Prevalence, causes, and consequences of moral distress in healthcare providers caring for people living with dementia in long-term care during a pandemic

Moral reckoning among nurses: A directed qualitative content analysis

BACKGROUND

When nurses face ethical challenges, they attempt to accept responsibility for their actions and start moral reckoning. Moral reckoning is the personal evaluation of one's behaviors or others' behaviors during ethically challenging situations.

RESEARCH AIM

This study aimed at exploring the concept of moral reckoning and its stages among Iranian nurses using Nathaniel's moral reckoning Theory.

RESEARCH DESIGN

This descriptive qualitative study was conducted in 2022 using directed content analysis.

PARTICIPANTS AND RESEARCH CONTEXT

Eighteen nurses were purposively recruited from three teaching hospitals affiliated to Golestan University of Medical Sciences, Gorgan, Iran. Data were collected via in-depth semi-structured interviews which lasted 50 minutes on average and were concurrently analyzed via the three-step directed content analysis method proposed by Elo and Kyngas.

ETHICAL CONSIDERATIONS

This study earned the ethical approval of the Ethics Committee of Golestan University of Medical Sciences, Gorgan, Iran (code: IR.GOUMS.REC.1400.171).

FINDINGS

During data analysis, 157 final codes were developed and categorized into 23 subcategories, 10 categories, and four themes. The themes of the study are ease (with the two categories of becoming and interacting), upset (with the two categories of mental upset and behavioral upset), resolution (with the two categories of making a stand and giving up), and reflection (with the four categories of remembering, telling the story, examining conflicts, and living with consequences).

CONCLUSION

Ethically challenging situations alter the ease stage of moral reckoning among nurses, cause them mental and behavioral upset, and thereby, require them to make stand or give up. Then, they continuously examine events in their mind and finally, live with the positive and negative consequences of the events.

Implementation of the Dementia Isolation Toolkit in long-term care improves awareness but does not reduce moral distress amongst healthcare providers

BACKGROUND

Healthcare providers may experience moral distress when they are unable to take the ethically or morally appropriate action due to real or perceived constraints in delivering care, and this psychological stressor can negatively impact their mental health, leading to burnout and compassion fatigue. This study describes healthcare providers experiences of moral distress working in long-term care settings during the COVID-19 pandemic and measures self-reported levels of moral distress pre- and post-implementation of the Dementia Isolation Toolkit (DIT), a person-centred care intervention designed for use by healthcare providers to alleviate moral distress.

METHODS

Subjective levels of moral distress amongst providers (e.g., managerial, administrative, and front-line employees) working in three long-term care homes was measured pre- and post-implementation of the DIT using the Moral Distress in Dementia Care Survey and semi-structured interviews. Interviews explored participants' experiences of moral distress in the workplace and the perceived impact of the intervention on moral distress.

RESULTS

A total of 23 providers between the three long-term care homes participated. Following implementation of the DIT, subjective levels of moral distress measured by the survey did not change. When interviewed, participants reported frequent experiences of moral distress from implementing public health directives, staff shortages, and professional burnout that remained unchanged following implementation. However, in the post-implementation interviews, participants who used the DIT reported improved self-awareness of moral distress and reductions in the experience of moral distress. Participants related this to feeling that the quality of resident care was improved by integrating principals of person-centered care and information gathered from the DIT.

CONCLUSIONS

This study highlights the prevalence and exacerbation of moral distress amongst providers during the pandemic and the myriad of systemic factors that contribute to experiences of moral distress in long-term care settings. We report divergent findings with no quantitative improvement in moral distress post-intervention, but evidence from interviews that the DIT may ease some sources of moral distress and improve the perceived quality of care delivered. This study demonstrates that an intervention to support person-centred isolation care in this setting had limited impact on overall moral distress during the COVID-19 pandemic.

Long-term care facilities' response to the COVID-19 pandemic: An international, cross-sectional survey

AIMS

To (i) assess the adherence of long-term care (LTC) facilities to the COVID-19 prevention and control recommendations, (ii) identify predictors of this adherence and (iii) examine the association between the adherence level and the impact of the pandemic on selected unfavourable conditions.

DESIGN

Cross-sectional survey.

METHODS

Managers (n = 212) and staff (n = 2143) of LTC facilities (n = 223) in 13 countries/regions (Brazil, Egypt, England, Hong Kong, Indonesia, Japan, Norway, Portugal, Saudi Arabia, South Korea, Spain, Thailand and Turkey) evaluated the adherence of LTC facilities to COVID-19 prevention and control recommendations and the impact of the pandemic on unfavourable conditions related to staff, residents and residents' families. The characteristics of participants and LTC facilities were also gathered. Data were collected from April to October 2021. The study was reported following the STROBE guidelines.

RESULTS

The adherence was significantly higher among facilities with more pre-pandemic in-service education on infection control and easier access to information early in the pandemic. Residents' feelings of loneliness and feeling down were the most affected conditions by the pandemic. More psychological support to residents was associated with fewer residents' aggressive behaviours, and more psychological support to staff was associated with less work-life imbalance.

CONCLUSIONS

Pre-pandemic preparedness significantly shaped LTC facilities' response to the pandemic. Adequate psychological support to residents and staff might help mitigate the negative impacts of infection outbreaks.

IMPACT

This is the first study to comprehensively examine the adherence of LTC facilities to COVID-19 prevention and control recommendations. The results demonstrated that the adherence level was significantly related to pre-pandemic preparedness and that adequate psychological support to staff and residents was significantly associated with less negative impacts of the pandemic on LTC facilities' staff and residents. The results would help LTC facilities prepare for and respond to future infection outbreaks.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

"You treat what you have to treat, and you don't care as much if they understand or if they feel good about it": Communication barriers and perceptions of moral distress among doctors in emergency departments

Doctors facing communication barriers when assessing patients in emergency departments (ED) is a frequent phenomenon, as the global prevalence of dementia and migration have increased. This study aims to explore how communication barriers influence moral distress as perceived by medical doctors working at emergency departments. Twelve doctors at 2 different EDs in Stockholm, Sweden, participated. Answers on communication barriers were collected from an interview guide on moral distress. Informants' responses were analyzed using qualitative thematic analysis. The results suggest that doctors experience moral distress when assessing patients with communication barriers due to an inability to mediate calm and safety and understand their patients, and due an increased need of resources and difficulties in obtaining consent before conducting examinations or interventions. In conclusion, communication barriers can be a cause of moral distress, which should be considered when developing tools and methods to mitigate and manage moral distress.