Recognising moral distress in midwives

Psychological distress on its own could be a result of many different experiences, like witnessing a car crash or not getting your kids to school on time. 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. 

The philosophy and the code of ethics for midwifery often conflict with the environments in which many midwives are working, says Mrs Foster.

“On one hand they're given a regulatory framework describing how a good 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, they don’t align. 

“Contemporary midwifery education, and the philosophy of midwifery promotes holistic woman centred approach to care, which midwives often feel they aren’t able to practise in accordance with.”

Recognise symptoms 

Midwives who experience moral stress may have feelings of guilt and powerlessness. 

“The feeling of guilt is overwhelming. Guilt prevents you from being able to do what you do. If witnessed a car accident for example and there was nothing that you could do for an injured person, you could appreciate having some trauma around that.”

Not so in moral distress, says Foster. “That's when the guilt comes in. With moral distress, an individual perceives that there was a way that it could have been changed, but it wasn't done.

Assess moral distress – new tool

Ms Foster has developed a moral distress tool. It can be used by 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. Go to The barometer of moral distress in midwifery: A pilot study

“It’s important for a midwife to be able to recognise in themselves that there’s something that's impacting on their mental health, but also for organisations to use it as a screening tool.”

There's a couple of ways that you can develop moral distress and it may not start as distress, says Mrs Foster.

Understand the escalation from frustration to distress and injury

“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 Ms 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 situations that have been highlighted in literature and by Australian midwives as being morally distressing. In saying that, there are any number of moral issues that happen in clinical spaces, which present moral issues for a person.”

Raise awareness, share experiences

The language around moral distress in midwifery is gaining traction but lack of awareness is remains an issue, says Mrs Foster.

“If you screened Australian midwives, a lot of them wouldn't know the term ‘moral distress’. But when you start talking about what it is, midwives can 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”.

“Using that language and bringing it to the forefront is important. If the terminology is used together with reframing the experience of that midwife, then it can be a bit easier to move forward with addressing the symptoms.”

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. 

“You can be validated - what your experiencing is understandable. So much emphasis has historically been put on resilience. 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. This is a result of working in environments that are preventing someone from working in alignment with the way they know they should be.”

Reference

Foster W, McKellar L, Fleet JA, Creedy D, Sweet L. The barometer of moral distress in midwifery: A pilot study. Women Birth. 2024 May;37(3):101592.