Study 1: Understanding the Nature and Prevalence of Moral Distress Experienced by Nurses Providing Dementia Care in Continuing Care Settings
Moral Distress in the Care of Persons with Dementia in Residential Care Settings in Southern Alberta
SHANNON SPENCELEY, RN, PH.D. | BRAD HAGEN, R.PSYCH., RN, PH.D.
BARRY HALL, PH.D. | OLU AWOSOGA, PH.D.
CHAD WITCHER, PH.D. | ROLAND IKUTA MD, FRCPC (C)
The main objective of this two year study was to explore the nature, extent and effects of moral distress among nursing caregivers (registered nurses, licensed practical nurses and health care aides) providing care to persons diagnosed with dementia and living in long term care (LTC) and assisted living (AL) environments.
The research was undertaken in Southern Alberta in two phases. Phase one involved interviews with 18 nursing caregivers of persons with dementia, to understand situations that contributed to moral distress, and to inform the development of a survey instrument. Phase two included survey development and piloting (n=68), followed by a survey of a larger sample of nursing caregivers across 30 care facilities (N=389) to better understand the prevalence of moral distress among caregivers in these settings, the situations that trigger it, and its effects.
Main Findings: Phase One
Five major themes about sources of moral distress emerged from the data collected:
- Managing dementia-related behaviours; inconsistency of care; poor treatment of residents; family issues; and a model of care that doesn’t fit.
Participants shared the negative effects that moral distress had on their well-being:
- Emotional, psychological, physical and relational costs, as well as impacts related to reduced job satisfaction and a desire to escape the workplace.
Participants shared strategies that they believed would decrease their moral distress such as:
- having more hands to do the work; the presence of supportive managers to listen, explore solutions and follow up; peer support, mentorship and opportunities to talk and even just share laughter; more education to care for residents with dementia.
Main Findings: Phase Two
Moral distress is prevalent in the nursing care of residents with dementia in residential care:
- 75.9% of respondents reported experiencing situations that caused at least a moderate degree of moral distress, at least weekly, over the past year
- Six out of the top 10 most distressing situations experienced by nursing staff were also among the situations most frequently experienced
- For all caregiver designations, the situation causing the highest levels of moral distress was reported to be “seeing the care suffer for residents with dementia because there are not enough staff to do the work”.
Moral distress had negative effects on nursing caregivers. At least weekly:
- 49.3% of respondents reported feeling frustrated
- 44.4% reported feeling physically exhausted
- 41.6% reported feeling emotionally drained
- 39% reported feeling powerless
- 33.1% reported engaging in unhealthy behaviours as a result of moral distress.
Moral distress contributes significantly to reduced job satisfaction:
- Approximately 40% of respondents reported that moral distress reduced their job satisfaction a “large” or “extremely large” amount, and another 35.6% reported it had reduced their job satisfaction a “moderate” amount.
- More than one-quarter of respondents (25.9%) reported that moral distress contributes to them wanting to quit their job a large, or extremely large amount
- 84.9% of respondents did not intend to quit their jobs in the next year
Moral distress can possibly be reduced with particular strategies. The strategies below were reported as ones that could help reduce moral distress “an extremely large amount” (proportion of respondents):
- “Having enough staff to provide good care for residents” (65.7%)
- “Sharing laughter and humour with colleagues” (49.6%)
- “Having a manager who will listen to my concerns, look into them, and get back to me with possible solutions.” (43.8%)
- “Having more education and training of staff about how to better care for people with dementia” (41.3%)
- Moral distress is a prominent feature of the nursing care of persons with dementia in residential care settings.
- Staffing levels in these settings have been identified as significant and frequent contributors to situations creating moral distress.
- Moral distress is contributing to a nursing workforce in these settings that is feeling frustrated, physically and emotionally exhausted, powerless and angry.
- Moral distress is also a significant factor in reducing job satisfaction; this has serious implications in a sector that is already experiencing staffing shortages and high turnover, and has potentially very serious implications for the quality of nursing care
- Leaders in continuing care would be wise to attend to the magnitude and frequency of moral distress suggested by this study, as well as to exploration of the strategies suggested as potentially helpful in reducing moral distress.
- Future research should explore the influence of suggested strategies to reduce moral distress including interventions focused on leadership development and team building, clear performance management processes and policies, as well as mentorship and knowledge development in dementia care.