86 | Chapter 4 midwives, however, because of the small number of hospital-based working midwives who responded. This study also has some limitations. We do not know how the non-response influenced the levels of exhaustion and burnout symptoms. Employees with high scores on burnout symptoms seem less likely to fill in the questionnaire.45 We may therefore have underestimated the prevalence of burnout symptoms. Another limitation is that we were unable to conduct a multiple regression analysis of work engagement and burnout symptoms with predicting variables for both NQMs and EMs. For a prediction model, 1015 cases per variable are needed for midwives with high levels of the dependent variable.46 We cannot therefore arrive at any conclusions concerning predictors of burnout and work engagement. Another limitation of this study is its cross-sectional design, which does not allow us to report causal relationships between different variables and midwives’ wellbeing. In addition, this study was performed in 2019, which is also a limitation. Recommendations for research and practice International research is recommended on work engagement among midwives to enable comparisons with midwives in other countries. However, the levels of work engagement among Dutch midwives cannot be extrapolated to midwives in other countries, although we did identify experience level as a determinant of work engagement. Further research is recommended to explore explanations for these differences in levels of work engagement between NQMs and EMs. In this study, we applied a heuristic model for occupational wellbeing (the JD-R model) in the midwifery profession. Further quantitative research with a higher number of respondents is necessary to identify determinants of work engagement and burnout symptoms for both NQMs and EMs. With a multivariable model, it is possible to identify independent determinants of occupational wellbeing, which could support the wellbeing of different groups of midwives. Furthermore, prospective longitudinal research involving multiple assessments is needed in order to gain an understanding of patterns of work engagement and burnout symptoms over the course of many years. Using the JD-R model,13 we were able to present a comprehensive view of midwives’ occupational wellbeing. By using this model, we added figures on work engagement among midwives, and we provided midwives with determinants which contribute to wellbeing. Therefore we propose that, in addition to a focus on lowering job demands, interventions that focus on an increase of job resources, such as career opportunities, the availability of learning resources and feedback, a high degree of autonomy and
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