Understanding moral distress in birth unit settings – A deductive interview study based on the Theory of Collective Capacity for Emotionally Charged Work

BACKGROUND: Morally challenging situations may lead to moral distress, when healthcare workers feel unable to act in line with their professional or ethical values. Moral distress among birth unit workers affects well-being and safety of care. Understanding how workers cope is essential for developing preventive strategies. AIM: To explore how healthcare workers on birth units use personal and organisational strategies to manage morally challenging situations, and how this can be interpreted through the Theory of Collective Capacity for Emotionally Charged Work. METHODS: Twenty semi-structured interviews were conducted with healthcare workers from seven birth units, including two university and five non-university hospitals. Participants included midwives (n = 10), physicians (n = 6), and assistant nurses (n = 4). The deductive content analysis was informed by the Theory of Collective Capacity for Emotionally Charged Work. RESULTS: Participants described interpersonal rather than organisational strategies for managing morally challenging situations. When strategies and conditions aligned, participants managed these situations, improving well-being and care safety. All components of the original model were identified, although some required expansion to fit the context of moral distress. Additional conditions, including personal resources and long-term adaptation, were identified. CONCLUSIONS: Birth unit workers mainly managed morally challenging situations through collegial and interpersonal strategies, while structured organisational support was limited. The Theory of Collective Capacity for Emotionally Charged Work was useful for understanding these strategies and the conditions that enabled them, but required extension to reflect the specific emotional, moral, and organisational features of moral distress in birth units. KEY MESSAGE: Managing moral distress in birth units relies on strategies of seeking confirmation, building collegiality, and creating space for emotional recovery and is supported by conditions such as task quality, influence on the core task, organisational resources, personal resources, and long-term adaptation. However, the findings indicate a lack of organisational support structures to enable these strategies.