Introduction

There is a unique culture distinct to long-term care (LTC) in comparison to acute care or other human service organizations which impacts ethical decision-making. Some of the differentiating features which contribute to the complex environment and to the emergence of unique ethical dilemmas include ongoing treatment and complex comorbidities of many residents; high rates of low mood, anxiousness, loss, and grief; increased numbers of residents with diminished competency; limited scope of resources (both personnel and financial); and congregated living of individuals with varying cognitive and physical abilities as well as diverse cultural, historical, philosophical, and religious backgrounds (Collopy, Boyle, and Jennings 1991; Waymack 1998; Powers 2000; van der Dam et al. 2011; Pijl-Zieber et al. 2016). Despite these differences, the ethical frameworks that are predominantly taught to front-line care staff in LTC are typically grounded in more normative ethical theories such as principlism, consequentialism, utilitarianism, and deontology (Woods 2005).

Principlism is an ethical framework based on weighing the four principles of autonomy, beneficence, nonmaleficence, and justice (Beauchamp and Childress 1989). Alternatively, using a consequentialist method, decisions are made based on the potential consequences or outcomes of the action(s). A utilitarian ethical framework aims to achieve the greatest good for the greatest number, and finally, deontology is a means of ethical decision-making that draws on rules and duties. Studies aiming to explore how staff reason in LTC typically stem from these normative frameworks.

Researchers such as Dunworth and Kirwan (2009), Van Thiel and Van Delden (2001), Mattiasson and Andersson (1995), and Jansson and Norberg (1992) have reviewed the ethical decision-making process of LTC staff using normative frameworks. Others like Bolmsjö, Edberg, and Sandman (2006), Bolmsjö, Sandman, and Andersson (2006), Fleming (2007), Carter (2002), Kuczewski (1999), and Mysak (1997) draw on normative ethical frameworks and propose how staff should reason through ethical dilemmas in LTC. These studies, however, were designed with an underlying assumption that LTC staff reason in a particular (normative) way. However, there are other ways in which LTC staff might reason ethically. For example, LTC staff might also draw on virtue ethics (Carr and Steutel 1999), narrative ethics (Baldwin 2015), feminist ethics (Card 1991), and casuistry (Slettebø and Bunch 2004b). Though, more recently, researchers such as Agich (2003) have challenged the applicability of normative ethics approaches in LTC and have sought to understand the ethical challenges faced by LTC staff (Bollig et al. 2015), normative frameworks continue to be largely accepted, taught, and reproduced. The literature reveals no studies which sought to explore and better understand staff’s actual reasoning processes within a practice context.

Moral distress (MD) is defined as being aware of the right, or ethical, action but feeling powerless to act accordingly as a result of either real or perceived constraints and thus engaging in ethical wrongdoing (Jameton 1984; Austin et al. 2005). Solum, Slettebø, and Hauge (2008) propose an incongruence between norms of good care and their implementation into daily care. The translation of these norms into policies and procedures carries the risk, in the LTC environment, of becoming restrictive. In these circumstances, staff are potentially subjected to the effects of MD.

Adopting an empirical ethics approach, this study seeks to clarify what ethical views staff actually endorse rather than what ethicists theorize are normative guidelines (Widdershoven, Molewijk, and Abma 2009b). In this study, “empirical ethics” is understood as research approaches that “see a value in using empirical data to inform the ethical analysis of practical dilemmas” (Dunn et al. 2012, 466). According to the empirical ethics approach, theoretical frameworks for organizational philosophies must evolve from the practice context and actual staff activities. By applying this approach to the LTC environment, this research project sought to explore the nature and extent of ethical issues in the provision of social care in LTC facilities and the ethical framework(s) deployed by LTC staff in making decisions in such situations. This article focuses on the finding of MD which emerged from the data.

While LTC staff are faced with numerous health-related ethical issues, because the LTC environment is heavily weighted as a daily ongoing activity as compared to acute care, they also deal with difficult ethical situations in the provision of social care, referred to as “everyday ethics.” Powers (2000) defines everyday ethics as consideration of the ethical aspects of ordinary issues of daily life affecting nursing home residents and those who care for them. The goal of the research is to gain a better understanding of how LTC staff reason ethically in a social care context, in particular, addressing the following questions: 1) How does the ethical reasoning of LTC staff reflect, align with, or conflict with declared institutional approaches, policies, and procedures in managing ethical issues? 2) On which ethical frameworks do LTC staff draw in their ethical reasoning? 3) How do LTC staff choose between competing or differing ethical values and frameworks? In exploring these questions, staff raised issues of MD, and this data informs the present article.

Methods and Data Collection

Setting and Recruitment

I conducted the research in partnership with four LTC facilities in an Atlantic Canadian province. The facilities provided for 72–190 residents, and typically staff were responsible for the care needs of nine to ten residents. To recruit participants, I worked closely with management at each organization. A letter of invitation to participate in the study and additional information was emailed to staff. Information posters were hung in staff lounges and in nurses’ stations at each participating location. Contact information for the researcher was included on all materials. Registered nurses (RNs), who act as “floor managers,” also directly informed their teams about the research and encouraged participation (teams working days, evenings, and nights were informed and invited to participate). Staff were informed they would be paid for their time and that a replacement staff member would be hired for the duration of their absence. Once staff expressed an interest in participating and contacted me, I provided them with an introduction letter via email.

Participants

Twenty front-line care staff were recruited to participate in the focus groups. Participants comprised ten registered nurses, six licenced practical nurses (LPNs), three resident attendants (RAs), and one nurse practitioner. It is important to note that a limitation of the study is the small number of RA participants. In Canada, RAs (also known as nurses’ aides, personal support workers, or healthcare assistants) are responsible for the majority (approximately 75–80 per cent) of the personal care needs (or “hands-on care”) of LTC residents (Estabrooks et al. 2015). A recent Canadian study (Pijl-Zieber et al. 2016) exploring the experiences of MD of LTC staff caring for individuals with dementia found RAs experience MD differently to LPNs or RNs. Because RAs are responsible for the most direct care of residents, “they see and experience the deficits in care resources most directly, and yet are the least able to advocate for change because of their relatively low position in the health care hierarchy” (Pijl-Zieber et al. 2016, 330). Consequently, RAs report more frequent and severe experiences of MD (Pijl-Zieber et al. 2016). It is difficult to speculate why so few RAs volunteered to participate in this research. However, in a discussion with a RA participant, she/he mentioned she/he tried to encourage RA colleagues to participate and faced many critical and sceptical comments: “It won’t change anything so what’s the point.” I also experienced similar pushback in my recruitment efforts with RAs. Having more RA participants would be ideal and the pushback and scepticism from RA recruitment highlights the importance of a) increased efforts to ensure the voices of RAs are heard and whenever possible acted upon, b) adopting research methods that reduce the lag between data collection and knowledge dissemination and action (e.g. Delphi method, see Linstone 1978), and c) addressing the systemic issues reported by LTC staff as contributing to experiences of MD. Further, although limited RA participants, the findings reflect and align with those of Pijl-Zieber et al. (2016), who had a large number of RA participants, suggesting the data is reflective of LTC staff experiences as a whole.

Participants were predominantly white women (one male participant), which is reflective of the reality of the work environment of these organizations. Women are responsible for 90 per cent of the hands-on care provided in Canadian LTC homes (Baines 2007). The majority of the participants worked in LTC settings for greater than fifteen years, and four of the participants were less than two years from retirement, having worked in LTC the majority of their careers. Five participants were closer to the beginning of their careers in LTC.

Research Design

Focus Groups

Focus groups are defined as a method which engages participants in unstructured discussion guided by a moderator (Krueger 1988; Peek and Fothergill 2007; Acocella 2012). Importantly for this research, focus group data allows for further understanding of the ethical awareness and reasoning of participants by helping to address the issue of theory–practice gap by giving direct access to the reasoning process of LTC staff that is inaccessible in other ways (e.g. observation) (Barter and Renold 2000; Renold 2002; Hughes and Huby 2004). Unlike other methods of collective inquiry, focus groups generate data explicitly through participant interaction and allow for the exploration of collective experiences and perspectives (Peek and Fothergill 2007; Wodak and Krzyzanowski 2008; Acocella 2012;).

I conducted seven interdisciplinary focus groups consisting of two to four participants, averaging ninety minutes in length. The focus groups took place at various locations in the participating facilities. There is disagreement in the literature on the “ideal size” of focus groups. However, the primary concern is the quality of the data, which is located in the interaction and discussion (Gill et al. 2008; Peek and Fothergill 2007; Morgan 1997). Smaller focus groups are typically more appropriate and effective when exploring emotional and personal topics that are likely to generate high levels of participant opinion and debate (and thus engagement), when participants have an interest in and extensive experience with the topic, and when participants are familiar with one another (Morgan 1997; Gill et al. 2008; Dilshad and Latif 2013). This was the case for all members of these focus groups.

Vignettes

During the focus groups, I presented staff with a vignette, which they read independently and then discussed as a group. If time allowed, a second vignette was explored. Vignettes are hypothetical short stories comprised of stimuli designed to reflect particular elements of reality and society, to which participants are invited to explore and respond (Finch 1987; Barter and Renold 2000; Hughes and Huby 2004; Given 2008). A strength of using vignettes is that beliefs and norms can be discussed in situated contexts concerning hypothetical third-party characters, thus distancing the participant from the issues and minimizing personal threat (Finch 1987).

To construct the vignettes, I drew on existing transcripts of qualitative individual interviews completed in a previous phase of the research in which staff were asked to explore experiences of “difficult decision-making.” Consequently, I wrote the vignettes to reflect situations that front-line staff described as part of their daily activities in social care. These themes included staff management of competing needs, limited resources (personnel and financial), sexuality, restraints, covert medication, safety and risk-management versus autonomy, and interaction with families.

The vignettes are composite cases, written to generate ethical debate and discussion. They were written to provide participants realistic case scenarios drawn from their experiences in LTC, providing access to how staff think and reason through these cases. In order to explore how staff themselves reason through ethically difficult situations, I asked participants to discuss how they would handle the presented situation(s) and why they chose a particular path (Finch 1987; Hughes and Huby 2004).

Document Analysis

To gain a better understanding of the working environment of staff I reviewed the partner organizations’ philosophies of care, policies and procedures, and values. Reviewing organizational documentation allowed me to explore how the ethical reasoning of LTC staff reflect, align with, or conflict with declared organizational philosophies in managing ethical issues.

Ethics Approval

Research ethics board permission was received from two university ethics boards in the province prior to the commencement of the research, and written informed consent was sought and granted by each participant prior to beginning the focus groups. Because of the personal nature of the data, transcripts were written anonymously and digital files were password protected.

Data Analysis

Focus groups were audio recorded, transcribed verbatim, and subjected to critical discourse analysis (CDA) (Fairclough 1989). In the context of this research, the purpose of using CDA is to emphasize the importance of analysing language to demonstrate how embedded power relations within dominant discourses, including dominant (normative) ethical frameworks, ultimately impact LTC staff’s ethical reasoning and decision-making. I analysed the data to explore how language, knowledge, discourses, social relations, and power/inequality are constructed, sustained, or reconstructed, and how these elements impact the reasoning processes and decision-making of LTC staff (van Dijk 1993; Crowe 2004). In vivo coding was conducted in ATLAS.ti, followed by clustering codes to create more generic “theme families.” The clustered themes allowed me to determine the dominant emerging themes. By deconstructing the texts using CDA, I sought to identify the ethical reasoning of staff in LTC, as well as the participants’ own meanings, concerns, and priorities in dealing with difficult situations and how power relations embedded within language influences these processes.

Findings

In the following section I will discuss the findings of the research, exploring the misalignment between organizational philosophies of care and staff perceptions of the environment, the ethical frameworks used by staff in making decisions, and how staff actually make ethical decisions on the front line.

Organizational Philosophies of Care

Though the two LTC organizations that participated in the research have distinct characteristics, in reviewing their philosophies and values I found that both organizations largely espoused the same philosophies of care—an environment in which

  1. 1.

    resident-centred care is paramount,

  2. 2.

    residents’ independence and dignity are protected and they have maximized opportunities to make decisions,

  3. 3.

    shared decision-making occurs,

  4. 4.

    residents’ choices are respected,

  5. 5.

    safety is prioritized,

  6. 6.

    staff are competent and caring.

Despite organizational efforts to achieve these fundamental care concepts, findings from the focus group data demonstrated staff perceive, and therefore make ethical decisions and take action within, a very different organizational culture and environment.

Staff Perception

Throughout the focus groups, staff discussed their perception of the complex environment of LTC in which they work and make ethical decisions. Staff described an environment rather contradictory to the environments of care outlined in organizational philosophies. As staff discussed the vignettes, a number of themes emerge in relation to the environmental characteristics of LTC. The dominant themes demonstrated that staff predominantly perceived the organizational environment and culture as one characterized and/or shaped by 1) hierarchy of power and lack of staff autonomy, 2) staffing restrictions and a task-oriented environment, 3) concern about liability, 4) family power superseding that of the resident, and 5) financial inequality. Each of these impacted staff’s ethical reasoning and contributed to their experiences of MD and are expanded upon below.

Hierarchy of Power and Lack of Staff Autonomy

The themes of hierarchy of power and lack of staff autonomy emerged as predominant and recurring themes within, and across, all seven focus groups. Through analysis, it is apparent staff perceived the environment as highly differential in terms of certain individuals holding authority and autonomy more than others. Staff within all of the focus groups made reference to the power of the medical team, including physicians, dieticians, pharmacists, occupational therapists, physical therapists, and at times, RNs: “ … if that’s the medical team’s recommendation we’d have to pretty much go with that” (LPN, LTC 002). An example from one focus group is a competent resident wanting to walk independently outside and members of the medical team asserting their power to restrict or prohibit the resident from doing so. Staff explored how, at times, they act in ways that conflict with, or contradict, what they believe to be ethical and/or in the best interest of the resident, simply because those with more power have directed them to do so. As one staff described, “ … they may not have liked it anymore, but they’re following the orders of the nurse and the care plan in doing it …” (RN, LTC 001).

In some discussions, staff overtly described themselves (and more generally “front-line staff” as a whole) as having very little autonomy, specifically in respect to RAs, the front-line staff responsible for the majority of residents’ daily care. RAs both portrayed themselves, and are framed by others, as having the least power and autonomy. RAs often used binary language of “us” versus “them” when discussing the hierarchy and imbalance of power, displaying their perception that amongst co-workers they have the least autonomy. As one RA says, “us ourselves would not, we wouldn’t have anything to say about it. The RN’s themselves would have a little bit more …” (RA, LTC 003). Staff participants who are not RAs also discussed this power imbalance, framing RAs as less capable and describing the expectation that RAs “look to registered staff” (RN, LTC 005) for guidance and direction to minimize potentially unethical decisions and actions, rather than acting autonomously.

The vignettes allowed staff to discuss power imbalances in terms of hypothetical third-party characters rather than themselves or their colleagues, thus distancing them from the issues and minimizing personal threat (Finch 1987). In discussing the lack of autonomy or involvement of RAs in the independent decision-making process, some staff made reference to the vignettes, saying, “I know sometimes that person (RA) might be more comfortable asking the RN.” Interestingly, however, it was more common in the focus groups for staff to openly discuss the imbalance of power, and thus expectations in terms of decision-making, between levels of staff. The openness of the discussion amongst staff appeared commonplace and suggests the strength and acceptance of this discourse in LTC settings.

Although discussions within and across the focus groups revealed an obvious perception of power imbalances specifically between RAs and other staff members, the data revealed almost all staff, regardless of position, perceived themselves as lacking autonomy and being restricted by the hierarchy of power within the LTC environment. Consequently, staff reported they often make decisions and act in ways that contradict their personal or professional values regarding care. Very seldom (only two instances, in fact) did licenced staff make reference to their professional organizations/standards/codes of ethics in terms of making ethical decisions and the conflict experienced in making ethical decisions. The conflict staff explore and express is in direct relation to their personal and professional values (not the values of the professional organizations but the individual’s professional values). It was apparent staff often followed directions or “do as they are told,” (RN, LTC 001) for fear of consequences during the ethical decision-making process.

I’m quite sure, in a run of a day that I do at least fifty things that I totally disagree with and think are very wrong … Even though I totally, totally one hundred per cent disagree with a lot of stuff that goes on here … But you get used to it. Eventually. Takes quite a few years. (LPN, LTC 002)

Staffing Restrictions and Task-Oriented Environment

In contrast to the stated values of resident-centred care and the protection of dignity and independence found within the LTC organizational philosophies of care, the data revealed staff perceive the LTC environment as being understaffed, thus undermining resident-centred and quality care. Staff discussed “staffing issues” (LTC 002), “not having enough staff” (LTC 003), and “being too busy” (LTC 005) to provide holistic, quality care to residents.

Respondent 1 (R1): … yeah, it’s that, there’s a time constraint there.

Respondent 2 (R2): Leading to there’s not enough staff in nursing homes …

R1: … no …

R2: … you can put that down (laughs).

R1: You can imagine doing personal care on nine people and this population is really busy, and we do help them but, in the mornings, but that care doesn’t end after you wash them up and get them dressed in the morning …

R2: … no …

R1: … you know I would say, half to three quarters of our clients are incontinent … you know, so it’s ongoing through the day that you’re looking after them, it’s not just, you get them up …

R2: …yeah. The little formula that you use, for whatever it is now, three point such and such hours per day …

R1: …yeah…

R2: … you know in nursing home, [um] you’ve used it all up, by eleven o’clock in the morning. Right, so you have another, few hours. (RN & LPN, LTC 004)

Staff expressed how understaffing necessitates a routine/task-oriented environment in order to fulfil workload demands and meet the basic care of residents. However, they also described the ethical dilemma and experiences of MD resulting from wanting to provide care that meets the holistic needs of the residents while working in an environment where the practicalities demand otherwise.

Staff discussed how an understaffed environment results in time constraints, leaving very little time for more than basic care and increased difficulty in balancing competing residents’ needs. “You know, you may have three or four bells ring at once, out of those four bells you need to determine which one’s priority” (RN, LTC 006). Further, the data revealed that as a result of the routine/task-oriented environment, residents’ physical needs are often prioritized above social/emotional needs.

I find here, too, and this is the reality in a nursing home we tend to focus more on the physical needs of a client … because they are the most time consuming, you know ... But the emotional side of clients here tend to get put down on the priority list. (LPN, LTC 006)

Staff also described residents as passive recipients of care, lacking involvement in decision-making and care. There are some instances where staff overtly discussed and described residents’ as passive recipients of care. For example, a staff member pointed out how neither staff nor family had thought to approach the resident for their opinion, stating, “Like no one’s asked her, everyone’s forced their decisions on her” (LPN, LTC 005). More common in the data are discrete examples of residents as passive and uninvolved recipients of care, identified through the analysis of the language used by staff. A common example of objectifying language, thus highlighting residents’ passivity, emerged frequently as staff discussed residents and walking, “Like at the first, you take her, go for a walk … ” (RN, LTC 003). In this quote a staff participant corrects the language, though initially portrays the resident as a passive object “to be walked,” rather than “walking with” the resident.

Concern About Liability

A dominant theme across all focus groups was the staff’s awareness of, and concerns regarding, liability. The data revealed staff are very cognizant of the realities and possible ramifications of liability within their scope of practice, which consequently influences the ethical decision-making process. Staff expressed an uneasy balance and tension between risk and liability, impacting their ability to act in ways they believed to be ethical. Staff described situations where a possibly “risky” decision is perceived as the ethical one, and yet such action will be thwarted by their fear of liability. As staff openly explored this awareness and the importance of protecting themselves, the related sub-theme of documentation emerged.

… I mean, we end up on a stand somewhere and you don’t have any documentation to back up anything that we’ve, any conversations that we’ve had with families or whatever, or what we did, you know how we handled things then, we’re really, up the creek without a paddle basically. (RN, LTC 004)

Despite having liability concerns, staff consistently emphasized their desire to enable residents’ to “have good things and enjoy today” (LTC 004) and to “be happy” (LTC 005). However, at the same time staff discussed the potential risks and safety concerns associated with resident autonomy. In exploring the vignettes, and discussing residents’ safety versus risk and autonomy, staff supported and respected residents’ rights and in all focus groups staff expressed and supported the statement “the resident has a right to choose.” However, if these choices were counter to that of LTC policy or the medical teams’ direction, staff stressed the necessity of having the family and/or the resident sign a waiver. As one staff highlights, “so, we do get the family to sign something … saying that it’s kind of our, not our responsibility if something was to happen” (RA, LTC 003). It is interesting, however, that while having waivers signed was raised in all focus groups, there was some disagreement between focus groups on the significance, or warrant, of waivers. Some staff expressed the importance of having waivers signed to ensure they, and the organization, are protected, while others shared the sentiment of this staff, “well, the waiver’s … it’s not worth a pinch in court” (LPN, LTC005).

Family Power Superseding That of the Resident

Analysis revealed an unexpected theme within and across all groups, where staff perceived the family as having utmost power, superseding that of the resident, regardless of the resident’s cognitive and/or competency status. Staff discussed how familial influence impacts their ethical decision-making and contributes greatly to experiences of MD. Staff described how “families call the shots more than they should” (RN, LTC 004) and expressed how staff sometimes make decisions and act in ways to appease the family rather than the resident: “ … so they’re [staff] doing whatever they have to do to please the family members which is what happens even here a lot … It’s not about the resident, it’s about the families” (LPN, LTC 002).

A staff member also explained how, at times, families perceptions of the staff and their perception of the quality of care being provided can begin to emotionally impact and influence staff actions, saying, “ … ‘what kind of nurse are you?’ and after you hear that every day for months and months you actually, you know it’s like, oh my goodness this is terrible look at her, I’m going to make her have a bath (slight laugh)” (LPN, LTC 002).

The power of the family is most apparent as staff explored vignettes in which patients were presented as either competent or non-competent. In all focus groups, regardless of competency status, staff emphasized the importance of family involvement and present family as crucial to the decision-making process. In some discussions, staff expressed more overtly the perceived power of the family and how this ultimately supersedes even a competent resident, stating, “if family wants her bathed every day against her wishes, it probably is going to be done. And there’s nothing that anybody can do about it, I guess” (LPN, LTC 002).

Staff shared how, at times, “dealing with the family sometimes is ten times more difficult than dealing with the clients themselves” (LPN, LTC 007). Others discussed that as a result of families not understanding the “bigger picture” complexities of the LTC environment, they have unrealistic expectations and demands of staff and the organization. Staff explored how, at times, overt and unwritten policy requires them to include family in decision-making, resulting in competing commitments to work with and appease the family while also wanting to maintain and uphold the resident’s wishes and best interests. Staff highlighted how there is often tension between these commitments, complicating the decision-making process and frequently resulting in staff feeling conflicted and constrained.

Staff shared three situations in which decision-making becomes increasingly complex, often resulting in MD: first, when family disagree on a care plan, saying, “they need to establish who is going to make the decisions because the son or the daughter and the husband are on different tracks” (LPN, LTC 006); second, when family perspectives differ from, or contradict, those of the residents; third, when staff and family perspectives differ, further complicating the ethical decision-making process. Staff members consistently shared that despite disagreeing with family perspectives regarding care, they “move forward with whatever the decision was made” (RN, LTC 004).

Financial Inequality

Staff perceived the LTC environment as one that is understaffed, making it difficult to provide the quality and/or quantity of care for residents. As a result, during the ethical decision-making process, staff frequently suggested the solution of family hiring private care or services to meet the residents’ needs, although this is always discussed in terms of the family’s ability to pay for these additional services:

… But there’s other, you know, like some people we always offer like, you know they, on the waiting list for physio and things like that, that they can get on that list but they can also go privately if they’re, if they want that physio right now, if they want it very quickly … (RN, LTC 006)

Staff also perceived residents’ limited finances as contributing to the ethically complex environment in which they make decisions. For example, staff explained residents recognize the cost of their prescriptions and will be non-compliant with taking medications in order to increase their “surplus” income each month. The fewer prescriptions residents take, the more money they have to engage in activities or purchase items they want. Staff explain many residents only receive a comfort allowance of a hundred and eight dollars each month, from which many must pay for their prescriptions. In the province where the research was conducted, medications are secured and dispensed to residents. However, if for example a resident is prescribed vitamin D and consistently refuses the medication, eventually during medication/drug review it is likely the medication will be discontinued from the monthly ordering for the resident, which means they no longer have to pay for it. Under the provincial drug plan, residents pay a co-payment for each prescription, which can add up quickly. The only time prescriptions cost less is when a resident happens to still have a personal drug plan covering their prescriptions costs, though this is rare. As one participant said, “my residents would choose a night out entertainment over a vitamin pill, because they only have a hundred and eight dollars a month, and if they’re thinking their quality of life, they can live without a vitamin D … ” (RN, LTC 004).

Evidence of Ethical Frameworks

From the data, it is apparent there is a contrast and misalignment between the declared organizational philosophies and staff’s perceptions of the culture and environment in which they work. Despite this misalignment, the data demonstrate staff typically do not have difficulty in determining the ethical thing to do, though at times disagreeing with one another on the right course of action. In fact, there is evidence throughout of staff drawing on a number of ethical frameworks and norms during the ethical reasoning and decision-making process. Within and across all focus groups, as staff worked and reasoned through the ethical issues within the vignettes, it is apparent they did not limit their ethical exploration and reasoning to a single framework. Staff used insights from multiple ethical frameworks during the decision-making process, including principlism, consequentialism, deontology, utilitarianism, and “the golden rule.” Further, there is evidence staff draw on a number of social norms during the ethical decision-making process.

In the following quote, a staff member can be seen weighing the principles of autonomy, beneficence, and nonmaleficence regarding the right to fall.

When you get into the, you know, right to fall and that, those sort of things, which is worse, her being agitated in a chair, is it, you know, taking a chance she might fall and have a bruise, or whatever. And I mean we go with this everyday, it’s, you know … are we going to let somebody fall, which is, you know, for some people that’s, the better choice. (RN, LTC 003)

Using a consequentialist argument, this staff member discussed a resident’s risk of falling.

So many people that we have are up and around and we know they’re at risk of fall, but we don’t tie them down, you know, the quality of life is, if somebody is sitting in a chair, tied to a chair twenty-four hours a day, is nil. They can still fall even if they are in the chair. They can injure themselves in the chair, and then the risks are even greater. You know, if you know, you’ve put somebody in a chair and they wiggle down under the tray and they, they asphyxiate themselves on the tray I mean, that’s an even greater risk than somebody having fallen. (NP, LTC 001)

At times staff drew upon the concept of duty (deontology): “It almost killed me to put food in that tube. But as a licensed nurse I had to do that. It’s part of my job” (LPN, LTC 002). Others drew on a utilitarian framework when making decisions: “For the good of everybody,” “for the greater good,” and “then you’re forced to make that decision for the sake of the whole unit” (RN, LTC 004). Finally, staff also use the more societally common golden rule, basing ethical decisions on the motto, “do onto others as you would have them do unto you”: “I think it goes back to, treat people how you would want to be treated” (RN, LTC 006).

In addition to drawing on insights from several ethical frameworks, there is also evidence staff use the societal norms of not forcing others to do things and the expectation to be bathed and clean in making various ethical decisions.

I don’t, don’t think anybody, ever, should be forcing something in somebody’s mouth … well, we shouldn’t be forcing anything on anybody. (RN, LTC 004)

Maybe it’s not ethical, and we’re not supposed to do that, but sometimes it just, you have to do something ... because if she’s here for a whole month and she hasn’t washed so much as anything … (RN, LTC 003)

Managing Experiences of Moral Distress

Though staff drew on a number of ethical frameworks and societal norms in the ethical reasoning processes, the data revealed they often feel restricted to act in the ways they believe to be right and ethical and consequently experience MD. To manage these experiences of MD, in practice, staff rely on four strategies to make ethical decisions: 1) comply with being told what to do out of fear of consequences, 2) defer decisions to family, 3) “have a meeting,” 4) adopt and defer to existing workplace culture. Below, I outline the strategies and share examples from staff discussions.

  1. 1.

    Complying with being told what to do out of fear of consequences. The RN in the quote below highlighted how staff do not always agree with the ethical decisions made but follow orders because they are afraid to get in trouble if they question, or go against, them.

    “And some others is you do as your told or you’re written up. … they may not have liked it anymore, but they’re following the orders of the nurse and the care plan in doing it.” (RN, LTC001)

  2. 2.

    Deferring decisions to family. Regardless of whether the resident was competent or not, staff frequently expressed the need to “include family” in the decision-making process. Staff across all focus groups also discussed the need to appease family members and the conflict this creates. “On my unit where the majority would be, you know, competent, [um] I still do the family meetings because the family play a part, a huge role in all of this” (RN, LTC004).

  3. 3.

    Having a meeting. “Yeah, like she says sometimes you can make the decision on your own, but other times you need the group” (LPN, LTC007). As this LPN highlights, throughout the focus groups, staff discussed the ability to make independent decisions regarding ethical situations and take action accordingly. However, in exploring the vignettes and when asked what the course of action would be for a given situation, staff almost always fell back on “having a team meeting.” They frequently expressed concern about making the “wrong decision” and wanting allies in the decision-making process. While this is seemingly a good thing, in actuality it can be problematic given the fast-paced environment of LTC that often requires prompt decision-making. In some “bigger” decision-making situations, one can respect the need to facilitate a meeting (e.g. a resident wanting to stop taking a particular medicine), while in other instances staff should feel confident to make an autonomous decision (e.g. a competent resident wanting to walk outside).

  4. 4.

    Socialization into and acceptance of workplace culture. “Even though I totally, totally one hundred per cent disagree with a lot of stuff that goes on here … But you get used to it. Eventually. It takes quite a few years” (LPN, LTC002). Here we see an LPN discuss the process of workplace socialization, where she/he has learned to accept the culture and processes of the organization over time, despite disagreeing with them. Workplace socialization includes the formal and informal experiences where staff learn about policies, hierarchy, internal culture, and the day-to-day function of the organization (Korte 2007). The concern with making ethical decisions based on socialization and acceptance of culture is when the culture and foundation for making decisions is problematic, which I explore in the discussion below.

All four means of ethical decision-making avoid individual responsibility and autonomous decision-making and support the idea of ethical climates rather than the active development of ethical cultures.

Discussion

The disconnect between organizational philosophy and staff experience can be understood in the light of the distinction between ethical cultures and ethical climates. An ethical climate is a descriptive construct, where individuals within the organization are broadly aware of ethics, though front-line carers typically have a narrow understanding of responsibilities, and ethics training is limited to what regulations require (Messikomer and Cirka 2008). Many LTC facilities seem to have adopted a business-model approach to care, whether this is purposeful or as a result of provincial policy and constraint, which results in an ethical climate where decisions and actions are founded on economic and legal obligations and there is a greater demand for efficiency, resulting in task-oriented routines (Powers 2000; Powers 2001; Rees, King, and Schmitz 2009; Jakobsen and Sørlie 2010). Ethical climates founded on schedules and strict standards rather than what is right and good for residents create an external barrier to achieving the best care and limit opportunities for ethical practice (Slettebø and Bunch 2004; Bolmsjö, Edberg, and Sandman 2006; Dierckx de Casterlé et al. 2008; Dunworth and Kirwan 2009). This description of ethical climates is similar to the environments and constraints described by staff.

Conversely, a positive ethical culture is established when leaders within the organization proactively recognize ethics as an integral component to the organization’s culture and success and “identify, order, and communicate values so that in situations where they conflict, employees can more easily identify and weigh courses of action” (Messikomer and Cirka 2008, 89). Organizational leaders play a vital role in establishing ethical cultures, as they “set the tone” and are essential in sustaining a culture over time through employee empowerment, support, and education (McDaniel, Roche, and Veledar 2011, 80). When organizational leaders understand the circumstances that could lead to potential ethical issues, it allows them to manage these issues more effectively by encouraging creative alternative courses of action, which the literature proposes can be effectively accomplished through fostering a safe environment for moral reflection and deliberation (see, for example, Abma, Molewijk, and Widdershoven 2009; Widdershoven, Abma, and Molewijk 2009a; Edwards, McClement, and Read 2013; and Jakobsen and Sørlie 2010).

The emerging theme of MD, and the subsequent strategies staff rely on to make ethical decisions within the actuality of LTC practice suggest, in order to better understand how/why front-line staff make ethical decisions in social care in ways that avoid individual responsibility and autonomous decision-making, we need to explore the real or perceived organizational constraints staff describe as restricting their ethical decisions and actions. To better understand these potential organizational constraints, we must expand the inquiry to include the larger sociopolitical context(s) which influences LTC organizational policies and procedures and thus the ethical decision-making environment of staff. Pijl-Zieber et al. (2016) similarly found organizational constraints (e.g. understaffing, limited recreational therapy, lack of resources) resulted in staff experiences of MD. Here, I support and echo the recommendations made by Pijl-Zieber et al. (2016, 30) as they propose “ … the experience of MD is a symptom of a greater problem within the continuing care sector, and that the most productive solutions can be arrived at by framing MD as essentially a structural concern” [emphasis added]. Exploring the interaction between public policy and LTC organizational policies and procedures and how these interactions can promote or hinder the development of an ethical culture in the provision of LTC would contribute to a better understanding of front-line LTC staff’s ethical decisions and actions as well as help address and rectify the constraints that result in staff experiences of MD.

Such an exploration is particularly relevant to front-line LTC staff as they are the individuals who frequently experience MD. This exploration could be used to improve the ethical environments for staff (thus reducing MD) through the development of ethical cultures rather than climates. Further, such changes would also improve care environments and quality of life for residents. Expanding the research to gain a detailed understanding of how public policy influences organizational policy and thus front-line care environments is a pivotal first step toward the development of a) relevant and appropriate LTC policy change and b) informed ethics training and professional support for front-line staff. While this is not the forum for discussion, a second phase of this research has been developed in light of the findings, which aims to explore how the interaction between front-line practice, organizational philosophies, and public policy promotes or hinders the development of an ethical culture in LTC, using a qualitative Delphi method (for more see Greason 2017).

The majority of the reported constraints resulting in MD are in fact structural, meaning they could be solved or at least reduced by examining and addressing the larger sociopolitical factors influencing LTC organizational policies and procedures and thus the ethical decision-making environment of staff. However, the reported constraint of family power superseding that of the resident, and the resulting MD, is much more complex, raising issues of relationships, values, culture, and inter- and intra-personal dynamics. Family involvement and the associated ethical dilemmas and MD experienced by staff is not a constraint that is easily resolved. Similarly, other studies have also identified the complex interactions between residents, staff, and families as a unique characteristic of the LTC that contributes to staff experiences of MD (Spenceley et al. 2017). In light of this finding, perhaps we need to consider that regardless of the ethical culture of the organization, some MD is inevitable in the context of LTC as staff and family encounter competing claims, values, and beliefs about what is “right” and “good.”

One possible avenue of reducing MD, given the complexity of family involvement, is to draw on Jurgen Habermas’ theory of discourse ethics (Finlayson 2005). Discourse ethics is a method of ethical reasoning founded on communication, emphasizing the importance of considering the viewpoints of everyone involved and designed to bring about consensus (Finlayson 2005). Through the communicative action inherent to discourse ethics, individuals can talk about differences and come to a common understanding and ethical decision, thus maintaining family involvement while also reducing the experiences of MD reported by staff. There are, of course, limitations and constraints to using this method in LTC settings, which would need to be considered and overcome (e.g. time constraints, facilitation, location of family). However, it is a possible avenue forward which could help reduce the reported MD experienced by staff as a result of family power superseding that of the resident.

In light of the findings, more research is needed in LTC settings to explore the ethical reasoning processes of staff, to determine the impact public policy has on the development of ethical cultures/climates and thus decision-making environments for front-line care staff, and to find solutions to the structural constraints resulting in staff experiences of MD.

Limitations

One limitation of this research is that it is a relatively small sample size of seven focus groups, consisting of a total of twenty participants from four LTC facilities, representing two organizations. While findings seem to resonate with staff from other LTC organizations, ideally future research would be conducted to broaden the scope of exploration to include a larger sample size and to include the voices of more RAs. Further, participants were predominantly white women. While this is a limitation, it is also reflective of the reality of these agencies.