 Wendy is a midwife, clinical educator and researcher and Wendy has clinical experience in a way of different settings including rural, remote and tertiary levels of care within Australia. As an educator, Wendy has demonstrated commitment to student learning through innovative teaching methods and enhancing simulation-based learning in clinical teaching. Wendy currently works with the Australian Nursing and Midwifery Federation as a researcher. Wendy is passionate about workforce preparedness, sustainability and professional development. Wendy is currently in the final year of her PhD, and is focusing on the concept of moral distress and psychological well-being of midwives. Her expertise in this area is invaluable for the field of midwifery and we look forward to learning from her insights today. I will now pass it over to Wendy. Thank you so much for that introduction, Bill. And thank you to everyone else who's joining me for this presentation today. So just before I get started, I'd like to acknowledge that I am presenting from Garnerland today and I acknowledge the connection that the Australian Indigenous people have to the Garnerland's past, present and future generations. So I'm going to be presenting today the concept of moral distress in midwifery practice and I'm going to be presenting the four different phases of research that has come out of my PhD. I'd like to thank my supervisors, Professor Lois McKellar, Dr Julianne Fleet and Professor Linda Sweet as well. So what is moral distress? Moral distress was first a concept that was first spoken about in 1984 by a man named Andrew Jameton and he was a nurse educator who was saying some distress in the nursing students who were working in ICU settings and they were talking about their experiences of having to provide painful end-of-life care. So things that they felt weren't necessarily beneficial to the patients under their care. So things like doing suction, taking blood tests, prolonging end-of-life where it wasn't deemed to be necessary. So since that time however the concept of what moral distress actually is has evolved quite a lot so we can see there that Andrew Jameton says that it's basically an institutional constraint that stops the individual from being able to pursue the right course of action or the morally correct course of action. So what is the problem that we have? Why did I want to look at moral distress? So Australian midwives are considering leaving the profession and we have a growing body of literature that suggests midwives aren't being satisfied in their profession. Moral distress may be a contributing factor to this and based on anecdotal evidence at the start of my PhD that is what I was hearing when I was practicing on the wards but there was really limited research regarding what moral distress actually was for midwives. So conceptually moral distress is limited as I said before it's changed quite a lot since 1984 when it was first described so having it not well defined obviously makes it difficult for people to apply to their own experiences as well. So for my project I set up an exploratory sequential mixed methods study so exploratory sequential mixed methods start with qualitative data and they build up to a quantitative phase. So I had three phases with four distinct sets of data collection so phase one was the concept analysis phase two were interviews and phase three was a tool development and you can see how that's progressed from qualitative through to quantitative data methods. So phase one is the concept analysis so a concept analysis is basically used when an area of practice or an area of concern isn't well understood or there isn't an excessive amount of literature around it. It's an inductive approach whereby we find all different sources of literature so everything from peer reviewed articles through to grey literature to find out how the terminology is being used in the context of the situation that it should be applied. So in this case it was looking at how the term moral distress was used in the context of midwifery practice. So we did actually only find eight articles which does demonstrate how the limitations around the amount of research that had been undertaken in this area previously. So I've got the eight phases that are set up there. Now just a little bit of a disclaimer I'm not going into depth with the concept analysis or phase two. They have already been published but I do have the QR codes for those publications available at the end of this section. So for the concept analysis the key findings are to identify the attributes, the antecedents and the consequences. So the attributes are basically what are the components of moral distress. The antecedents is what happens right before and then the consequences are those outcomes. So we had moral actions and inactions so basically what that spoke to was that moral distress occurred when people did the wrong thing but it also occurred when people weren't able to do or felt that they weren't able to do the right thing. So just as an example that could be in the context of midwifery that was either doing an induction or not stopping someone from doing what they thought was improper care. Conflicting needs so trying to balance the needs of an organisation for example and the needs of the woman and as themselves as a midwife personally as well and then there were negative feelings and emotions so basically what we found was that they were the kind of construct needs for it to be called moral distress. So in order for someone to develop moral distress we identified that they needed a moral awareness so very difficult for someone to experience moral distress if they didn't have a moral understanding of the care obligations. Uncertainty so if they just weren't sure on how to care that could also provide a setup for moral distress and then a negative psychological impact. So you can see from that first the definition from Andrew Jameton it didn't actually specify that they needed to be a negative psychological impact and that's one of the things that came out of this. So the consequences there were personal professional and organisational and we'll go into them in a little bit more depth. So at the end of that concept analysis what we came to was a new definition for moral distress in midwifery and that was a psychological suffering following clinical situations of moral uncertainty and or constraint which resulted in an experience of personal powerlessness where the midwife perceives an inability to preserve all competing moral commitments. Now this is the link to the concept analysis publication so please feel free to have a look at that. It does go a lot more into depth on the methodology behind the concept analysis. So phase two were the in-depth interviews now the in-depth interviews all of the questions that we put together for this were derived from the concept analysis so we recruited currently practicing midwives from across Australia and we use social media and a study website where the consent and participant information sheets were as well. So we had 14 participants that contributed to the interviews they were the recordings were transcribed and then thematic analysis was undertaken using NVivo. Now I'm really sorry I know that's a very small picture there but you can see we had a really great range of demographics so everyone from graduate midwife in their first year of practice through to 21 plus years we had representation from New South Wales South Australia Victoria Queensland and Western Australia so a predominant or a majority of the states in Australia were accounted for and then we had a great range of clinical practice scopes so MGP private hospital rotation independent practice education labor and birth and special care nursery. So the themes that came out of that were the experience of moral compromise and that related to navigating conflicting professional and practice values, termination of pregnancy and the cumulative effect and then moral constraints dilemmas and uncertainty which was very much around succumbing to hospital culture and working with fear and uncertainty around that and then looking at the personal and professional consequences. So what I've provided here are the pivotal quotes that we brought out of those that really related to each of the subheadings that I had so navigating conflicting professional and practice values so this quote we felt really demonstrated that it extends to where we can't deliver any care because of a bureaucratic I've just got this just got something sitting over the top of my wording there and then you lie awake at night and you go this is just so wrong I think there's the things that we do that create the dilemma or the distress but there's the things that we can't do that creates equal distress. Termination of pregnancy with something that was very emotive the termination of pregnancy didn't come through with all of the interviews that we did but the people who did speak about it were so incredibly passionate about it that we did include it as a sub theme. Now a lot of the midwives that mentioned this were talking about it in the context of late gestation terminations so some of these were 30, 35, 37 week gestation terminations and this quote really represents that but certainly the stress of knowing that baby died and I've contributed to that it takes a piece of your soul. The cumulative effect so basically what the cumulative effect referred to was repeated exposure to morally compromising situations and how that wore down on the resilience the moral resilience of the person. So you think what am I going to face today am I going to face really bad constraints on the system am I going to face being overstretched am I going to have to am I going to face having to carry out something that I don't want to do how am I going to cope with the constraint of it how am I going to cope with another moral dilemma they just get repeated all over time just in different circumstances they never go away and they never really heal. So the hospital culture and hierarchy so again in the situations where this was brought up it was quite emotive for the midwives who spoke about it so the relationship in one of these was described as subservient excruciatingly difficult punitive and distressing. So fear and uncertainty so this sub theme related to what actually happened to midwives if they did challenge poor practice or if they acted in a manner they felt was appropriate but it went against hospital norms. So this particular participant said I've had more than one conversation when I've said you need to remove your hands from that woman and it bodes very poorly for me so I can't I feel like my job is on the line. So from the interviews that we had we developed based on a another model by Litz and Kerrig this kind of trajectory where we saw there was everything from quite mild negative psychological outcomes through to pretty extreme psychological outcomes and we mapped it across a bit of a trajectory where we said as the stress response increased and the ability to reconcile those negative feelings and emotions decreases we have this trajectory from moral frustration being quite a mild form of distress and then through to moral distress and then moral injury. So we really started developing terminology around how these how these experiences fit in the context of the psychological outcomes of that. So this has also been published so again QR code there if you would like to access the publication. So phase three was a Delphi study. So a Delphi study is basically a method of reaching consensus on topics. So in this instance we took the findings from the concept analysis and the interview and we developed a list of situations that may lead to moral distress and we developed a list of psychological outcomes. So we were basically looking to find out what are the situations that are really placing midwives in a situation where they may have to work against their own moral values and what how does that actually impact on them and the purpose of this was to develop a tool that could be used which we will pilot in the final phase. So we recruited 28 academics, researchers and clinically practicing midwives. So we had 28 that consented and 20 who participated. So we started off with 44 situation items and 21 psychological outcomes. We used three different rounds whereby we took the list of items sent them to the participants and they ranked them as to how relevant they felt they were. They sent them back with any comments. We provided feedback and sent it back again and we did that process three different times. So we analyzed everything with SPSS version 25. So again you can see we've got some a great range of participant demographics there and again from very junior to very senior and across the whole scope of practice of the midwife. So round one the highest ranking of consensus was around workload that the work load was too great for them to provide the type of care they felt was necessary. The lowest was around termination of pregnancy. Now qualitative feedback that we're given led to additional two items which related to work load but focused more on the individual. So the additional item, one of the additional items was around the fact that the midwife did provide the level of care that they felt was required for the woman but it occurred at a personal cost. So skipping meals, working late, starting early. So it was really a moral compromise to themselves. There was positive consensus on four out of the 21 psychological outcome statements but the participants felt that they were required to force fit them into one of the categories. So we had asked them to refer to them as either moral frustration, moral distress or moral injury. So the feedback we got back was at the midwife said actually this one for example I cry after my shift that could relate to moral frustration or moral distress or moral injury. So they asked us to open it up so that they could have multiple responses or to say it's not applicable at all to this to moral distress. So in round two we had 16 participants and that's quite normal in a Delphi study to have some drop off and we received a consensus in 14 of the 23 situation statements. So the highest consensus was around intervention without informed consent and the lowest again was around termination of pregnancy. We plotted the psychological outcomes across a trajectory so instead of them being forced fit into the individual sections when we plotted it against the trajectory and you can see that on the table that I've provided. 19 of the 21 actually fit across a pattern so if for example the participants may have picked moral frustration and distress or they may have picked moral distress and moral injury so it still went along a trajectory but it didn't fit exactly within the confines of a specific term. So in round three we had 18 participants so an extra two joined back into this round and we received positive consensus in another four of the seven situations that were sent back. The highest consensus was around organisations not supporting normal physiological pregnancy and birth. Termination of pregnancy and religious and spiritual beliefs still didn't reach any level of consensus and it was the most divisive situation in all three rounds so there was a basically 25% across each of the responses. There was a strong consensus on the proposed trajectory that we put back to the participants however. So this resulted in 40 situation statements and 19 outcome statements and that became the contents of the pilot study. Now I can tell you that this Delphi study has also been accepted for publication and that will be out soon but if anyone would like access to that when it comes out I'm happy to forward that on when it becomes available. So the final phase and a bit of a caveat to this I am still analysing the data for the pilot study but I'd like to present you with some of the initial findings. So we invited Australian midwives who had practised within the last five years the same social media strategy that we had previously used and we left the survey open for eight weeks. So we received 122 responses 102 of them were completed that were usable and all of the data was again analysed using SPSS. So I've already spoken about how we developed the survey so I'm not going to go back into that just in the interest of time but this was our participant demographic so RNM and RM direct entry again good range of practice years all areas of practice were represented in every state and territory was represented as well although not equally. So the frequency of exposure the most frequently reported situations leading to moral distress where that care occurs at my own expense so this was very much about the midwives not being able to take care of themselves and recognising themselves as a as a moral entity unto themselves. The level of workload was too high to be completed to the standard that the midwives felt that it should be and then there were interprofessional issues and that tied in with the organisational culture as well. So the least frequently reported involved with holding choices from families not speaking up and performing unnecessary interventions. Now this was some of the we developed scoring around that trajectory as I said before we plotted the psychological outcomes so an outcome of one would have been moral frustration two was between moral frustration and moral distress three was moral distress four was between moral distress and moral injury and five was more injury so if we scored them based on what the participants the psychological outcomes that they felt they had experienced the maximum they could they could score was 61 so in this cohort we had a mean of 29.9 minimum of 2 and a maximum of 61 so of those you can see there's some pretty concerning data that came out now remembering that this is a relatively small sample size but also remembering that we asked these midwives to declare what type of moral distress they had so they could choose a moral frustration distress or injury and a lot of these midwives suggested that they had all three of those were represented by the midwives responding. I cry following my shift though that was 42 percent of our respondents suggested that was a psychological outcome for them. I feel powerless to make a difference 51 percent I'm not proud of my work 28 percent I'm burnt out with 61 percent and I'll let you read through them but there's one down here the second to bottom one my work environment has a negative impact on my self-esteem so that was 48 percent of the respondents in this study who selected that as a psychological outcome so pretty intense findings so we used the those scores that we developed and we used the Copenhagen burnout inventory to compare the two scores to see whether there was any kind of validity between the two so in the three sub-scales of the Copenhagen burnout inventory and the midwives who responded to this study work-related burnout was an average of 70.7 which is considered to be moderate to high personal burnout was 69.3 and client-related burnout was only 38.8 so what that really tells us is that the midwives are experiencing a situation not related to the women this isn't about the midwifery care it's about the environments that they're practicing in so how this correlates and I'll go through this really quickly and again early data analysis but the burnout the work-related burnout and the total burnout client-related burnout and the personal burnout all correlated positively with the total score from the the moral distress tool that we were creating so it does show some consistency in that and it does indicate that it's it's worth pursuing some further testing of the of the study so basically the the discussion for this is that moral distress does appear to be prevalent in Australian midwives the burnout rates do look like they've increased and that's probably a you know a side study all on its own but other literature from Australia has shown that it's gone up quite significantly significantly but also remembering that this study was taken through them undertaken through the middle of COVID which may account for some of that as well the mental health outcomes that have been identified through this study are really significant though having the workplace impact on self-esteem is quite concerning as well as the other psychological outcomes so the preliminary data does indicate that the pilot of the moral distress tool may be useful in screening for moral distress but it does need psychometric evaluation before we could actually use it as a diagnostic tool that was that was basically my entire PhD there's three years work that we've put into into 28 minutes so I've got a couple of questions that are there you know mate I said we do have a chance for questions so I just make it a few people a chance to write some in but I do have a question for you before we begin so can you tell me a bit more about your vision for how aware you can see the tool you developed could be using the future yeah thanks Belle so we we have to obviously there's two sub-scales that we can get some data from with this tool one of them are the situations and the frequency that midwives are experiencing those situations so obviously that's really important for organizations to be aware of so I do see that organizations may be able to use this tool in the future to kind of do some kind of environmental scanning of what the what the ethical climate is in their own organizations but it does help midwives as well to give the language to the experiences that they're having so whether that's a tool that they're able to use to identify why they're having the feelings and emotions that they're having around their workplace so as I said we may be able to use it as a screening tool initially before it goes on to have further testing but definitely for organizations to improve their workplace environments but also for midwives to be able to talk more about their situations with language development I imagine once we sort of have the screening tool we can then sort of look at how we can manage it or help with it as well absolutely and I know there are some I think it's the American College of Nurses has actually put some information about moral distress into some of their clinical practice guidelines as well I'm just going to throw over the city she's going to ask some questions from the public chat for us I'm not sure if she may not have any sound that's all right I'll ask them for them so one of them was a question about your pilot study and just wondering whether they'd be advised in the sample whether they were from the same work environment yes so um can I can I scan back and um yeah definitely there we go so we had great representation um across different demographics so we had um rotation group practice delivery antenatal gynecology postnatal um private independent practice um education um management and special care nursery so we had most of those um practicing were from a public setting so public hospitals um we did categorize country so our rural and remote health um midwives into a different category uh just because it's it's a different context um we then had private practice and other as well so other tended to be more around um uh management or clinical education um so we did have a quite a big um demographic of people and I can tell you in the I've done some more analysis of um these findings and there was not actually any um correlation between the settings the years of practice um the state of none of the demographic information correlated with um the moral distress scores or the um burnout scores so definitely um at this stage with the early um with the early data analysis there doesn't seem to be much of a correlation in that in the interviews that we had um even the private independent midwives were talking about their moral distress um and that was that was really related to having to transfer women into hospital um and how they were going to be received when they got in there so they felt that they changed their practice to suit an environment that they were going into so we had thought initially that um private practice may be um a little protected from that moral distress being able to work much more autonomously um but with the small sample size we have it hasn't shown that um in particular imagine that's an interesting finding that you came across yeah there was also um another question about whether you can talk about emotion work in midwifery practice yeah um look there is there is quite a lot um Billy Hunter has done a lot of work around that space as well um I guess the midwives do give a lot of themselves and it's something I think that that key finding that we had with the situations that are leading to moral distress really identifies that as well that the top situation that causes moral distress in midwives is that they're trying to give from an empty cup is essentially what what that reads to for me is that they're saying I'm giving and giving and giving I'm giving the care that these people need but there's nothing left for me and indeed again in the interviews the midwives did say to us um uh when I go home I don't have anything to give my families as well so again that morality of of what does this mean to me what does this mean to my family I can't I can't keep um maintaining all of these competing demands yeah which would be interesting there's a couple of people from different places not just in Australia interesting they want to throw in the public chat where they feel like it could be similar in their sort of own areas you don't have to but you are welcome to um there was a question Anita we sort of just sort of covered that when um about the different sort of private public midwives involved so I need to just throw in if you have any more questions about um that does anyone else have any other questions I can just say quickly for Anita um student midwives were not involved um but midwives who had already left practice were involved um and sorry just in relation to the autonomy um we had very small sample size um so at the moment it would be difficult to say um yes or no it has to do with autonomy um but what I can tell you is that in the interviews those midwives still talked about a certain level of moral distress so I do think it's uh I think anecdotally there would be a level of protection around autonomy but it definitely is not um is not like a a complete shield against it but um there's a lot of comments learning like it is important work so thank you for sharing that your work with us today um so then instead of after your study do you have an impression that midwifery is not good for health personal and professional on what can be done oh um look I think there's there's a few things that we need to be really cautious of when we when we're assessing the findings of this study is that of course there's going to be some sample um or response bias that um you would know a lot of the people who respond to a study about moral distress are already going to be um in a place where they feel they may have some moral distress so that could potentially be impacting on the findings that we have so um please keep that in mind um I think I have been a practicing midwife up until about six months ago um and I had some amazing experiences and I think it's a wonderful profession um but we need to support the midwives more um I believe that we need to do more to get back to a a bigger scope for the midwife um and there needs to be different ways for midwives to practice that suit their practice values um yeah thank you is there anything else you want to add Wendy before we finish um I guess all I would like to say now is um just to remember to look after yourselves um look after your colleagues um if anyone's experiencing any kind of negative psychological emotions um please seek help as well I think we do need to be using this language and talking about the experiences that we're having but um the seeking help is also so important um yeah thank you very much um I'm sure everyone is the same as I've enjoyed discussion I mean hopefully look forward to a bit more of your work in the future