Moral distress is the pain or anguish affecting the mind, body or relationships in response to a situation in which a person is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action; yet, as a result of real or perceived constraints, cannot do what is thought to be right (Nathaniel, 2004). Moral distress as experienced by nurses has been explored most often in hospital settings, and has been linked with negative effects on nurses, high job turnover, and harmful effects on patient care (Todd & Watts, 2005; Vernooij-Dasssen et al., 2009).
Very little research has been done on moral distress in residential care facilities, and in particular with nursing care providers who care for people living with dementia. Recent research by the lead investigator in 30 residential (continuing) care facilities in southern Alberta has found high levels of moral distress in nursing care staff providing ongoing care to people living with dementia (Spenceley et al., 2015) and that it is having negative consequences for these care providers—people who provide care for some of society’s most vulnerable citizens. This study builds on this previous work and has four goals to be achieved in collaboration with leaders in residential care facilities across the whole province:
- Using a survey instrument (the Moral Distress in Dementia Care Survey, or MDDCS) to measure moral distress and discover the situations triggering it in nursing care providers in Covenant Health and Covenant Care continuing care facilities across Alberta.
- Create an evaluation tool based on the MDDCS
- Engaging with nursing care providers to discuss and develop possible solutions
- Trialing suggested solutions for moral distress and evaluating the solutions using an evaluation tool based on the MDDCS
The questions we wish to answer with this research include:
- What are the frequency, intensity and consequences of moral distress as experienced by nursing care providers in the residential care of people living with dementia across Alberta?
- How reliable and valid is the MDDCS in measuring moral distress in this context?
- What is one feasible, practical and relevant intervention to reduce moral distress in nursing staff providing residential dementia care in Alberta?
- What is the effectiveness of the intervention in reducing moral distress, as assessed in two continuing care settings in Alberta?
This study uses a combination of methods. We will collect data with the MDDCS survey instrument to help us understand the situations causing moral distress and measure its severity and frequency. We will obtain an overall numerical measure of moral distress in participating care facilities. After we survey all interested providers across the 16 participating facilities, we will share survey results with nursing staff, and use the results to inform discussion with these care providers in order to learn from their experiences with moral distress and develop possible solutions. These solutions will then be tried and evaluated in two sites. Two comparable sites will serve as control sites, and will undergo the same measurements, but with no intervention.
The study will take place in three phases, over two years.
Phase I (6 months): Piloting the revised MDDCS with approximately 100 nursing care providers in two sites. Following any needed revision, and in collaboration with study champions in each site, we will then use the MDDCS to survey nursing staff across the remaining 14 Covenant Health and Covenant Care facilities in Alberta that provide ongoing care to people living with dementia.
Phase II (6 months): Analyzing and sharing data from surveys, developing an evaluation tool based on the analysis, and engaging with care staff. With the support of organizational leadership, we will arrange two conferences involving front line nursing care staff, managers, and educators from all involved sites. At each event survey results will be shared, and issues will be identified and discussed with all participants. The goal: To derive feasible, practical and relevant strategies aimed at reducing moral distress.
Phase III (6-12 months): Two sites will be selected as intervention pilot sites, in collaboration with Covenant leadership. Based on all information/learning from earlier phases and working closely with staff on two selected sites, we will design, carry out and evaluate an intervention (using an evaluation tool based on the MDDCS). Two comparable control sites will also be selected, and will be measured over the same intervals as the pilot sites, but will have no intervention introduced.