An examination of the moral habitability of resource-constrained obstetrical settings

Introduction

The impact of healthcare work environments on nursing practice has widely been described by studies from higher income countries. Nurses have described being embedded in complex socio-moral environments dominated by a corporate and biomedical ethos, staffing shortages, the inappropriate use of or inadequate resources, workplace hierarchies and oppression, and a lack of value for nursing work. ^{1 –7} Others have also described the overwhelming impact of these factors on various facets of nurses’ professional life including the presence of compromised standards and values, increased workloads, incoherent moral responsibilities, the witnessing of unnecessary suffering, conflicting values, and decreased emotional contact with patients. ^{2,3,5 –12}

Several studies have also uncovered the influence of the work environment on the moral practice of nurses. ^2,11 Exploring the moral habitability of the nursing work environment in Canada, Peter et al. ² discovered that nurses characterized the work environment as oppressive because they felt powerless, marginalized, and exploited, and experienced incoherent moral responsibilities as they struggled to sustain their moral values. Moreover, the nurses portrayed the work environment as “toxic” and “lacking sympathy” (p. 360) ² and filled with interpersonal violence. Similarly, in analyzing the responsibility of caring for patients in an emergency department in the United Kingdom, Hillman found that nurses negotiated their practice in a context shaped by institutional priorities of accountability and resource allocation through the practice of “effacement,” a situation in which patient care is reduced to faceless and impersonal interactions with limited moral regard which contributed to diminished moral proximity and demoralized social spaces. ¹¹ While these studies have contributed to understanding how the healthcare environment influences ethical nursing practice in high-income countries, little is known about the nature and influence of the work environment on nurses and midwives in resource-constrained obstetric settings like Ghana.

Midwives and nurses form the backbone of Ghana’s maternal healthcare program. Their responsibilities range from antenatal services, delivery services, postpartum services, family planning and comprehensive abortion care, treatment of sexually transmitted infections including HIV/AIDS counseling, child health services, and health promotion activities. ^13,14 Despite these enormous responsibilities and their contributions to meeting Ghana’s maternal health goals, they work in an unfavorable healthcare environment that is plagued with numerous challenges associated with the frequent lack of basic medical supplies and equipment, inadequate staffing, infrastructure issues, and the absence of an effective ambulance and referral system. ^{15 –17} These challenges impact the provision of quality care to childbearing women, contribute to preventable maternal deaths, and serve as a constant threat to the moral identity and ability of nurses and midwives to practice safely and ethically. Although several studies have described the nursing and midwifery work environments in resource-constrained settings, such as Ghana, as precarious with dire consequences for the personal and professional lives of midwives and nurses, ^{18 –23} they have not identified the ethical implications for those working in such environments. The purpose of this study, therefore, was to explore the moral habitability of obstetric settings in Ghana and how this influences the moral agency of nurses and midwives. This research is the first to explore the social-moral dimensions of the work environment of nurses and midwives in Ghana, highlight their marginalized voices, and make transparent the ethical challenges confronting them.

Theoretical underpinnings

The work of Margaret Urban Walker, ^24,25 a feminist ethicist was used as an interpretive lens. Walker ²⁴ underscores the importance of context in understanding a given situation and describes it as a “particular environment or set of circumstances that determine whether something is acceptable or makes sense” (p. xi). Context shapes the understanding of people about their responsibilities and becomes a reference for guiding their everyday moral thinking, judgment, practices, actions, and choices. ²⁴ Therefore, critically examining the context in which people are situated is important for determining the moral habitability of a place. Morally habitable places promote collaboration, cooperation, recognition, and shared goods as opposed to those that perpetuate suffering, oppression, and violence. ²⁵ Because the context of moral-social orders, like healthcare institutions, is laden with hierarchical relationships, imperfect understandings, conflicts, diverse worldviews, and resource inequities, it can render people’s moral lives incoherent, their voices muted, and their moral agency compromised. ²⁵ Moral agency is central to moral life because it reflects the kinds of things for which people take responsibility and is defined as the ability of an individual to act or make choices or decisions based on their values, responsibilities, and relationships. ²⁵

Critically analyzing moral understandings and diverse views allow for the values, material conditions, power, and oppressive conditions to be made transparent to determine the moral habitability of an institution or a community. ²⁵ This type of analysis also creates a possibility for transformative change and action. Critical analysis of the moral habitability of moral-social orders requires the examination of moral practices to determine what kinds of identities, relationships, and responsibilities sustain these practices. Moral identity comprises what a person values, assumes responsibility for, and cares about. ²⁵ These values are prioritized and shape peoples’ understanding of their responsibilities. Relationships are developed through an expectation of trust, past and present histories, and a possibility for continuity. ²⁵ But in a social world in which hierarchical relations are the norm and people are differently located, there are bound to be violations in mutual understandings and expectations. ²⁵ Walker ²⁵ acknowledges that frequent exposure to complex life circumstances and the unlimited demands they place on us can lead to a strain on our responsibilities, exhaustion, and sometimes compromise values.

Methodology

Because moral life is intricately enmeshed with social life, there are aspects of the social-moral orders that are not visible even to those who live within them unless they are subjected to critical analysis and interpretation. Walker ²⁵ suggests critically analyzing documents and using historical, ethnographic, and sociological accounts to make transparent the moral habitability of moral-social orders. Consequently, we chose critical moral ethnography as the methodology because it provides researchers with the intimate knowledge of participants’ social worlds and serves as a powerful tool for reflexive analysis of moral life from within and outside moral-social orders.

The study was conducted in obstetric departments of three tertiary-level facilities located in Ghana. These hospitals provide 24-h services in obstetrics and gynecology, medical-surgical, pediatrics, and other specialties. The nurses and midwives provide a 24-h presence on the ward through a three-shift system with four to five nurses and midwives running the day schedule with the night shift having two. Data were collected in the three health facilities between January and June 2018 through interviews, observation, and documentary materials. Due to the ethical requirements of respecting privacy and confidentiality and the complexity of obtaining informed consent in a healthcare setting, the observation part of this study was limited to the spatial arrangements, everyday activities, and the organizational structure. Because people make meaning of their lives and those of others through stories, ²⁵ semi-structured interviews were used to generate narrative accounts of 30 nurses and midwives who had worked 6 months or more in the different subunits of the obstetric department, comprising of lying in and labor, maternity (prenatal and postnatal), maternal ICU, and recovery wards. The participants were invited to share a story about their everyday experience in the maternity or labor ward, to describe their work environment and their relationships with their patients, other midwives/nurses, women and their families, and doctors. Interviews were conducted at locations chosen by the participants to ensure confidentiality. For example, some of the participants chose to be interviewed in the homes while others opted to have their interview at selected locations within their facility. Each interview lasted between 1 and 2 h and was audiotaped and transcribed by the first author. A total of 22 of the participants had training in midwifery and the remaining were generalist nurses with their ages ranging between 24 and 56 years. Eighty hours of observation were undertaken in the three health facilities during different shifts and documentary materials including nursing and midwifery curriculums, ward procedures and protocols, media publications, and the professional code of ethics were retrieved to support the discussion. The amount and types of data collected were sufficient to answer the research questions in this critical ethnography.

Ethical considerations

The study was approved by University of Toronto Health Sciences Ethics Review Board and the Navrongo Health Research Center Institutional Review Board. Written informed consent was obtained after the risks and benefits of participating were clarified. Participants were informed about their right to withdraw their consent, and pseudonyms generated from everyday conversational words were used to conceal their identities. The names of the healthcare institutions and their specific locations were not identified to avoid linking quotes to participants.

Data analysis

Thematic narrative analysis was used for data analysis and interpretation. This approach to analysis allows a researcher to explore meanings embedded within the content of stories ²⁶ and to highlight “an insider’s view of what a profession is really like” (p. 96). ²⁷ In a narrative analysis, the coding strategy is focused on grouping the narratives into patterns instead of the line-by-line coding done in other forms of qualitative analysis. ²⁸ A critical interpretive stance was maintained during the data analysis by paying close attention to power relations, oppressive structures, and shared meaning. Although narrative analysis seeks to understand the meaning of people’s experiences, it is imperative to take note of power and other oppressive forces shaping participants’ narratives when the research is framed with a critical perspective. ²⁹ This type of analysis serves as an opening wedge for understanding the moral habitability of a given place and gives voice to participants and their stories. The initial phase of this analysis began with a careful reading of the transcripts, field notes, and documentary materials while highlighting key expressions and statements that depicted institutional context, significant happenings, events and the narratives of values, identities, relationships, and responsibilities. The second phase of analysis was focused on an in-depth analysis that took into consideration the research questions and the theoretical underpinnings to illuminate the relationship between individual narratives and the broader social context that shaped them. ³⁰

The next phase of the analysis involved the synthesis of all the concepts and meanings from the second phase to determine the emergence of narrative patterns and generate possible explanations. In the final phase, consideration was given to the theoretical concepts and relationships among emerging themes and labeling of the themes. The data were managed with Dedoose qualitative software. Rigor was demonstrated by ensuring congruence between the research questions, methodology, and the theoretical underpinnings. ³¹ Considering the first author’s previous role as a nurse educator in Ghana and her embedded knowledge about the research setting, the participants were informed at the outset of the study that the research was not to evaluate their practice but to gain an understanding of what it meant to practice in the obstetric setting from their perspective. Given this inherent power difference, the research was co-created with the participants’ stories. Recognizing this shared process of knowledge production “forces us to acknowledge our own power, privilege, and biases just as we are denouncing the power structures that surround our subjects” (p. 8). ³²

Findings

Five overarching themes depicting morally uninhabitable work environments and their influence on the moral agency of participants were discovered: (1) Holding onto the values, identities, and responsibilities of being a midwife/nurse; (2) Scarcity of resources as limiting capacity to meet caring responsibilities; (3) Gender and socio-economic inequities shaping the moral-social context of practice; (4) Working with incoherent moral understandings and damaged identities in the context of inter- and intra-professional relationships; and (5) Surviving through adversity with renewed commitment and courage.

Discussion

Participants described holding onto the values of being nurses or midwives as important in how they understood their moral responsibilities and negotiated their practice. Doing the right thing was described as a means of acknowledging and affirming their commitment to patients, profession, and their identity of being a good nurse or midwife. Statements such as “as a nurse you want to do the right thing” are consistent with Walker’s understanding that upholding integrity is an evaluative measure of one’s “unconditional commitments, or uncorrupted fidelity to a true self” (p. 112). ²⁵ This sense of “uncorrupted fidelity to self” was expressed in their desire to do the right thing as a way of preserving their identities which is consistent with previous findings that upholding integrity in nursing is mediated by nurses’ responsibility to patients and their profession. ^{33 –35} Such an understanding deepened their awareness and increased their sensitivity to unethical practice and sense of altruism.

The socialization of these Ghanaian nurses and midwives, both personally and professionally, shaped their commitment and sense of altruism. According to Gyekye, values such as kindness, compassion, empathy, concern for others, respect, and human dignity are the basis for moral teaching. ³⁶ The internalization of these values becomes the foundation of a person’s moral life. It was, therefore, not surprising when the nurses and midwives described their social-moral upbringing as shaping their caring commitments. The centrality of nursing care lies in the “human connection that is largely intangible, unmeasurable, unquantifiable aspect of nursing practice that caregivers value most” (p. 348). ³⁷ This sentiment was echoed by the nurses and midwives who acknowledged that being appreciated by patients was important to sustaining their commitment and work engagement. Such recognition of their effort, although intangible, gave meaning to their sense of being and an affirmation that nursing was truly a rewarding and satisfying career. Peter et al. ³⁸ reported that nurses maintained their identity through a process of reciprocal recognition in which recipients of care can express gratitude and appreciation to nurses as a means of affirming their identity as good nurses. Although this was based on mutual recognition, the unequal nature of the power between nurses and patients in situations of misrecognition or ingratitude could affect the caring process. ³⁸ In this study, these nurses and midwives work under extremely difficult conditions to provide care, and therefore any misrecognition or ingratitude could severely impact the caring process.

Our findings show that the obstetric work environment of nurses and midwives was morally uninhabitable. The participants described working in an environment that did not promote collaboration, recognition, and shared goods but one that contributed to their suffering, distress, and oppression. They characterized the obstetric work environment as one that was dominated by business-oriented values that were inconsistent with their values. Nurses interact and understand their responsibilities to patients in moral terms anchored in values, beliefs, and notions of vulnerability. The emerging profit-driven healthcare environment in Ghana is altering this relational dynamic between nurses and patients. In this ecology, nurses are expected to substitute their moral relationship with an economic relationship in support of an institutional agenda of enhancing efficiency and maximizing profit. When values such as efficiency become the driving force in healthcare organizations, patients and healthcare become constituted as commodities to be traded for profit. ³⁹

In a context where poverty is endemic, healthcare resources are extremely scarce and there is a high obstetric risk, these nurses and midwives envisioned that treating patients and care as mere commodities had dire consequences for patient safety, blurred the boundaries of their moral responsibilities to their patients, and led to a fragile nurse–patient relationship. These findings reflect those of Weiss et al. ³⁹ who found that when organizational values take precedence over important components of professional practice, such as relational work and patient safety, they cloud the fiduciary responsibility of nurses and threaten their moral identity. The participants described how the drive toward efficiency and profit maximization resulted in the rationing of supplies and contributed to the scarcity of resources, thereby constraining their moral agency, compromising their practice, and leading to an overwhelming sense of failure and incompetence. These situations left them feeling unaccomplished and exposed them to suffering and distress as they became witnesses to women suffering and dying because of a lack of basic resources. When people are made incapable of fulfilling their commitments or their best attempt to fulfill them is hindered, it “inflicts on people miserable costs and terrible losses, including psychic ones” (p. 132). ²⁵ Bearing witness to injustice or gross violations and being unable to prevent them exposed the nurses and midwives to unendurable suffering and distress. They described experiencing incoherent moral responsibilities in which they felt overburdened by endless, multiple, conflicting, and complex obstetric demands of women, which sometimes exceeded their capacity to prioritize and address. Differing demands on different persons or the same person ²⁵ might result in conflicting responses and cause a person to weigh their choices by determining what they can tolerate and what sacrifices can be made. Under these circumstances, the nurses and midwives were compelled to leave care undone, incomplete, or delayed as they tried to fulfill other urgent demands.

The participants described their work environment as overwhelmingly oppressive and dominated by power struggles. When hierarchical power relations and epistemic lines collide, “people may literally not know who is who and what is what unless or until some moral understandings are shared” (p. 236). ²⁵ Because knowledge and interventions are created by different epistemic positions and authority, the nurses and midwives described experiencing incoherent moral understandings as treatment decisions and interventions were frequently changed. Their attempt to navigate through these diverse epistemic positions led to crises of conflicting loyalties as they struggled to determine whose treatment intervention to implement. Nurses and midwives have endured a long history of marginalization and diminished status through what Walker describes as representational practices. These are socially constructed identities of people that are made to fit them by virtue of their existing social location and role, shaping how they see themselves and how others perceive them. ²⁵ Nelson ⁴⁰ argues that the effect of these social processes and representational practices on those who bear these identities is the deprivation of important social goods and self-respect. Such representational practices resulted in the nurses and midwives being marginalized, disregarded, devalued, and disqualified as competent knowers. Under these circumstances, interprofessional collaboration became impossible since it damaged their identity and eroded their sense of responsibility. Similarly, Sabone et al. ²³ found that physician domination and lack of recognition of nurses’ role hindered interprofessional collaboration among nurses and doctors in Botswana.

The institutional and societal privileging of doctors, especially in a context where their numbers are few, has allowed some to exploit the interprofessional relationship among them and nurses within the healthcare work environment. Maykut ⁴¹ has argued that sustaining morally habitable places requires a shared commitment between employees and management in order to challenge the dominant construction of the self embedded in social and political structures. We add that challenging these dominant institutional and societal authorized identities will require developing counterstories ⁴⁰ within and outside healthcare systems that project nurses and midwives as indispensable to the functioning of any healthcare system not only during crisis. Telling these counterstories will also require “interpersonally effective voices” (p. 228) ²⁵ that allows nurses and midwives to draw critical language to confront these unjust social arrangements.

The nurses and midwives also described how the oppressive socialization of women created conditions of dependency and deprived laboring women of the opportunity to access healthcare and to exercise autonomy. As participants became witnesses to the “daily miseries, indignities, the intergenerational effect of poverty and social marginality” (p. 217), ²⁵ their responsibilities expanded to include the roles and responsibilities otherwise taken by families.

Nurses and midwives revealed that their work environment promoted acts of violence and aggression toward them. Threats of violence, or the experience of it, coupled with the absence of security created fear and insecurity which impacted how the nurses and midwives responded to their moral responsibilities. These findings are supported by other studies which found that workplace violence led to staff demoralization, dissatisfaction, and decreased workplace productivity. ^{42 –44} Encountering a morally uninhabitable work environment threatened the moral identity of nurses and midwives and exposed them to unendurable suffering. People who experience moral wounds or shattered identities require support to restore their identity and self-respect and to re-establish moral equilibrium. ⁴⁵ However, participants described an overwhelming lack of support and resources to help them heal and cope. This lack of concern for their suffering, a form of normative abandonment, may lead to a second injury that leaves people with unbearable feelings of rage, anguish, humiliation, and bitterness. ⁴⁵

Nevertheless, the participants described fostering resilient identities through faith and prayer and the recognition of their moral commitment to childbearing women. According to Gyekye, because “Africans live in a religious universe” (p. 1), ³⁶ they tend to depend on God for support and strength in all aspects of their work life including during times of adversity. The dependence on God was a recognition of their inadequacies as nurses and midwives and the need for a continuous dependence on God for strength, support, and guidance. Such acknowledgment gave meaning to their situation, provided emotional upliftment, and enabled them to overcome their difficulties which all contributed to renewing their commitment and re-establishing moral equilibrium in times of adversity. While the appraisal of their adversities through a religious lens enabled them to cope, there is a possibility that this may likely have led to failure to take responsibility to act and confront the constraints impacting their moral agency. Other studies outside nursing have similarly reported that while religious interpretation of personal problems and oppressive conditions enabled people to cope and defer their problems to a supreme being, it may have likely concealed their ability to take responsibility to address the situations they encountered. ^46,47

While some found ways of demonstrating resistance by asserting their voice and summoning collective courage, the fear of retribution and unresponsiveness of their institutions regarding their concerns discouraged them from speaking out and contributed to maintaining a system that perpetuated their suffering and oppression. Similar studies have reported nurses being ignored by authorities for raising concerns, fear and blame, and retribution as reasons nurses did not speak out about their poor working conditions at the Mid Staffordshire NHS Foundation Trust and other hospitals. ^{48 –50} Walker states that when an act of injustice to others is committed by people with power, they set up a corresponding system, or political arrangement, to silence victims with the expectation that these injustices will not be uncovered. ²⁵ This punitive culture disempowered and deterred nurse leaders from demonstrating courage and resistance against the health system as well as supporting other nurses and midwives.

Conclusion

The findings portray the work environment as morally uninhabitable in which nurses and midwives in Ghana struggled to sustain their moral ideals. The nurses and midwives confronted the myriad of constraints through the influence of their moral values and in many instances navigating through these morally uninhabitable places and conditions inflicted on them unendurable pain and suffering. Given the impact of morally uninhabitable work environments on nurses, midwives, and childbearing women, addressing these challenges through investment in the health sector and instituting interprofessional practice guidelines and workplace violence prevention policies could promote ethical and safe nursing and midwifery practice.

Limitations

The exclusion of the voices of doctors, administrators, and childbearing women in this research hindered the ability to examine, compare, and contrast those aspects of social-moral life influencing and shaping the moral habitability of the obstetric settings. While recognizing that the inclusion of this group of people would have added more insight, involving such a large and diverse sample was beyond the scope of this research project. Nonetheless, this study is the first to analyze the moral habitability of obstetric settings in Ghana and highlight the marginalized voices of nurses and midwives.