Moral distress occurs when individuals experience a compromise to their moral beliefs.
While validated tools exist to assess moral distress in various health professions, none are specifically tailored for midwifery in the Australian healthcare system.
Midwife, clinical educator and researcher Wendy Foster and her colleagues conducted a series of studies, including a pilot study The Barometer of Moral Distress in Midwifery. Through these studies, they aimed to understand the concept of moral distress within the context of midwifery practice.
As a result, they developed the first moral distress tool that can be used for both midwives and organisations to assess the frequency of exposure to morally distressing situations, and psychological outcomes which combine to provide the user of a risk score for moral distress.
The Barometer of Moral Distress in Midwifery provides valuable insights for midwives and organisations to assess and address moral distress.
Why do midwives experience moral distress?
Psychological distress on its own could be a result of many different experiences, but moral distress specifically has to have the component of a moral situation first, as well as a negative psychological impact such as stress, anxiety, and feelings of powerlessness, says Mrs Foster.
The philosophy and the code of ethics for midwifery often conflict with the environments in which many midwives are working, she says.
“On one hand they’re given a regulatory framework describing how a midwife will practise in accordance with standards and the code of ethics. And then they’re going into environments which often, due to cultures, hierarchy, policies, and procedures, don’t align”.
Historically, the result has often been midwives who either fought against the system, became despondent in not getting anywhere, became institutionalised into the process, or maybe even left the profession.
Three overarching key factors for moral distress were identified in the research: professional identity; inadequate resources; and unethical cultures.
Awareness
The language around moral distress in midwifery is gaining traction but lack of awareness remains an issue, says Mrs Foster.
“If you asked Australian midwives, a lot of them wouldn’t know the term ‘moral distress’. But when you start talking about it, midwives can usually relate to what it is and how it happens.
“And often, the midwives will start telling you about experiences they have had that they would now call moral distress, where previously, they did not have the language to articulate that experience”.
Understanding and defining the language provides midwives with a structure to go back to their organisations and clearly articulate: ‘look, this has put me in a vulnerable position. This doesn’t align with my values, and this is what happens to me when I’m put in these situations’. To be able to frame their experiences around that kind of language is important.
Using the tool to identify moral distress
The use of the barometer tool is two-fold. Firstly, for a midwife to be able to recognise in themselves that may be something that is impacting on their mental health and wellbeing, but also for organisations to use it as a screening tool. There are two parts to it: morally compromising situations and then the psychological outcome.
First, it’s important to recognise that not everyone who uses that tool will have moral distress, says Mrs Foster.
“There’s a couple of ways that you can develop moral distress and it may not start as distress. You may have what we call a moral frustration where you feel uncomfortable but can see what happened and you feel able to navigate through those feelings and come out the other side relatively unharmed. You’re able to keep going on. Moral frustration is considered short term with relatively low levels of psychological harm.”
Moral distress is more significant and may persist for months and with more severe psychological impact than moral frustration, says Mrs Foster.
“You could have one very significantly distressing situation. For example, witnessing clinical care that led to a particularly poor outcome for a woman or baby. Or there may be cumulative distress, where you are facing day in, day out – that restriction on giving good care. So it might be that you are frustrated, and frustrated, and frustrated and then over time it develops into moral distress and then potentially, moral injury. Moral injury is where we start seeing quite severe psychological harm which has been likened to symptoms of PTSD.
“Part of this is knowing that moral distress is individual. A situation that precedes my moral distress may be very different to a situation that another person feels is morally distressing. There is no prescriptive list of morally compromising situations, however the tool that we have developed does include a number of situations that have been highlighted in literature and by Australian midwives as being morally distressing. In saying that, there are any number of moral situations that happen in clinical spaces, which present moral issues for a person.”
Individual response
Self-recognition is key, says Mrs Foster. “It starts by recognising that this is actually moral distress. So much emphasis has historically been put on resilience. I think a lot of nurses and midwives have been told ‘You’re not resilient enough to handle what’s happening in this organisation’ and it becomes a personal problem.
“What we want to frame is that this isn’t a personal failing. It’s a really critical part of trying to relieve some of the burden of moral distress is this is not a personal failing. This is a result of working in environments that are preventing someone from working in alignment with their personal and professional values and morals.”
Part of moral distress is really characterised by feelings of guilt, feelings of powerlessness,” says Mrs Foster.
“And that feeling of guilt is overwhelming. Guilt prevents you from being able to do what you do. If you saw a car accident for example, and there was nothing that you could do for that person in what happened and you saw it, you could appreciate some trauma around that, but not the moral distress that’s when the guilt comes in. But with moral distress, the person perceives that there was a way that that could have been changed, but it wasn’t done.”
Organisational response
It’s important for organisations to be able to screen so they can potentially identify the morally or ethically compromising situations that come up repeatedly.
“Whether people are having the distress or not, there’s a potential for it to turn that way. So, it might be that an organisation screens their workplace environments, and it shows that some people in the service feel like they can’t advocate for women. So, what can we do about advocacy? What things do we need to change as an organisation to make sure that midwives are supported to advocate for the women in their care? Another example may be that midwives feel like informed consent is not occurring. So again, there is space for the service to review what is occurring to cause that and what steps need to be taken to improve this component of care.
“You might think these processes would already be in place in a hospital system, but quite often cultures will take over and they’ve become accepted behaviours in organisations.
“And part of this is knowing that moral distress an individual. My moral distress will be very different to your moral distress, which means that it needs to have lots of input in to how you fix it.
“If it is decided we’re going to make changes, then we need to get the women, the midwives, the doctors, the policymakers, we need to get all of these people together to make the changes rather than having a top-down approach.
“So that through your experience of moral distress you’re informing the changes that are made – it comes back to addressing that powerlessness. So, first of all, the organisation or facility has identified or worked with people to say this might be a problem, let’s work together and then find out solutions to that together as well.”
Reference
Foster W, McKellar L, Fleet JA, Creedy D, Sweet L. 2024. The barometer of moral distress in midwifery: A pilot study. Women Birth, 37(3):101592.
