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ORIGINAL ARTICLE
Year : 2022 | Volume
: 9
| Issue : 2 | Page : 146-151
Stress of conscience and affecting factors in midwives in the delivery room
Pervin Sahiner
, Sena Dilek Aksoy
Department of Midwifery, Faculty of Health Sciences, Kocaeli University, Izmit, Kocaeli, Turkey
Correspondence Address:
Dr. Sena Dilek Aksoy
Department of Midwifery, Faculty of Health Sciences, Kocaeli University, Izmit, Kocaeli
Turkey
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jnms.jnms_134_21
Context: Midwives who perform the act of child delivery, which is one of the most sensitive and private occasions for women, can face the stress of conscience when they fail to perform their duties in this process for any reason or cannot decide what to do. There is very little information about the stress of conscience levels of delivery room midwives.
Aim: This study aims to determine the stress of conscience and related factors in midwives who deliver a baby actively in the delivery room.
Settings and Design: This descriptive and cross-sectional study was performed in April 2021 at six public hospitals in Kocaeli, Turkey.
Materials and Methods: The study was conducted with 67 midwives who worked in delivery rooms through the census method. The data were collected using a “Demographic Information Form” and the “Stress of Conscience Questionnaire.”
Statistical Analysis Used: Descriptive statistics, including frequency, mean, and standard deviation, and analytic statistics, including Mann–Whitney U- and Kruskal–Wallis tests, were used.
Results: Among the participants, 61.2% stated that they experienced a guilty conscience while working in the delivery room, and they stated that the biggest (28.4%) reason for a guilty conscience was problems related to mother–infant health. The ethics training of the midwives was a factor that increased their stress of conscience scale internal factors subscale scores (P = 0.01). In addition, being married was a factor that increased their internal factor subscale scores (P = 0.008), and having worked in the delivery room for more than 6 years was a factor that increased their external factor subscale scores (P = 0.02).
Conclusions: The results of the present study, the married midwives, those who had worked in the delivery room for longer than 6 years, and those who had received ethics training were found to have high stress of conscience levels. Sharing the results of such studies with managers can be a guide in solving problems.
Keywords: Conscience, Delivery rooms, Midwifery, Stress
Conscience is the emotion that judges the morality of our actions and makes us feel guilty about the bad things we do or situations for which we feel responsible.[1] Conscience is affected by moral sensitivity, ethics, education, family, religion, and social norms, it is shaped by an individual's deep thoughts, and it creates a strong impact on one's personality.[2] Therefore, it is stated that conscience exists in individuals on various levels, and it is the strongest sanction of a person. It is stated that health professionals also resort to their conscience when they cannot decide what to do on certain occasions while performing their profession.[3] Being conscientious is considered necessary for good patient care. This is because conscience is considered an encouraging power, a factor that limits behaviors, and a source of sensitivity to patient problems for patient care. Although conscience is a positive force in human life, it may lead to stress of conscience, which refers to a guilty conscience, when an individual fails to behave in accordance with their values.[2] The stress of conscience is a type of stress that can arise in case of the repeated occurrence of stressful situations which disturbs one's conscience.[4]
It is suggested that midwives, especially those who work in the delivery room, experience stress. A study showed that 41.5% of delivery room employees experienced stress.[5] Situations that increase the stress levels of midwives were determined as an unfavorable working environment, lack of management support, lack of staff, lack of equipment, fear of litigation, and fear of disciplinary investigation. It was stated that midwives who could face complications that threatened the health of both the mother and the infant experienced burnout and wear out when they failed to manage their stress.[6] Nevertheless, there are not enough studies to determine the stress of conscience of midwives working in an environment where there is plenty of stress, and it is possible to face ethical dilemmas, such as a delivery room. Previous studies have mostly aimed to determine the stress of conscience in nurses and doctors.[2],[7]
This study aimed to determine the stress of conscience levels of midwives who worked in delivery rooms in the Kocaeli Province of Turkey and the affecting factors.
Materials and MethodsThis descriptive study was performed in delivery rooms of six different public hospitals in Kocaeli, Turkey, in April 2021.
Participants and research context
The population of the study was 70 midwives who participated in active birth in delivery rooms in six hospitals. Due to the limited sample, all midwives constituting the population were included. The inclusion criteria for the study were working in a delivery room and voluntarily agreeing to participate in the study. The survey forms brought by the researchers were handed out to all midwives by the supervisor midwife at each hospital. The aim of the study and that participation was on a voluntary basis were explained in writing at the beginning of each survey form. The completion and delivery of the forms by the participants showed their consent to participate in the study.
Data collection procedure
The data were collected by using a “Demographic Information Form” and “the Stress of Conscience Questionnaire (SCQ).”
Demographic information form
The form that was prepared by the researchers included 23 questions to collect information on the sociodemographic characteristics of the midwives, their working conditions, and their statuses of having received training on ethical issues in in-service training (not currently implemented in all hospitals).
Stress of Conscience Questionnaire
The questionnaire was developed by Glasberg et al.[2] Aksoy et al. adapted the scale to Turkish and carried out its validity and reliability study. In the Turkish language, Cronbach's alpha value of the questionnaire was reported as 0.74.[8] The scale has two dimensions: internal factors and external factors. SCQ contains nine items, each consisting of two questions categorized as A and B. Question A asks how often a selected stressful situation occurs, while question B asks about the degree of troubled conscience the situation described in A generates.
The response options for question A in each item are as follows: “Never” (0 points); “Less than once in 6 months” (1 point); “More than once in 6 months” (2 points); “every month” (3 points); “every week” (4 points); and “every day” (5 points). The response options for question B in each item are as follows: “it does not disturb my conscience at all” (0 points) and “Yes, it disturbs my conscience to a great extent” (5 points). Based on the scoring system described for the original form of the questionnaire, the score of question A is multiplied by the score of question B for each item, showing the total “stress of conscience” level associated with that item. Therefore, the score of each item varies in the range of 0–25, while the minimum and maximum total scores of the questionnaire are 0 and 225. Higher scores show higher stress of conscience levels.[2]
Statistical analysis
The data were analyzed using the IBM SPSS Statistics (version 23) package program. In the descriptive section, mean, frequency, and standard deviation were used. Normality assumptions were tested with Kolmogorov–Smirnov. Nonparametric methods were used for the measurement values that were not normally distributed. As nonparametric methods, “Mann–Whitney U-test” (Z table value) was used in the comparison of the measurement values of two independent groups, whereas “Kruskal–Wallis H test” was used in the comparison of the measurement values of three or more groups. For all analyses, P < 0.05 was considered to be statistically significant.
Ethical considerations
The study was conducted after receiving permission dated April 6, 2021, and numbered E.43861 from the chief physicians of all hospitals, the Kocaeli Provincial Directorate of Health, and the noninterventional Human Research Ethics Committee. All procedures performed in the processes involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The midwives were informed about the study, and their voluntary consent was obtained.
ResultsThe midwives who participated in this study completely constituted 96% of all midwives (n = 67) in the population. In the study, the mean age of the midwives who participated in the study was 34.76 ± 8.88 (minimum = 23, maximum = 60). [Table 1] shows the other sociodemographic and work-related characteristics of the participants.
Table 1: Sociodemographic and work-related characteristics of midwives (n=67)Majority of participants stated that they experienced a guilty conscience while working in the delivery room [Table 1], and the biggest (28.4%) reason was problems related to mother–infant health.
All participants but two stated that they performed practices that were not included in their job description. Although they were not on duty, their practices included intervening in risky deliveries, receiving informed consent for cesarean section, and processing the referral and discharge of patients. The most reason why the participants performed practices that were not included in their job description was determined as protecting the mother and the newborn [Table 2].
Table 2: Types of practices out of the duties of midwives and reasons for these practices (n=67)The mean total SCQ score of the participants and their scores in the dimensions of SCQ are shown in [Table 3].
Table 3: Scores of midwives in the Stress of Conscience Questionnaire and its dimensionsIn this study, the items related to issues creating the most stress of conscience in the participants were those concerning their job in the health service taking all the energy from committing to themselves or close ones (9.80 ± 8.31), time restrictions for providing care to the patient (8.13 ± 7.49), and dealing with inconsistent requests at work (7.19 ± 7.28).
[Table 4] shows that according to the results of the Mann–Whitney U-test, the married participants and those who had received ethics training had significantly higher internal factor subscale mean scores than the single participants, and the participants who had worked for 6 years or longer had significantly higher external factor subscale mean scores.
Table 4: Relationships between sociodemographic characteristics and scale total and subscale scoresIn the Mann–Whitney U- and Kruskal–Wallis H tests, no significant difference was found in the total and subscale mean scores of the participants based on their characteristics, including having children, educational status, the status of loving their profession, working life satisfaction, knowing legal duties and responsibilities, experiencing ethical dilemmas, experiencing a guilty conscience, experiencing sleep problems at night, eating problems, or having health problems (P > 0.05).
DiscussionThis study aimed to determine the stressful situations that can result in the stress of conscience in midwives in the delivery rooms, internal and external stress factors, stressful situations creating a guilty conscience, and its extent.
The researchers of this study concluded that midwives working in the delivery room had a mean stress of a conscience score of 47.5 for all questionnaire items. This result was higher than that of nurses working in psychiatric clinics (43.04)[9] and lower than that of nurses providing care for geriatric inpatients with delirium (63.6).[7] The finding that the stress of conscience score in this study was lower than that of nurses who provided care for patients with delirium could be because the midwives who were included in this study provided care for patients who could express themselves; they knew the patients' requests well and acted accordingly. Patients with delirium are usually old, and their attention and cognitive functions are impaired.[10] The higher scores of nurses who provided care for psychiatric patients than those in this study may be due to the instant decisions of the midwives in this study affecting the health of the mother and the infant, their thinking about whether the decision they made was correct, and their experience of a guilty conscience.
The stress of conscience may result from external factors such as the structure of the job, lack of personnel, time pressure, heavy workload, and lack of resources, as well as internal factors such as the individual's ability to cope with a suffering patient.[2] The results of this study revealed that the stress of conscience scores of the participants associated with internal factors was lower. This may be because midwives can deal with the suffering patient more easily because the outcome of suffering in this case is birth, which is accepted as the desired outcome.
Almost all midwives who were included in this study noted that while they were carrying out their job, they performed many tasks increasing their workload that were not included in their job description. They stated that they performed these tasks to “prevent any harm to the pregnant women/babies,” “avoid stress of conscience,” and “avoid legal damages. These expressions showed that confusion in work life affects midwives negatively. A study that examined factors hampering advanced midwifery practices showed that the complexity of the practice process created obstacles to working life.[11] Another study conducted in the United Kingdom emphasized that midwives left their jobs due to role confusion in their clinical practices and organizational inadequacies.[12] A study conducted with nurses revealed that factors such as increased workload and time restrictions limited patient care.[4]
In our study, the mean internal factor subscale score of the married participants was found to be significantly higher than the mean score of the single participants. This result may be due to the nature of the job in the profession of midwifery, the inability of married midwives to spare enough time for their family, friends, and relatives, and their inability to fulfill their personal responsibilities.
In this study, it was observed that the participants who had been working for 6 years or longer experienced the stress of conscience due to external factors. This result may be because midwives experience stressful situations that disturb their conscience more often as their working years increase, they experience similar problems repeatedly, and they worry more about making mistakes in their professions. A study conducted with 488 nurses in Sweden showed that the stress of conscience and burnout scores of the participants gradually increased along with their years of working, requests from co-workers and people for whom they provided care increased their levels of stress of conscience, thus resulting in burnout.[13] A study conducted with 350 nurses in Finland also stated that the feeling of inability to meet requests from one's environment created stress of conscience, and especially those who provided care for 5 years or less had the lowest stress of conscience levels, while those with an experience of 10 years or longer in providing care had very high stress of conscience levels.[14] It was found that nurses who provided care for patients with delirium in Australia experienced more stress of conscience as their years of working increased.[15]
The scores of the participants in this study who had received ethics training associated with the internal factors creating stress of conscience were significantly higher than the scores of those who had not. Conscience is a notion connected with morality and ethics.[2] How and to which extent conscience is affected may differ depending on how conscience is perceived. Ethics training is believed to be important in the perception of conscience. This training is important for people to be morally sensitive. Being morally sensitive is effective in identifying ethical issues in patient care, making ethical decisions, and making the right decision in cases of ethical dilemmas.[15] When individuals fail to make the right decision, they may experience stress, live internal conflicts, and have a guilty conscience.[16] A study related to nurses stated that nurses experienced the stress of conscience when their personal beliefs conflicted with professional norms, and they worked in a way that was against their conscience.[4]
In this study, the items about issues that created the highest stress of conscience based on the mean scores of the participants were those concerned with the job in the health service taking all the energy from committing to oneself or close ones, time restrictions for providing care to the patient, and dealing with inconsistent requests at work. The findings obtained in this study were similar to those of a previously conducted study.[7],[13],[14] This may be an indicator that delivery room midwives experience stress similar to that of nurses who provide care for vulnerable patients such as patients with dementia, or elderly people.
The strength of this study is that it is the first study that examined the stress of conscience levels of midwives in Turkey. However, this study had important limitations. For instance, no observations were made regarding the participants' levels of stress of conscience, and the data were collected based on self-reports.
ConclusionsAn individual's inability to behave according to their values causes conflicts in their inner world and results in the stress of conscience. In this study, the married midwives, those who had worked in the delivery room for longer than 6 years, and those who had received ethics training were found to have high stress of conscience levels. It is believed that both internal and external factors affecting stress of conscience are reflected in professional life and increase stress levels. This study can inform midwives and their co-workers working in the delivery room about the issue of experiencing stress of conscience. It is recommended that more research be conducted on the stress of conscience of midwives working in the delivery room. Sharing the results of this study with administrators may guide for solving problems.
Conflicts of interest
There are no conflicts of interest.
Authors' contributions
Study concept and design: P.S.; analysis and interpretation of data: S.D.A. and P.S.; drafting of the manuscript: P.S. and S.D.A.; critical revision of the manuscript for important intellectual content: S.D.A. and P.S.; statistical analysis: S.D.A.
Financial support and sponsorship
Nil.
Acknowledgments
We sincerely thank all of the midwives who participated in this study.
References
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