Moral distress and the Australian aged care worker: A mixed methods study

Abstract

BackgroundSupporting the older person to age well within residential and community care environments requires a healthy and sustainable workforce. Moral distress is a complex phenomenon, and emerges when a worker “…as a result of real or perceived constraints, participates, either by act or omission, in a manner he or she perceives to be morally wrong” (Nathaniel, 2006, p. 421). Morally distressing situations create physical and psychological effects; contribute to decreased quality of care and diminished workplace satisfaction for staff, lead to physical and emotional illness, burnout, and staff turnover. Understanding and reducing the frequency of exposure to, and the intensity of, moral distress felt by workers, is necessary in providing a psychologically safe work environment. Health care delivery is complex, resource pressures and differing beliefs on what constitutes health and health care mean that moral challenges are inevitable. The moral agency of nurses is frequently challenged and as such moral stress is unavoidable. While moral distress has been investigated across a range of clinical contexts and countries, little research exploring moral distress in either the Australian or the aged care contexts is evident. Despite the lack of current evidence, anecdotally moral distress does exist within the Australian aged care workforce. Accurate data regarding moral distress will support the development of targeted interventions to reduce the occurrence, intensity and consequences of the experience. Interventions that consider the needs of the worker and individual contexts of Australian workplaces will reduce the intensity of moral distress, and allow workers to better manage the psychological strain stemming from moral challenges.Research DesignThe aim of this mixed methods study was to explore the effect of moral distress on Australian aged care workers in residential and community aged care. An explanatory mixed methods approach, grounded in pragmatism was used. The Job Demand-ControlSupport model (JDCS) was used to explore links between moral distress, the worker, and organisational support structures. Participants consisted of Registered Nurses, Enrolled Nurses, and Personal Care Workers (Assistants in Nursing) working in community and residential aged care facilities in Queensland and Victoria. The study was conducted in two phases. In Phase 1 the Moral Distress Scale– Revised was amended, tested and validated with participants (n=106). This instrument uses a 5 point Likert scale to measure both the frequency and intensity of moral distress. Amendments to suit the Australian aged care environment were made, resulting in a 20 item instrument, the Moral Distress Scale – Revised (aged care). Psychometric testing for reliability and validity was conducted. To further illustrate the experience of moral distress for this population a series of telephone interviews and case study scenarios were used in Phase 2. Participants for this phase were drawn from Phase 1 participants who elected to participate in Phase 2. Initially telephone interviews (n=9) were used to explore participants’ understanding of moral distress, identify situations in which participants encountered this distress, and elicit the specific outcomes of moral distress on the worker. A reflective journal was used to record observational, theoretical and methodological notes during the telephone interviews; with member checking at time of interview and investigator triangulation used to ensure trustworthiness of data. Interviews were transcribed verbatim, with thematic analysis relying on constant comparison of textual data used to identify themes and inform the development of case study scenarios.Data from the telephone interviews and contemporary moral distress literature were then used to develop two case study scenarios. Scenario 1 focussed on unmet care needs, and Scenario 2 futile treatment. Scenarios (n=16) were returned and data subsequently subjected to thematic analysis relying on constant comparison of data. These data were used to inform the final findings; identifying common experiences emerging from participants’ experiences of moral distress.ResultsIn Phase 1 statistical testing of the amended instrument indicated strong reliability: the frequency component of the instrument demonstrated a Cronbach’s alpha of 0.89, the intensity component 0.95, and the instrument as a whole 0.94. Item mean scores indicated moral distress occurred with low frequency (0.36-1.73) but moderate intensity (1.66-2.93) within this population. Exploratory factor analysis identified three factors, labelled as: Quality of Care, Capacity of Team and Professional Practice. Phase 2 qualitative data demonstrated workers experiencing a range of psychological effects such as sadness, unhappiness, powerlessness and extreme frustration related to the impact on themselves, other workers, and the older person. Inadequate resourcing, lack of time, futility of the situation, inadequate consultation, and division about the correctness of decisions emerged as contributing factors. The role of the nurse as central to resolution of these issues was highlighted: with participants clearly identifying a desire to either; work harder and do more (“Doing Work”) or engage in communication with others (“Speaking with Others”).ConclusionThe Moral Distress Scale - Revised (aged care) is a valid and reliable instrument. Moral distress does exist within the Australian aged care workforce, albeit at a relatively low frequency. However, when it occurs it causes a moderate level of distress for the worker. Psychological effects such as sadness, unhappiness, powerlessness and frustration were experienced. Participants clearly expressed a desire to be centrally involved in communication strategies aimed at reducing the occurrence and outcomes of moral distress. This is the first study demonstrating links between the JDCS and moral distress, and using the JDCS to frame moral distress provides a valid foundational structure for evidence-based interventions.