Exploring moral distress in Australian midwifery practice
Introduction
Across the world, midwives are considering leaving the profession [[1], [2], [3], [4], [5], [6]]. Midwives have cited reasons such as excessive work load allocations and inappropriate staffing levels [1], increasing levels of administrative duties [1], non-family friendly rostering and clinical hours [6] traumatic work place events [1,2] and burn out [[3], [4], [5]]. Nationally, it has been identified that almost half of Australian midwives surveyed had considered leaving midwifery practice in the subsequent 6 months [1]. The primary reason given for considering leaving included both dissatisfaction with the organisational structure of midwifery and an inability to practice in accordance with their practice philosophy [1].
Midwifery is underpinned by a philosophy that places women and their families at the centre of care, with a commitment to ethical practice and evidenced based care [7]. The International Confederation of Midwives, International Code of Ethics for Midwives states: “Midwives have responsibilities to themselves as persons of moral worth, including duties of moral self-respect and the preservation of integrity” [8, p. 2]. As an ethically informed profession, there is a high likelihood that midwives experience morally challenging situations [9,10]. When unable to protect professional and personal values in the workplace, midwives have reported psychological trauma [10], primary and secondary traumatic stress [2,11,12], and burnout, anxiety, and depression [2,13]. The concept of moral distress may be one factor that has been largely overlooked when evaluating the psychological wellbeing of midwives.
Moral distress is described as a negative psychological reaction to working in situations that challenge an individual’s moral and ethical agency [14]. Research has suggested that the incidences of moral distress are expansive in healthcare, however, research to explore moral distress in midwifery practice is limited, and often specific to only one aspect of practice [15,16]. The purpose of this paper is to explore Australian midwives’ experience and consequences of moral distress.
Section snippets
Background
The term ‘moral distress’ is used to describe the negative psychological impact following situations where an individual acts in a manner that is inconsistent with their own morals [17]. Initially described within the context of nursing practice by Jameton in 1984, moral distress was defined as occurring ‘when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’ (16 p. 6). Since this initial definition however, there has
Aims
The study aim was to explore Australian midwives experience and consequences of moral distress. The overarching question guiding this research was ‘How do Australian midwives experience moral distress’.
Research design
This qualitative descriptive research is the second stage of a sequential exploratory mixed methods study. In the first stage of this study, a concept analysis [14] was undertaken to establish the context of the term ‘moral distress’ in midwifery practice. This initial stage allowed the
Discussion
The aim of this study was to explore Australian midwives experience and consequences of moral distress. It is our understanding that this is the first study to investigate this phenomenon within an Australian midwifery context. Semi-structured, in-depth interviews assisted to elicit the experiences of moral distress from midwives across varying years of experience and practice settings.
Moral compromise is defined as being in a situation, or acting in a manner that does not align with an
Limitations
The primary limitations of this study are the relatively small sample size, lack of generalisability, and sample bias. Despite the small sample size however, it is not uncommon for in-depth qualitative studies to use a sample size of 14, or less participants [57]. Given the rich data collected through the interviews, this does not appear to have impacted on the quality of the findings of this research. The midwives who responded to this study all described experiences of moral compromise and
Conclusion
Australian midwives in this study described situations of moral compromise, and experiences of moral distress. Describing hierarchical and oppressive health services, midwives indicated they are unable to adequately advocate for themselves, their profession, and the women in their care. Although it is unclear if moral distress contributes to attrition from the profession, the midwives in this study described the psychological impact of these situations had detrimentally impacted their
Author contributions
- a
Wendy Foster was responsible for the conceptualisation of the study, ethics approval, data collection, analysis and reporting.
- b
Lois McKellar was the primary supervisor through the project. She assisted with data analysis, significant writing and editing of the manuscript.
- c
Julie Anne Fleet was a secondary supervisor of the project and contributed through data analysis, writing and editing of the manuscript.
- d
Linda Sweet was a secondary supervisor of the project and contributed through data analysis,
Conflict of interest
There is no conflict of interest from either Mrs Wendy foster or Dr Julie-Ann Fleet. Professor Linda Sweet and Associate Professor Lois McKellar hold editorial duties with this journal. To remove any conflict of interest, neither will have a role in the processing or peer review of this paper.
Ethical approval
We hereby confirm that this project has received approval from the Human Research Ethics Committee at the University of South Australia. Approval was granted on the 18th of June 2020. Approval number 202801.
Funding sources
None declared.
Acknowledgement
Wendy Foster would like to acknowledge the support of The University of South Australia through the PhD process.
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