace wellbeing on which to collectively construct future ways of working. Qualitative data from several methods (below) were inductively thematically analysed.\u003c/p\u003e\u003cp\u003e\u003cb\u003eResults\u003c/b\u003e\u003c/p\u003e \u003cp\u003eBetween October 2018 and July 2020, data derived from 83 paper and 13 online questionnaires; 59 interviews; 16 comments on data displays; three emails; three action groups; and six peer participant reviewers. Three themes represented sources of workplace wellbeing: emotional, professional, and physical nourishment. Culture shifted to be more compassionate and inclusive, and morale, positivity, and atmosphere improved. Ways of working changed: colleagues more proactively cared for each other; worked well together in teams; expressed thanks and feedback; and instigated interventions for colleagues\u0026rsquo; and women\u0026rsquo;s welfare. Participants proposed that IPAR activities prompted change including: the researcher being considered an accessible colleague wellbeing resource; raised awareness of the importance of HCW wellbeing; and strengthened HCW relationships. The HEARS wellbeing intervention model (\u003cb\u003eH\u003c/b\u003eCW driven; \u003cb\u003eE\u003c/b\u003everyone involved; \u003cb\u003eA\u003c/b\u003esk what makes a person feel good at work; \u003cb\u003eR\u003c/b\u003eesponses displayed; \u003cb\u003eS\u003c/b\u003eteps taken) was developed to frame processes by which HCW participation catalysed impact towards workplace wellbeing.\u003c/p\u003e\u003cp\u003e\u003cb\u003eConclusions\u003c/b\u003e\u003c/p\u003e \u003cp\u003eThis is the first study to use IPAR towards enhancing HCW wellbeing. Colleagues from diverse occupational groups improved individual and collective wellbeing through self-determined action. The use of participatory methodology and positive psychology encouraged a more compassionate and inclusive culture. Subject to implementation research evaluating these strategies\u0026rsquo; impact in different settings, we propose the HEARS wellbeing intervention model and workplace-based Colleague Support Volunteers as actions towards wellbeing and retention in healthcare organisations.\u003c/p\u003e","manuscriptTitle":"Enhancing maternity healthcare workers' wellbeing using Insider Participatory Action Research","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-05-30 16:03:51","doi":"10.21203/rs.3.rs-4408146/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-15T05:05:09+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-14T04:16:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-01T12:20:09+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"87258223086299856383399092839722689472","date":"2024-10-31T23:21:35+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"196739560667752373475486871929869399362","date":"2024-10-17T16:56:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233294163176657578850612451225324519789","date":"2024-09-11T09:16:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-05-21T05:31:13+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-05-15T08:46:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-05-15T08:36:47+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2024-05-12T10:34:00+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"398bedb6-35a1-41b1-b1b3-acb29c067420","owner":[],"postedDate":"May 30th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-02-03T16:04:44+00:00","versionOfRecord":{"articleIdentity":"rs-4408146","link":"https://doi.org/10.1186/s12913-025-12331-6","journal":{"identity":"bmc-health-services-research","isVorOnly":false,"title":"BMC Health Services Research"},"publishedOn":"2025-01-31 15:58:12","publishedOnDateReadable":"January 31st, 2025"},"versionCreatedAt":"2024-05-30 16:03:51","video":"","vorDoi":"10.1186/s12913-025-12331-6","vorDoiUrl":"https://doi.org/10.1186/s12913-025-12331-6","workflowStages":[]},"version":"v1","identity":"rs-4408146","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4408146","identity":"rs-4408146","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}