MORAL DISTRESS AND MIDWIFERY

"From the beginning of our education, it’s ingrained in us that we’re with women; in partnership, promoting physiological birth and all of the normal, wonderful parts of pregnancy and the early postnatal period. That’s entrenched in us as midwives and when we don’t have the time to really be with women, it feels like we’re not doing our jobs properly" (Midwife Manager).

Midwifery is both an art and a science and often midwives feel a great sense of pride, joy and satisfaction when they are able to practise it true to their values, ethics and morals. Whilst these will vary somewhat from midwife to midwife, a common minimum standard of professional midwifery care prevails and all midwives can surely agree that our role in protecting and promoting physiological pregnancy, labour, birth, postnatal recovery and transition is vital, as is providing positive birth care for women who require medical intervention.

Midwives are attracted to the profession for a variety of reasons, but it is certainly not a vocation one happens to fall into. For many, there is a drive to work with women, babies and whānau through a momentous life event.

While many aspiring midwives feel affirmed by their undergraduate experiences, students may also have reality-grounding insights as they progress through their education. For many, these experiences strengthen their determination and resolve to continue, whilst for others, the reality could not be further from their expectations, and they make the difficult decision to walk away.

As midwives enter the profession, the journey can be challenging, causing some to question their decision to become a midwife. Present day workforce shortages mean many midwives may grapple with disillusionment as they try to provide the standard of care they were educated to. This state of inner conflict, which many midwives have come to experience daily in their work, is known as moral distress.

A widespread phenomenon in healthcare settings, moral distress is stress caused by ethical dilemmas (Oelhafen & Cignacco, 2020; Kälvemark et al., 2004), which Foster et al. (2021) suggest is the cumulative effect of repeated exposure to situations which precipitate moral compromise. Foster et al. (2021) define it as:

“…a psychological suffering following singular or repeated moral compromise, which result in an experience of personal powerlessness and a significant negative psychological impact where the midwife perceives an inability to preserve all competing moral responsibilities” (p. 9).

Current staffing issues within our maternity facilities, combined with high-acuity, increasingly complex clinical situations, and subsequently over-stretched work environments can lead to this phenomenon becoming a daily reality for midwives. Due to the symbiotic nature of the professional relationship between both community and employed midwifery workforces, this distress can have profound effects for both groups. Institutional constraints such as short staffing readily result in ethical dilemmas for all midwives, as they struggle to provide the quality of care that they are educated, or desire, to provide. When it is impossible to pursue a desired course of action, moral distress ensues.

Kälvemark et al., (2004) propose another definition of moral distress midwives may identify with:

“Traditional negative stress symptoms, such as feelings of frustration, anger and anxiety, which might lead to depressions, nightmares, headaches and feelings of worthlessness, that occur due to a conviction of what is ethically correct but institutional and structural constraints prevent the desired course of action” (p. 1077).

These ethical dilemmas or morally compromising situations can be insidious, particularly for those midwives working in high-risk, high-acuity maternity units; moral distress can run undetected, as highly resilient midwives adapt to their environments over time. A classic example of this can be found on busy postnatal wards. As midwives, we are educated in the importance of observing a full breastfeed and encouraged to be as hands-off as possible when assisting. Ideally, mother and baby are gently guided to learn and practise together, and the woman is left feeling empowered. But we all know this doesn’t often happen in reality. A midwife’s caseload on a shift in a high-acuity postnatal ward includes babies on regimented feeding plans requiring blood sugar monitoring, breastfeeding and top-up feeds, whilst their mothers’ needs relate to recovery from a cascade of intervention, which has set them up for delayed lactogenesis and reduced levels of oxytocin.

Under these circumstances, the dream of enabling a wahine and her pēpi to learn to breastfeed together is often reduced to just that: a fantasy. Instead, midwives find themselves entering rooms, testing a baby’s blood sugar and latching them to the breast as efficiently as possible (usually by doing, rather than teaching) in order to attend the room next door, where the same routine is already 15 minutes overdue.

The next shift is simply a rinse and repeat, and before long, midwives have adapted to a new normal; what was once a distressing experience of not being able to provide the ‘caring’ aspect of the care, becomes background noise as midwives adopt various unconscious strategies to avoid or ignore their distress.

One midwife illustrates the inner conflict as she describes her distressing adjustment to work as an employed midwife in a busy tertiary unit, having come from a predominantly primary background as an LMC:

“I’ve always been really patient when it comes to breastfeeding and I loved it as an LMC. But in this environment I’ve become precisely the kind of midwife I swore I’d never be; walking into rooms, hurriedly latching babies on to breasts and running to the next thing. It’s heartbreaking” (Midwife). A survey of College members published in 2017 found that levels of stress and feelings of depression were high for all midwives, but the group of midwives providing continuity of care had "Being task-orientated isn’t part of higher average emotional health scores than the group the midwifery psyche, but that’s working in the hospital what you have to become in (employed) environment. order to survive. You have to learn The study identified a correlation between to prioritise the observations and inadequate resources to the medications, and what falls support midwives’ work, to the wayside is the nurturing. and burnout. Resource adequacy involved having You physically don’t have the time enough midwives to provide to do that without someone else quality care, enough missing out, or being put at risk" time and opportunity for midwives to spend time with (Midwife Manager). wāhine, and the ability to discuss care concerns with other midwives. THE IMPACTS OF COVID-19 The College acknowledges that working within a global pandemic compounds these issues further. It’s not news to midwives that we, along with many other health practitioners, have been experiencing increased levels of work stress and burnout during the Covid-19 pandemic. The intensity of midwifery care provision during the pandemic has been exacerbated by existing workforce issues, concerns about clients with Covid-19 infection, anxiety about personal/family safety and wellness, alongside feelings of being undervalued and overlooked by the government.

The College undertook a survey of midwives in 2020 to ascertain the impact of the Covid-19 pandemic on midwives and midwifery care, and found that the majority of the 781 midwife respondents (26.8% of practising members at that time) agreed that Alert Levels 3 and 4 had impacted their work environment, and that this had been a major influence on their workload (Dixon, 2020). The New Zealand media has published many articles about the midwifery shortage and burnout, and highlighted the potential risk to mothers (Henry, 2021; Corlett, 2021; Wilson, 2022), which MERAS co-leader Caroline Conroy describes as a factor creating more stress for midwives (Quinn, 2021).

“Knowing that we were already beyond breaking point, running on skeletal staffing every day; the fear of how we would survive with further staff absences felt debilitating at times, not to mention the possibility of providing care for Covid-positive patients. That was complete overwhelm and I struggled to see a way through” (Midwife Manager).

Research by Foster at al. (2021) looking at why Australian midwives were leaving their profession found reports of psychological trauma, primary and secondary traumatic stress, burnout, anxiety, and depression, suggesting that moral distress may be a contributing factor.

Findings in the Foster et al. study (2021) identified three key themes:

• experiencing moral compromise • experiencing moral constraints, dilemmas and uncertainties • professional and personal consequences.

Midwives also indicated that they were unable to adequately advocate for themselves, their profession, and the women in their care within the hierarchical and oppressive systems in which they were working (Foster et al., 2021). Harvie et al. (2019), analysed data collected as part of the Australian arm of the Work, Health and Emotional Life of Midwives (WHELM) project (1,037 midwives) and examined the incidence of, and the reasons why Australian midwives were considering leaving the profession. They found that midwives felt their ability to provide quality maternity care was constrained by a fragmented medicalised system that did not work for women in their care, or themselves. Themes identified in the work by Harvie et al., included “I cannot be the midwife I want to be”, where midwives described being rushed, pressured, constrained and restricted. Another theme was “I am at breaking point”, where midwives described feeling overwhelmed, stressed, anxious and burnt out all the time. Profound levels of hopelessness were

experienced and midwives felt that their passion for midwifery had been eroded.

The College 2020 survey included questions about the impact of the Covid-19 health response on the work of employed midwives and community midwives (Dixon, 2020). Hospital-employed midwives experienced a range of issues including increased time pressures due to screening procedures, as well as providing the majority of labour and birth care for women who were Covid-positive or suspected of being positive. Community midwives’ administrative and non-clinical workloads increased and they faced additional challenges of negotiating both telehealth and shorter in-person assessments.

The emotional, psychological and spiritual needs of new mothers and their whānau as they navigate a transition which is just as much a cultural, spiritual or emotional experience as it is physical, needs to be acknowledged. Midwives are acutely aware of these needs, but in the face of short-staffing and high acuity, are forced to prioritise physical or clinical care, leaving whānau at a loss as they try to steer through an inherently emotional journey in busy, overwhelmed institutions. Women and their whānau aren’t the only ones who feel this disconnection; midwives feel it too, to varying degrees, contributing further to moral distress and feelings of despair.

In order to manage the detrimental effects of moral distress, midwives may choose to reduce their working hours, or at worst, leave the profession altogether. These drastic actions can leave individual midwives feeling further defeated or disempowered, and the workforce even less sustainable in the long-term.

In spite of the stressors associated with the pandemic, some midwives have felt increased pride throughout it, knowing their contributions as essential front-line health workers - during an anxiety-inducing time - has been valued immensely by whānau receiving their care, particularly as other health providers reduced their services. The schools of midwifery have all reported a surge in applications since the onset of the pandemic, as the value of essential workers has become more visible.

WHAT PROTECTS AND SUSTAINS MIDWIVES? What can help mitigate or prevent the experience of moral distress, so that midwives can continue to experience the pride, joy and satisfaction the work offers? Although there are some factors within one’s individual control, midwives work within a much wider professional and systemic context. Therefore it is worth considering the contributing factors at personal, professional, environmental and structural levels, as these same factors may also reveal some protective measures.

This concept is perhaps best illustrated by way of an ecological model, demonstrating the ways in which these layers - and their relationship to one another - contribute to a midwife’s sense of moral integrity and professional fulfilment.

Personal: what is within the midwife’s individual control, e.g. personal health and wellbeing, lifestyle, sleep, mindfulness, level/years of midwifery practice experience, family and social connections, permission to do the best job one can under the circumstances.

Professional: relationships with clients and colleagues, professional support mechanisms, mentoring/clinical coaches, education and professional development, professional organisation membership e.g. the College. Environmental: workplace culture, collegiality, teamwork, clinical leadership which promotes autonomy, sustainable working conditions.

Structural: access to resources and education, safe staffing, CCDM, career pathways, workforce retention initiatives, improved working conditions in employment contracts, community practice support.

WHAT IS WITHIN OUR PERSONAL POWER? Harvie et al. (2019) found that midwives described they were happiest when they could “just be a midwife”. They commented on their love and passion for their profession and how “privileged” they felt providing care for women and their families. However, in order to experience this joy, midwives need to be emotionally present for women and whānau, in all contexts and settings (from busy tertiary units to community practice). We owe it to those we care for to be fully present with them, at a point in their lives which is of momentous significance – such as birth and becoming new parents.

But of course midwives cannot begin to be present for others until they are first present with themselves. Care providers are also in need of care, and acknowledging one’s own need for compassion and support is an essential part of this. Accepting that a midwife can only do what they can do on any given day or shift is integral to self-care. Berating oneself for the things that weren’t achieved is counter-productive; a kinder approach would be to grant oneself permission to do one’s best, knowing that it is enough. Using mindfulness techniques, developing a meditative practice or simply taking the time to connect to one’s own emotions without judgment all have the potential to bring more presence to life. Finding a sense of calm or joy looks different for every individual and could range from jujitsu to gardening, listening to podcasts, sharing kai with family and friends, going to the gym, launching DIY home projects, practising yoga, walking or running in nature, reading, volunteering, and everything in between. Taking time to

centre ourselves and set an intention before starting a shift, clinic, or birth can help us to bring our midwifery hearts and expertise to the people we care for. Processing difficult and frustrating situations by debriefing with a colleague, or journaling, can help us gain useful insights from these experiences rather than carry them as burdens. These acts of self-love and compassion are all about connecting to and taking personal responsibility for one’s inner environment. Taking personal responsibility should not be conflated with culpability, or taking blame for the working conditions midwives find themselves in. Nor should it be confused with condoning oppressive behaviours or structures. This approach is not suggested at the exclusion of continued advocacy work to improve working conditions and increase recognition of the value of women’s health and the vital role midwives play within it. Instead, these approaches simply serve to remind midwives of the personal power, or mana, they possess at all times. Ultimately, the only thing anybody truly has control over, is their inner landscape, and to wait for external circumstances to improve in order to feel calm, happy or fulfilled is to give away one’s personal power, keeping those more desirable states eternally out of reach. There are numerous approaches offering techniques to experience inner peace or calm more frequently, most of which originate in Eastern philosophies. Whilst these hold immense value, closer to home, te ao Māori also contains keys, which are explored further on pg.26. PROFESSIONAL CONNECTIONS Midwives internalise the profession’s values and practices, demonstrating commitment and dedication to providing skilled, knowledgeable care. Hunter and Warren (2013), in their study on midwives’ sustainability, found that when midwives feel a sense of professional belonging and identity, this supported their resilience. Collectivisation as midwives can be grounding and "As a manager, that fear of protective; College and MERAS meetings provide professional something going wrong, or spaces to engage with colleagues about regional midwifery and support collective action on local and national issues something being missed because affecting our work. Team or practice meetings and other of how chronically under- midwifery gatherings can also bring collegiality and perspective to our practice.staffed we are is ever-present. Education, regulation and an effective midwifery And then on top of that, you’re professional association are important to ensure midwives worried your staff are unhappy have access to the support systems and structures necessary and not feeling fulfilled. You’re for them to be the midwives they want to be. Each of these frameworks supports quality of midwifery care through the constantly trying to fill the void setting of professional standards, the maintenance of those of understaffing, shuffling things standards and ongoing education (New Zealand College of around to make it as doable as Midwives, 2018). possible, so that your staff There are a variety of professional mechanisms to support midwives’ sustainability and professional practice. These come back the next day" include mentoring, reflective processes such as midwifery (Midwife Manager) standards review, peer review, ongoing education, and professional development. These all aim to provide midwives with opportunities to explore various aspects of care and

recognise their own value as health professionals, by allocating dedicated time and space for midwives to receive collegial support.

The quality of professional relationships with clients and colleagues relies on, among other things, individuals working together in agreement, communicating clearly, listening and being available to one another, and where possible, meeting each other’s needs. These are common goals of health professionals and are supported by the profession through a number of mechanisms, some of which are identified above.

THE ENVIRONMENT MATTERS Never has there been a more important time to address workplace culture, especially within the current climate. When facilities invest in an environmental culture which promotes trust and supports autonomous practice, midwives are much more likely to feel valued and safe at work. Effective teamwork directly affects midwives’ experiences of workplace culture and builds capacity to give quality safe care to mother and baby (Hastie & Barclay, 2021; Nash, 2021). Unsurprisingly, when midwives have access to approachable colleagues, they are more likely to thrive and develop further confidence in their midwifery skills and ability to work autonomously (Matthews et al., 2021).

Working within a supportive environment has the potential to transform stress triggers into challenges, rather than stressors. Hammond et al. (2013) found workplaces with cultures of increased trust, reduction in stress, and empathetic colleagues triggered the release of oxytocin, increasing job satisfaction and provision of quality care.

A culture of trust can also aid in sustaining and retaining midwives by providing increased stability, allowing for healthy collegial relationships to develop. In such an environment, especially after an emergency event, feelings of isolation are dispelled and midwives feel reassured and emotionally cared for. Positive initiatives such as the newly developed clinical coach roles contain the potential to address midwifery workforce issues and reduce stress levels for midwives.

The real and reported issues facing midwives strongly suggest a current midwifery workforce emergency state, which will extend long into the future without strategic and radical action now. Acknowledging and addressing the factors that have led to the current shortage of midwives, and the potential future midwife shortage, alongside providing better support for midwifery educators and institutions offering midwifery degree programmes, is vital. The Covid-19 pandemic has certainly seriously hampered the already overdue need to address the issues facing midwifery and this has contributed to an increase in workplace tension and strain.

STRUCTURAL SUPPORTS Although personal, professional and environmental factors can be protective, the wider system in which midwives work plays an integral role in ensuring midwives are sufficiently supported to mitigate the effects of moral distress.

As Purser (2019) points out, “…anything that offers success in our unjust society without trying to change it is not revolutionary…”, reinforcing the need to continue to push for radical action addressing the political and economic frameworks currently shaping the external midwifery landscape. MERAS and the College have been collectively focused on continuously advocating for the changes needed to improve systemic resourcing and recognition of midwifery as a distinct profession with unique needs. This advocacy occurs nationally, regionally and of course politically and is aimed at seeking short, medium and long-term solutions to address retention and recruitment.

Many of the successes already achieved have been celebrated within the pages of this magazine, including: the establishment of clinical coach roles; CCDM outcomes; Trendcare calculations; career pathways for DHB employed midwives; pay equity claims and continual advocacy for improving working conditions in employment contracts. Other wins include improvements to Section 88 payments, successful advocacy for the establishment of DHB midwifery leadership positions, establishment and retention of primary maternity facilities, along with community practice supports, such as funding for locum relief.

These structural supports are an essential layer in the matrix surrounding midwives, however they need to be continually built upon and strengthened. Within an inadequately resourced health system, midwifery’s voice must continue to be loud and present, in all decision-making forums, so that our working environments become places where midwives are nurtured to flourish and thrive. “You come back to work because you want to support your team, as hard as it is. Having colleagues who understand makes the world of difference and if you get an opportunity - in between racing around - to share a laugh, it makes it easier to get through" (Midwife Manager).

CONCLUSION

“You come back to work because you want to support your team, as hard as it is. Having colleagues who understand makes the world of difference and if you get an opportunity - in between racing around - to share a laugh, it makes it easier to get through. Positive feedback from whānau when you’ve made a difference to their care; that’s another thing that keeps me coming back - being able to provide clear guidance at a crucial time in their lives when they’re surrounded by so many different opinions and influences. Despite it all, I just can’t imagine myself doing anything else” (Midwife Manager).

Not all midwives will necessarily be suffering from moral distress, but for those who can now name their experience, it is hoped that this article has shed light on some of the contributing factors, including those within our individual control. Whilst these are not a fix-all, they can be empowering tools for midwives, alongside the continuous advocacy work being undertaken by the College and MERAS. Most importantly, this article has aimed to acknowledge midwives all over the motu, across all work settings, who may be feeling this distress, to remind them that they are not alone. square

References available upon request.