Moral distress and moral competences in midwifery: A latent variable approach

Abstract

Like other health professionals, midwives need moral competences in order to cope effectively with ethical issues and to prevent moral distress and negative consequences such as fatigue or impaired quality of care. In this study, we developed and conducted a survey with 280 midwives or midwifery students assessing the burden associated with ethical issues, moral competences, and negative consequences of moral distress. Results show that ethical issues associated with asymmetries of power and authority most often lead to the experience of distress. The results are critically discussed in the context of the conceptualization and operationalization of moral distress.

Keywords

ethical issues midwifery moral competences moral distress psychological distress

Introduction

Moral distress is a widespread phenomenon that has been investigated in a variety of healthcare professions and different healthcare settings (Pauly et al., 2012). Although there is ongoing debate about how to define it, McCarthy and Gastmans (2015) note that there is some consensus on the experience of moral distress as “the psychological–emotional–physiological suffering that nurses may experience when, constrained by circumstances, they participate in perceived wrongdoing by action or omission” (p. 132). According to Andrew Jameton’s original notion of moral distress, there is a distinction between negative feelings such as frustration or anxiety when faced with an ethical issue and constraints (initial moral distress) and the individual failure to react to initial moral distress (reactive moral distress; Johnstone, 2013; Lützén et al., 2010). Perhaps, more importantly, from a clinical point of view, a great number of empirical studies have shown that high levels or prolonged experience of moral distress may have negative consequences such as decreased quality of patient care and job satisfaction or increased rates of burnout and job attrition (McCarthy and Gastmans, 2015; Pauly et al., 2012). Therefore, it is crucial to understand the factors leading to the experience of moral distress and its negative consequences on both an individual level and a healthcare systems level. However, Morley et al. (2017) conclude that, so far, there is little agreement on the factors causing it.

Jameton’s definition of reactive moral distress, the failure to react, has similarities to other forms of distress. For example, symptom distress can be conceived as discomfort or suffering as a consequence of physical symptoms (Ridner, 2004). Psychological distress, a concept frequently studied in psychology, medicine, and nursing, is also characterized by a state of discomfort and negative emotions resulting from a specific stressor. For example, the Psychological Distress Manifestations Measurement Scale assesses feelings of pessimism or social withdrawal, among other things (Massé, 2000; Ridner, 2004). However, the relationship between a stressor and resulting distress is not a direct one: whether stressors are experienced as stressful depends on the context and whether stressors also translate to maladaptive reactions to this stress depends on the available coping resources (Wheaton and Montazer, 2010). Furthermore, stressors do not necessarily have to be present but can also be anticipated (Ridner, 2004). If these types of distress are comparable with moral distress, one can predict that individual competences (or coping resources) and the institutional ethical climate (or context) determine whether the moral stress associated with ethical issues will result in moral distress. As a working definition and in line with Jameton’s reactive moral distress, moral distress can be conceived as the suffering and discomfort resulting from a failure to effectively deal or cope with a moral event (cf. Morley et al., 2017). For example, midwives frequently mention late abortions as a moral issue, but in contrast to moral issues related to limited patient autonomy, many of the midwives learned to cope with these situations and do not experience moral distress (Oelhafen et al., 2019). Understanding which aspects of moral events may lead to the experience of moral distress and what kind of competences or coping resources may prevent it is not only a conceptual question but should also be assessed empirically.

Operationally, moral distress is most often assessed with the Moral Distress Scale (Corley et al., 2001), which has now been revised, translated, and validated in many countries (Lamiani et al., 2017; McCarthy and Gastmans, 2015). However, these questionnaires focus on the intensity and frequency of experienced moral distress related to specific situations, not an overall state of discomfort as described above. These negative feelings elicited by specific ethical issues may be a normal reaction or an indicator of ethical awareness or the willingness to do good (Kulju et al., 2015; Lützén et al., 2010). Conversely, the negative consequences such as job attrition, decreased quality of care, low job satisfaction, or burnout (DeTienne et al., 2012; Dodek et al., 2016; Kleinknecht-Dolf et al., 2017; Lamiani et al., 2017; Pauly et al., 2012) seem to be a much more distinct indicator of moral distress.

Taken as a whole, research should focus on the interplay of ethical issues, individual competences, and ethical climate to prevent these negative consequences. As Lamiani et al. (2017) pointed out, studies have so far been predominantly correlational and more sophisticated data analytic procedures are necessary to disentangle the causes and effects of moral distress. Also, both ethical issues and moral competences should be considered in the cultural and professional context (Asahara et al., 2015; Hamric, 2012).

Aims of the current study

Taking account of these requirements, and based on the results of a qualitative interview study being published elsewhere (Oelhafen et al., 2019), we developed a questionnaire specific to the midwifery setting in order to assess:

The burden associated with and the frequency of ethical issues;

Moral competences, which we defined as a set of skills, attitudes and knowledge needed to effectively deal or cope with these issues;

Ethical climate;

Negative consequences following prolonged moral distress, such as fatigue or the tendency to leave a job;

Other demographic characteristics, such as age, work setting, and work experience.

Using a factor analytic approach and subsequent multiple regression analysis, the goal was to understand the structure of ethical issues and moral competences, and to empirically assess the factors leading to moral distress and the negative consequences mentioned above.

Method

Design

This study is the second phase of a sequential mixed-methods approach. Whereas the first phase was a qualitative interview study to inductively describe the essential elements of ethical issues, moral competences, and moral distress in midwifery (Oelhafen et al., 2019), the second part is a web-based cross-sectional questionnaire survey aiming to assess these concepts quantitatively and understand their relationship.

Participants and procedure

Participants were recruited via the newsletter and the national journal of the Swiss Midwives Association. The recruitment text stated that we were looking for currently employed midwives from the inpatient and outpatient setting in the German-speaking part of Switzerland. In addition, midwifery students in the third and fourth year of their training at the Zurich University of Applied Sciences and the Bern University of Applied Sciences were contacted directly by email.

Demographic information of the final sample can be found in Table 1. In total, 280 midwives or midwifery students filled out the questionnaire, of whom 254 (90.7%) completed all sections. The estimated response rate was 16 percent for midwifery students and about 9 percent of German-speaking midwives currently employed in Switzerland. Of the 254 respondents who completed all sections, 55 were working in the outpatient setting, either in birth houses or working independently (21.7%) and 199 in the inpatient setting, that is, in university, cantonal, regional, and private hospitals (18.5%, 26.4%, 19.3%, and 14.2%). About half of the currently employed midwives had more than 10 years of work experience.

Table 1.

Demographic information of the sample.

	n	Age (SD)	Experience in years (SD)
Total	280
Completed questionnaires	254	37.7 (11.7)
Midwives	208	40.1 (11.1)	13.7 (10.6)
as other health professional	76		5.9 (5.1)
Midwifery students	46	26.8 (7.1)	1.4 (1.1)
as other health professional	20		4.1 (3.2)

Some of the midwives and midwifery students reported to have had previous experience working in another health profession.

Measures

In the first phase, we created a list of 73 items, organized in five domains, to assess the following:

Level of disturbance and frequency of moral problems (29 items);

Negative consequences of moral distress (4 items);

Self-assessed moral competences (24 items);

Ethical climate (7 items);

Demographic information and work setting (9 items).

To assess moral problems, negative consequences of moral distress, and moral competences, we generated items that were based on themes that emerged in the qualitative interview study (Oelhafen et al., 2019) or were derived from items of other related questionnaires (Asahara et al., 2015; Gustafsson et al., 2010; Kleinknecht-Dolf et al., 2015; Lützén et al., 1997, 2006; McDaniel, 1997; Mischo, 2003; Sekerka et al., 2009) and adapted to the peculiar context of midwifery. The goal was to create items that were similar to the concrete formulations found in the qualitative study in order to describe observable issues and competences close to everyday clinical practice that would spontaneously lead to a response (Rost, 1996; Schuler Braunschweig, 2006).

In the second phase, the list of 73 items was sent to 10 experts in the field, that is, lecturers in midwifery/ethics and mostly experienced midwives working in the in-patient and out-patient settings. These experts rated 64 items regarding clarity (“yes”/“no”) and relevance for midwifery practice (“not at all”/“somewhat”/“moderately”/“very”) (Polit and Beck, 2006). Nine items related to demographic information and work setting did not undergo content validation. Of the evaluated 64 items, 44 items were selected based on relevance ratings. Items that were both overlapping with other items and having similar relevance ratings were excluded in order to reduce content redundancy. 96 percent of the final items were rated as both clear and as moderately or very relevant. For some items, comments were also used to improve clarity or relevance.

In the third phase, the questionnaire was implemented in SurveyMonkey (www.surveymonkey.com). After initial information about the questionnaire was presented, study participants were asked to rate 19 ethical issues regarding disturbance on a five-point Likert scale (“not disturbing”/“slightly disturbing”/“moderately disturbing”/“quite disturbing”/“very disturbing”). Furthermore, using the same list of 19 ethical issues, participants were asked to report on frequency, that is, how often they experienced a situation like this during work within the last 12 months (“never”/“rarely”/“sometimes”/“often”/“very often”). Then, they were asked how often in the last 12 months ethical issues like the ones they had rated previously led to any negative consequences, using the same five-point Likert scale as before for four items. After that, they were shown a list of 16 moral competences, which we presented as “behaviors and ways of thinking,” stating that these should not be evaluated in terms of correctness, but that the participants should state how much these statements reflected their behavior during work (“strongly disagree”/“rather disagree”/“partially agree”/“rather agree”/“completely agree”). In the last section, the same scale of agreement was used for five items regarding the ethical climate in their current work institution. In the end, several questions regarding their current and previous experience of work were assessed. While the order of all scales was fixed, the item order within them was individually randomized using SurveyMonkey built-in functionality.

Data analysis

The primary goal of the analysis was to retain as many items as possible to uncover the latent structure of all scales by conducting an exploratory factor analysis. Therefore, we adapted Kline’s (2013) suggestion and excluded items only when they had both a corrected item-total correlation < 0.3 before factor extraction and no factor loading > 0.3. In a first analysis, we calculated Cronbach’s alpha for all scales and manually inspected all items regarding mean, SD, and range. Then, Bartlett’s Test of Sphericity and the Kaiser–Meyer–Olkin measure of sampling adequacy (MSA) were calculated as indicators of whether the scale was appropriate for factor analysis. To determine the number of factors to be retained, parallel analysis and Velicer’s minimum average partial (MAP) criterion were applied, which are both favored over other approaches (Henson and Roberts, 2006). Within this range, we chose the simplest solution with a root mean square error of approximation (RMSEA) < 0.05 (Browne and Cudeck), a Tucker–Lewis index (TLI) > 0.90 (Matsunaga, 2010), and a minimum of cross-loadings > 0.3.

After factors and factors score estimates using the Bartlett method (DiStefano et al., 2009) were calculated, we tested the influence of contributing factors such as ethical issues, moral competences, and ethical climate on the negative consequences using multiple linear regressions. More specifically, we tested if the frequent occurrence of ethical issues that were considered to be very disturbing led to more negative consequences of moral distress such as thinking about changing one’s job or having the feeling of not being able to recover enough, by controlling for demographic variables such as age and years on the job (DeTienne et al., 2012). Data analysis was conducted using R and RStudio for base analyses and multiple linear regressions, the psych package (Revelle, 2017) for subsequent item analysis and exploratory factor analysis and the packages lm.beta (Behrendt, 2014) and rms (Harrell, 2017) for regression diagnostics.

Ethics

A non obstat statement was obtained for the complete project from the ethics commission of the Canton of Bern, Switzerland, stating that in accordance with the Swiss Law on Research with Humans, no further ethical approval was needed for this kind of study. On the first page of the questionnaire, participants were informed that no personal data would be recorded that would allow any deanonymization and that they could terminate filling out the questionnaire at any time.

Results

Item analysis

Cronbach’s alpha for the disturbance scale (19 items) was 0.83 (95% confidence interval (CI) [0.79–0.85]) and 0.87 [0.85–0.89] for the frequency scale (19 items). The ethical issues rated as most disturbing were related to inadequate staffing and lack of trust in the midwives’ professional competence. The most frequent problems were situations where the patient receives conflicting information from different health professionals, cesarean sections, or other interventions without a medical reason and, again, problems associated with inadequate staffing. Item characteristics of all items are available in Tables S1a–e (see Supplementary material).

Cronbach’s alpha for the moral competences scale (16 items) was 0.76 [0.72–0.80]. A few items had rather high values with potential ceiling effects, but all items met at least one of our criteria, that is, a corrected item-total correlation or at least one-factor loading > 0.3.

The scale on negative consequences (4 items) had a Cronbach’s alpha of 0.80 [0.76–0.84]. On average, the highest ratings were recorded for an item reflecting the feeling of not being able to recover enough during one’s leisure time, which participants reported having “sometimes” (29.7%), “often” (9.8%), or “very often” (4.5%).

On the ethical climate scale (5 items), there were some missings because we instructed participants to skip items which they thought would not apply to their work setting (e.g. institutional support for ethical issues as a freelance midwife). Cronbach’s alpha was a bit lower, 0.70 [0.63–0.76], but it still met the usual requirement of a minimum Cronbach’s alpha of 0.70 (Rattray and Jones, 2007).

Exploratory factor analysis

Ethical issues

While one goal of this study was to interpret the frequency and the disturbance associated with ethical issues independently, we only applied exploratory factor analysis to the disturbance scale. While the frequency scale most likely reflects the work setting a midwife is working in, for example, how often a kind of ethical issue arises in a large university clinic, the disturbance is theoretically more interesting, as it reflects the burden associated with the ethical issue but also the context and individual coping resources or competences.

Both the MSA and Bartlett’s Test of Sphericity indicated that the data from the disturbance scale were adequate for factor analysis (MSA = 0.85; χ² = 1459.3, df = 171, p < 0.001). Parallel analysis and Velicer’s MAP criterion suggested solutions between two and four factors, where three factors was the simplest solution with an acceptable fit (RMSEA = 0.045, TLI = 0.930). The resulting factor solution can be found in Table S2 (see Supplementary material). Eigenvalues of 5.0, 2.3, and 1.5 associated with these three factors indicated that the linear components accounted for 46.3 percent of total variance. The first factor was termed moral conflicts, as these problems mostly relate to value conflicts or conflict of interests. The second factor abortions loaded predominantly on items related to abortions, and the third factor was named asymmetries of power and authority (cf. McCarthy and Gastmans, 2015), referring to problems resulting from midwives’ feelings of a lack of trust in their professional competence, inadequate staffing and conflicts of loyalties. In a final step, to be able to measure the influence of disturbance and frequency of these factors independently, we applied the same regression weights for the disturbance and the frequency scale. This means, that if, for example, the factor abortions loads high on an item in the disturbance scale, it loads high on this item in the frequency scale too. The average level of disturbance and the average frequency of items for these three factors are shown in Figure 1.

Figure 1.

Mean disturbance ratings and frequency of different ethical issues. Likert scales ranged from 1 (“not disturbing”) to 5 (“very disturbing”) and 1(“never”) to 5 (“very often”), respectively. Error bars represent 95 percent confidence interval.

Moral competences

For the scale measuring moral competences, both the MSA and Bartlett’s Test of Sphericity indicated that these data are also adequate for factor analysis (MSA = 0.80; χ² = 825.7, df = 120, p < 0.001). Parallel analysis and Velicer’s MAP criterion suggested solutions between two and five factors, where, again, three factors was the simplest solution with an acceptable fit (RMSEA = 0.046, TLI = 0.905). Eigenvalues of 3.7, 1.9, and 1.3 associated with these three factors indicated that the linear components accounted for 43.1 percent of total variance. The first factor was called assertiveness, the second factor was called moral motivation, including items measuring the motivation to self-reflect, and the third was labeled with the psychological term self-distancing, which has been associated with the ability to control one’s emotions (self-regulation), with perspective-taking during conflicts and with increased problem-solving behavior (Ayduk and Kross, 2010), which seem to relate well to the items on which this factor loads (Table S3, see Supplementary material).

Negative consequences

For negative consequences, both MSA and Bartlett’s Test indicated adequacy for factor analysis (MSA = 0.78; χ² = 344.0, df = 6, p < 0.001). Parallel analysis and Velicer’s MAP criterion suggested a one-factor solution, which also had a good fit (RMSEA = 0.048, TLI = 0.989). The resulting factor solution can be found in Table S4 (see Supplementary material). An eigenvalue of 2.5 associated with this factor indicated that the linear component accounted for 62.9 percent of total variance.

Ethical climate

Again, both MSA and Bartlett’s Test indicated adequacy for factor analysis (MSA = 0.75; χ² = 231.4, df = 10, p < 0.001). Parallel analysis and Velicer’s MAP criterion suggested solutions between one and two factors, but only two factors led to an acceptable fit (RMSEA = 0, TLI > 1). The first factor ethical climate was clearly related to interprofessional exchange, respect, and trust; the second factor to institutional support. However, because a latent variable based on only two indicators is less reliable, we decided to extract only one latent variable (RMSEA = 0.112, TLI = 0.844). The resulting factor solution for all subscales can be found in Table S5 (see Supplementary material). An eigenvalue of 2.3 associated with this factor indicated that the linear component accounted for 46.2 percent of total variance.

Multiple linear regressions

A multiple linear regression was carried out to test if the level of disturbance and frequency, moral competences, and ethical climate predict the frequency of negative consequences, while controlling for several control variables. Separate regressions were used to predict the level of disturbance of moral conflicts, abortions, and asymmetries of power and authority. All results are shown in Table 2.

Table 2.

Summary of multiple linear regression analyses for variables predicting negative consequences of moral distress and disturbance of three types of moral problems (moral conflicts, abortions, and asymmetries of power and authority) (n = 210).

Variable	Negative consequences			Moral conflicts			Abortions			Asymmetries of power and authority
Variable	t	p	β	t	p	β	t	p	β	t	p	β
Level of disturbance
– Moral conflicts	1.65	0.10	0.09
– Abortions	2.54	0.012	0.12*
– Asymmetries of power and authority	0.76	0.45	0.04
Frequency
– Moral conflicts	0.86	0.39	0.05	4.05	<0.001	0.29***
– Abortions	−0.24	0.81	−0.02				2.18	0.03	0.19*
– Asymmetries of power and authority	3.71	<0.001	0.19***							2.58	0.011	0.17*
Moral competences
– Assertiveness	−3.61	<0.001	−0.18***	−0.38	0.70	−0.03	−0.76	0.45	−0.06	−1.04	0.30	−0.08
– Moral motivation	1.38	0.17	0.06	2.74	0.007	0.16**	1.06	0.29	0.07	4.98	<0.001	0.31***
– Self-distancing	0.32	0.75	0.01	−0.25	0.81	−0.01	−0.54	0.59	−0.03	0.97	0.33	0.06
Ethical climate
– Ethical climate	−3.78	<0.001	−0.26***	−1.17	0.24	−0.11	−1.42	0.16	−0.13	−0.41	0.68	−0.04
Control variables
Outpatient setting (yes/no)	2.15	0.03	0.33*	3.53	<0.001	0.73***	−0.14	0.89	−0.03	2.11	0.04	0.46*
Student (yes/no)	−2.02	0.04	−0.32*	0.31	0.76	0.07	0.63	0.53	0.15	1.01	0.31	0.23
Age	1.05	0.29	0.01	−1.05	0.30	−0.01	−1.54	0.12	−0.01	−1.28	0.20	−0.01
Years in institution	−1.33	0.19	−0.01	0.99	0.33	0.01	1.51	0.13	0.02	1.39	0.17	0.01
Employment level	0.55	0.59	0.00	1.27	0.21	0.00	−1.52	0.13	−0.01	0.64	0.52	0.00
R ²	.45			.22			.08			.22
Total F	10.69*** (15, 194)			5.60*** (10, 199)			1.69 (10, 199)			5.47*** (10, 199)

t-values (t), significance (p), and standardized coefficients (β).

p < 0.05; **p < 0.01; ***p < 0.001.

The first model to predict negative consequences had an acceptable fit, R² = .45, F(15, 194) = 10.69, p < 0.001. The largest effects could be observed for the frequency of asymmetries of power and authority (β = 0.19, p < 0.001), the moral competence assertiveness (β = –0.18, p < 0.001), and ethical climate (β = –0.26, p < 0.001). Therefore, while high self-assessed ratings of assertiveness and a positive ethical climate were associated with a reduction in negative consequences, frequent occurrences of asymmetries of power and authority were linked to more negative consequences, irrespective of how disturbing these events were to raters. Conversely, participants who rated abortions as very disturbing also reported more negative consequences (β = 0.12, p = 0.012), irrespective of how often they experienced these situations. Furthermore, working in the out-patient setting was linked to an increase in negative consequences (β = 0.33, p = 0.03), whereas being a student was associated with fewer negative consequences (β = –0.32, p = 0.04).

Regression models predicting the disturbance level of moral problems yielded similar results, although the model for disturbance by abortions did not result in an overall significant effect, R² = .08, F(10, 199) = 1.69, p = 0.08. In all three models, more frequent problems were associated with higher levels of disturbance (all βs ⩾ 0.17, all ps < 0.05), while higher self-assessed moral motivation (both βs ⩾ 0.16, both ps < 0.01) and the out-patient setting (both βs ⩾ 0.46, both ps < 0.05) lead to higher levels of disturbance in moral conflicts and asymmetries of power and authority.

Because the model predicting negative consequences suggested a strong mutual dependence of competences, problems, and context, we again conducted three linear multiple regressions predicting self-assessed moral competences with frequency of ethical issues, ethical climate, and the same set of control variables as used before. The regression model for self-assessed assertiveness resulted in an overall significant solution, R² = .25, F(9, 200) = 7.26, p < 0.001, with the frequency of asymmetries of power and authority (β = –0.14, p = 0.047), the ethical climate (β = 0.19, p = 0.04), and being a midwifery student as significant predictors (β = –0.77, p < 0.001). Therefore, midwives often experiencing situations associated with power asymmetries had lower ratings of assertiveness. The regression model predicting moral motivation did not attain a good fit, R² = .07, F(9, 200) = 1.70, p = 0.09, with only working in the out-patient setting as a significant predictor (β = 0.69, p < 0.01). Finally, the model for self-distancing was significant, R² = .13, F(9, 200) = 3.31, p < 0.001, with ethical climate (β = 0.48, p < 0.001) and age (β = 0.03, p < 0.01) significantly predicting its outcome.

Discussion

In conducting a web-based cross-sectional questionnaire survey and subsequent factor analyses and multiple regression analyses, the goal of the current project was to understand the structure of ethical issues and moral competences in midwifery, and to estimate the factors leading to moral distress and its negative consequences, such as fatigue or thinking about leaving one’s job. Based on a qualitative interview study that we conducted (Oelhafen et al., 2019), we generated a comprehensive list of items measuring the disturbance level and frequency of ethical issues and the moral competences needed to cope effectively with these situations. After exploratory factor analysis, the three factors moral conflicts, abortions, and asymmetries of power and authority emerged as groups of ethical issues, and assertiveness, moral motivation, and self-distancing as relevant moral competences.

The results illustrated mutual dependences of ethical issues, moral competences, ethical climate, and moral distress. For example, self-assessed assertiveness was strongly dependent on asymmetries of power and authority, while both together were the two most important predictors of negative consequences such as fatigue or impaired work quality. This dependence suggests that our measure of assertiveness particularly assesses self-efficacy for assertiveness. According to Bandura (1977), self-efficacy reflects the degree of control someone perceives regarding specific situations or challenges. These convictions and expectations about their own effectiveness also influence coping efforts and emotional regulation in given situations (Bandura, 1977; DeTienne et al., 2012). Therefore, frequently experienced situations with a lack of control (asymmetries of power and authority) may decrease midwives’ self-efficacy regarding assertiveness and may result in midwives not trying to cope with these situations (moral distress). Furthermore, Bandura (1977) states that people start to fear specific situations and choose other settings because they believe that the challenges of a threatening situation exceed their coping skills, which might explain why assertiveness predicts negative consequences such as the intention to leave one’s position. Similarly, Browning (2013) found that low psychological empowerment leads to increased moral distress. Interestingly, self-efficacy is highly task-specific and malleable, which makes it an interesting starting point for intervention research (Rathert et al., 2016). In a similar vein, self-distancing, the ability to reflect on negative events effectively in “taking a step back” (Kross and Ayduk, 2017), to analyze situations rationally and calmly and to be flexible, depended to a certain extent on a positive climate. Although the relationship was not very strong, one could hypothesize that in an institution with a low ethical climate, midwives view respect for the patient’s autonomy as being much more at risk, which makes it more difficult to “step back” and be less empathetic with the woman.

Although our results are in line with those of other studies stressing the importance of involvement in decision-making and the quality of interprofessional collaboration (Lamiani et al., 2017), we have argued that an assessment of disturbance or the intensity and frequency of ethical issues may not be a valid indicator of moral distress. While we cannot answer this question conclusively, there are some remarks to be made. First, moral distress is usually measured with a composite score, multiplying the frequency (0–4) by the level of disturbance (0–4) of all ethical issues (Kleinknecht-Dolf et al., 2017). However, a composite score makes it much more difficult to understand the exact causal relationship between the experience of certain ethical issues, moral competences, or coping resources and the resulting moral distress. Our results suggest that there are ethical issues that are difficult to cope with irrespective of the level of disturbance, such as a lack of respect for or trust in one’s professional competence, and then, there are ethical issues related to child death or abortion that may lead to moral distress only for some midwives because they have not learned to cope with them effectively. However, composite scores may be helpful in an applied context to monitor moral distress. Second, the level of disturbance of an ethical issue largely depends on the moral motivation and the work setting, which again overlaps to a certain extent with moral motivation. This can be interpreted to mean that the level of disturbance reflects moral stress, not distress, and is an indicator of moral motivation or sensitivity (Kulju et al., 2015; Lützén et al., 2010). As outlined in the introduction, having sleep problems or feeling unable to recover enough seems to be a more distinct indicator of moral distress.

As Morley et al. (2017) pointed out, even if psychological distress is a necessary condition of moral distress, it still needs to be linked to a moral event in order to become moral distress. Among the 19 different ethical issues described by midwives, we identified three factors. Moral conflicts included ethical issues where parents decide to have a cesarean section or an induction of labor, although from a midwife’s perspective, they are not medically indicated. Even if midwives do perceive these situations as difficult, they are certainly able to argue for their position based on professional values (cf. Oelhafen et al., 2019). However, these situations can also be labeled as “moral discomfort,” the negative feeling associated with moral subjectivity and not the inability to act (Repenshek, 2009). The same holds true for abortions, the second group of ethical issues. For example, even when a midwife cannot understand a client’s decision to have a late termination of pregnancy, she would never intervene and try to convince the woman not to do so. That is, from a professional point of view, they are not unable to act, and it is a subjective feeling of discomfort associated with the situation. Finally, while ethical issues in the group asymmetries of power and authority most closely match Jameton’s original definition of moral events in which a health professional is restricted to act in accordance with a moral judgment, it is unclear whether the moral aspects of these situations are relevant for feelings of distress. Working in an environment that entails limited involvement in decision-making, a felt lack of respect or even degradation certainly results in distress without the added insult of having one’s moral judgment ignored. In summary, there are still open questions regarding the right conceptualization and operationalization of moral distress, and research projects certainly have to include all relevant aspects in order to shed more light on the complex interplay.

Our study has some important strengths and limitations. First and foremost, all items and the underlying concepts were transferred from a qualitative interview study with midwives. This allowed us to generate items with midwifery-specific situations and formulations with which we hoped to provoke more spontaneous reactions to clear and observable situations and behavior. All items were rated in terms of relevance and clarity by a heterogeneous sample of experts in the field of ethics and midwifery. On the downside, we remained in a “closed system”: all predictor and response variables were measured with the same questionnaire, which may have biased the observed relationships to a certain degree (Siemsen et al., 2010). Also, we have only marginal external validation of what our sample of midwives conceived as being morally competent. Also, as with many other studies, the patients’ perspective is completely missing. This is not negligible, because, for example, our interview study suggests that many midwives see themselves as being closer to the woman compared to other health professionals, and as better understanding her needs and preferences (Oelhafen et al., 2019). However, if this perception of a situation and the subsequent moral judgment is not validated by patients, there is also no evaluation of moral competence (Johnstone and Hutchinson, 2015; McCarthy and Gastmans, 2015).

Supplemental Material

Table_S1a-e – Supplemental material for Moral distress and moral competences in midwifery: A latent variable approach

Supplemental material, Table_S1a-e for Moral distress and moral competences in midwifery: A latent variable approach by Stephan Oelhafen and Eva Cignacco in Journal of Health Psychology

Supplemental Material

Table_S2 – Supplemental material for Moral distress and moral competences in midwifery: A latent variable approach

Supplemental material, Table_S2 for Moral distress and moral competences in midwifery: A latent variable approach by Stephan Oelhafen and Eva Cignacco in Journal of Health Psychology

Supplemental Material

Table_S3 – Supplemental material for Moral distress and moral competences in midwifery: A latent variable approach

Supplemental material, Table_S3 for Moral distress and moral competences in midwifery: A latent variable approach by Stephan Oelhafen and Eva Cignacco in Journal of Health Psychology

Supplemental Material

Table_S4 – Supplemental material for Moral distress and moral competences in midwifery: A latent variable approach

Supplemental material, Table_S4 for Moral distress and moral competences in midwifery: A latent variable approach by Stephan Oelhafen and Eva Cignacco in Journal of Health Psychology

Supplemental Material

Table_S5 – Supplemental material for Moral distress and moral competences in midwifery: A latent variable approach

Supplemental material, Table_S5 for Moral distress and moral competences in midwifery: A latent variable approach by Stephan Oelhafen and Eva Cignacco in Journal of Health Psychology

Footnotes

Acknowledgements

Special thanks to Lilian Flühmann for her valuable work developing our questionnaire. The authors also like to acknowledge the help of all experts validating the questionnaire, all participants of the final survey, and Michael Kleinknecht-Dolf for providing helpful information on the development of their questionnaire.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study received funding by the “Käthe-Zingg-Schwichtenberg-Fonds” of the Swiss Academy of Medical Sciences and the Fund “Research & Teaching” of the Lindenhof Foundation Bern.

ORCID iD

Stephan Oelhafen

Supplemental Material

Supplemental material for this article is available online.

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