Strategies to mitigate moral distress as reported by eldercare professionals

ABSTRACT

Eldercare workers experience higher levels of moral distress than other health and social care service workers. Moral distress is a psychological response to a morally challenging event. Very little is known about moral distress in the context of eldercare and about the mechanisms of preventing or mitigating moral distress. This qualitative study was conducted as part of the “Ensuring the availability of staff and the attractiveness of the sector in eldercareservices” project in Finland in 2021. The data were from 39 semi-structured interviews. This qualitative interview data were examined using two-stage content analysis. The key finding of this study, as reported by eldercare professionals, is that strategies to mitigate moral distress can be found at all organizational levels : organizational, workplace and individual. The tools that emerged from the interviews fell into four main categories: 1) organizational support and education 2) peer support 3) improving self-care and competence and 4) defending patients. The main identified categories confirmed the earlier findings but the qualitative, rich research interview data provided new insights into a little-studied topic: mitigating moral distress in eldercare. The main conclusion is that, in order to mitigate moral distress, ethical competence needs to be strengthened at all organizational levels.

KEYWORDS:

• Eldercare professionals
• moral distress
• interview study
• ethical competence
• workplace tools

Introduction

Nursing is a fundamentally ethical profession because it is based on the moral requirement of promoting the well-being of another human being. Ethical questions and problems are inherent to the field, and even seemingly mundane tasks and actions can have grave moral consequences (Carse & Rushton, 2017; Gastman, 2002). Nurses are often required to detect and solve moral situations in a demanding and stressful work environment. Unfortunately, ethical conflicts and moral distress have been linked to lowered work ability (Selander et al., 2022) and to the intention to leave the job and the nursing profession (Petersen & Melzer, 2023). These findings are alarming since health and social care services are already struggling with labour shortage (WHO, 2023). As eldercare workers experience higher levels of moral distress compared to other health and social care service workers (Selander et al., 2022), and the number of elderly people needing care is increasing rapidly, there is urgent need to find solutions to mitigate moral distress in elderly care.

Discussion about the definition of moral distress, especially regarding what can be accepted as its necessary condition is ongoing [see i.e (Carse & Rushton, 2017; Fourie, 2017; Johnstone & Hutchinson, 2015; McCarthy & Gastmans, 2015; McCarthy & Monteverde, 2018; Morley et al., 2019)]. Moral distress was originally conceptualized by Jameton (1993, pp. 542) as an unpleasant feeling when “a nurse knows the morally right course of action to take, but institutional structure and conflicts with other co-workers create obstacles.” In this study, moral distress is understood in a broader sense, as a negative psychological response to a morally challenging event. Following Carina Fourie’s (2015) definition, moral distress can arise if an agent is constrained from acting in accordance with moral standards. Additionally, the distress can be caused by moral conflict or dilemma, in which the employee is not certain about how to resolve the situation in an ethically acceptable manner or is forced to choose between two equally valid ethical values. To summarize, moral distress has two necessary components: 1) an ethical trigger and 2) a negative psychological reaction to it (Fourie, 2015, 2017; Kälvemark et al., 2004; Tigard, 2019).

Researchers have linked moral distress to feelings of guilt, frustration, anger, powerlessness (Morley et al., 2020), anxiety, depression, burnout (Smallwood et al., 2021) and moral numbness (Hyatt, 2017). However, some writers have argued that moral distress is not a merely negative phenomenon. The unpleasant emotions may help an employee to better recognize and understand one’s values, and further motivate one to act when those values are threatened. Therefore, because it is not possible to eliminate moral distress totally in the elderly care context, it can be considered as an opportunity for moral growth and possibility to develop institutional policies or practices (Carse & Rushton, 2017; Tigard, 2019) in order to enhance well being of employees. The most typical factors behind moral distress in the health and social services (HSS) are related to inadequate resources and insufficient staffing levels (Burston & Tuckett, 2013; Morley et al., 2020; Nikunlaakso et al., 2022), disagreements over clinical decisions (McCarthy & Gastmans, 2015; Wiegand & Funk, 2012), poor ethical climate or work environment (Lamiani et al., 2017; Rego et al., 2022), and social conflicts (Nikunlaakso et al., 2022; Pijl-Zieber et al., 2018; Woods, 2020). Moral distress has been established to be connected to the environment in which an employee operates, and the dimensions of moral distress may vary in different settings (Atabay et al., 2015). Since moral distress is significantly more common in elderly care (Selander et al., 2022), it is important to establish and identify the characteristics of elderly care.

The Ministry of Social Affairs and Health sets the guidelines for developing services for older people, drafts the relevant legislation and guides the implementation of reforms in Finland. The Ministry of Social Affairs and Health, together with the Association of Finnish Local and Regional Authorities, has also published a quality recommendation that aims to guarantee a good quality of life and effective services for all older persons who need them (STM, 2020). In addition to national laws and recommendations, each social and health care organization has its own guidelines, which each work unit applies to its own activities. The training and qualifications of professionals working in elderly care are also regulated by law. Hence, majority of the professionals are either practical or registered nurses (Kehusmaa & Alastalo, 2022). Like in several other European countries, traditional institutional care has been replaced mostly by home care (Heggestad et al., 2021; Hoppania, 2015).

Home care as a work environment differs markedly from that of hospitals and nursing homes, and thus their ethical situations also distinct. Since nurses mainly work alone under time pressure in their clients’ private homes, they lack the support of colleagues when making care decisions (Andersson & Sjölund, 2022; Choe et al., 2015; Fjørtoft et al., 2021; Selander et al., 2022). Private homes can be considered particularly intimate settings, which require employees to possess a heightened degree of social and ethical sensitivity (Andersson & Sjölund, 2022; Choe et al., 2015; Heggestad et al., 2021). Furthermore, elderly patients’ complex healthcare needs place significant pressure on nurses’ competence (Fjørtoft et al., 2021; Marks et al., 2021; Podgorica et al., 2021). Clients in elderly services are often afflicted with multiple illnesses and health conditions affecting their functional abilities. In the case of elderly individuals with cognitive impairments, ethical questions linked to autonomy are accentuated (Bozzaro et al., 2018; Magelssen & Karlsen, 2022; Marks et al., 2021; Podgorica et al., 2021). Previous studies have also shown that conflicts around patient autonomy are especially prominent in home care (Heggestad et al., 2021; Lindberg et al., 2023; Öresland et al., 2008).

Ethical-existential questions associated with ageing are prevalent in the elderly care. Although elderly people typically have multiple illnesses, old age itself is not a disease nor can it be cured. Death or dying do not define old age as an experience or a phenomenon, but its proximity is undeniably a central part of old age and elderly care (Muldrew (Née Preshaw) et al., 2019; Schenck & Roscoe, 2009; van der Vaart & van Oudenaarden, 2018; Young et al., 2017) Questions of good life and death become even more delicate with scarce resources. Indeed, elderly care is not only guided by the care needs of the population but also by political decisions (Hoppania, 2015). Securing sufficient financial and personnel resources in the HSS is an international problem and does not only concern elderly care. However, the sheer and increasing volume of the elderly people in need of services makes the shortage of personnel a particularly significant problem (Tynkkynen et al., 2022) Although many of the previously mentioned features and moral situations of elderly care also apply to other HSS settings, we suggest that together these characteristics form a unique framework for elderly care professionals to operate and navigate moral decisions.

Surprisingly, very little attention has been paid to moral distress in the context of eldercare as shown by the scoping review by Nikunlaakso et al (2022), in which they aimed to identify and to map relevant research evidence regarding moral distress in elderly care. This systematic scoping review (Nikunlaakso et al., 2022) included studies of causes and consequences of moral distress among eldercare workers and the intervention studies to mitigate moral distress published in years 1997–2022. According to the scoping review, most of the studies were qualitive and aimed to describe ethically challenging and draining situations (Nikunlaakso et al., 2022). The causes of moral distress in eldercare were organizational restraints such as policies or inadequate resources, relational and power-related issues, conflicts with colleagues, patients and their family members, and other professionals. Situations and decisions related to patients’ care and services may cause moral distress when professionals have different understandings about the right way to act, or when the decision-making process is unclear. In addition, a lack of workers’ competence and work safety problems can also create uncertainty and lead to moral distress (Nikunlaakso et al., 2022).

The mechanisms of preventing or mitigating moral distress have been examined in other HSS sectors (Amos & Epstein, 2022; Nikunlaakso et al., 2022). Most intervention studies have developed the ethical competence of nursing staff through training (Allen, 2016; Kälvemark Sporrong et al., 2007; Molazem et al., 2013; Monteverde, 2014) or reflective practices (Allen, 2016; Chiafery et al., 2018; Hamric & Epstein, 2017; Kälvemark Sporrong et al., 2007; Molazem et al., 2013; Monteverde, 2014; Robinson et al., 2014; Wocial et al., 2017) or by improving the personal resilience of nurses (Davis & Batcheller, 2020; Rushton et al., 2021; Vaclavik et al., 2018). Only a few studies have focused on identifying the organizational and workplace structures that underlie moral problems and on developing practical ways to change them (Hamric & Epstein, 2017). Amos and Epstein (2022) pointed out that more systematic intervention studies are needed. To develop strategies to urgently prevent and mitigate the harmful effects of the phenomenon an even deeper understanding of the factors behind moral distress are needed. In addition, the solutions described above may not be directly transferable to elderly care or at least they must be tailored to the context. Moral distress is deeply rooted to the context in which the employee works, so the solutions offered to mitigate moral distress and its harmful consequences should also be context specific.

Only three studies describing strategies to mitigate moral distress in eldercare (Kim et al., 2020; Trifunovic-Koenig et al., 2022) (Rainer et al., 2018) were found in the scoping review by Nikunlaakso et al. (2022). These strategies were classified into four main categories: organizational support and education, peer support, improving nurses’ self-care and competence, and finally, defending patients (Nikunlaakso et al., 2022). Organizational support and education include strategies to achieve more resources for care and to increase education and leadership support and trust from supervisors. Peer support refers to being able to rely on group morality in decision making and opportunities to share feelings and choices with colleagues and one’s team. Further, improving self-care and competence emphasize the need to pay attention to self-care, maintaining self-soothing behaviour, psychological support, and understanding how the elderly express their needs. The category of defending patients contains all strategies based on the principle of defending the interests of the client, such as respect for autonomy. Despite these findings, no previous study has focused exclusively on exploring the ways in which moral distress is prevented and managed in eldercare organizations.

Therefore, the aim of this qualitative study was to describe the strategies and practices used to mitigate moral distress in eldercare organizations. Our research question was:

What kind of strategies and practices to mitigate moral distress do eldercare professionals describe?

Materials and methods

Ethics approval statement

This qualitative study was conducted as part of the Hyvä veto study (an implementation project of the age programme) in Finland in 2021. The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of FIOH (ethical approval (12/2020). The study data were based on semi-structured interviews (N = 39) of nurses and supervisors in elderly care.

Hyvä Veto, an implementation project of the age programme

Recruitment strategies

The interviewees received information about the study project from the researcher and their own organization. In each organization, there was a contact person who communicated internally about the study. An information letter about the study was send the organizations. The organization’s contacts promoted the study through email, the intranet, and during supervisor meetings. Due to COVID-19 restrictions the researchers held information sessions about the study for supervisors through Teams and produced a video explaining the possibility of participating in the study for personnel. Nurses could enrol voluntarily for the interviews through a Webropol-survey.

The survey asked nurses about their interest in participating in the interviews (yes, no), their background information (work unit, type of employment, work experience, job title, and educational background), and contact information (email). (The background information did not include gender etc. information.) The survey indicated that not all nurses would be selected for the interview. In total, 58 nurses were interested in the interview. A total of 46 interviewees were selected for the interviews. However, six interviews were cancelled by the interviewees. Some of the nurses were on a vacation during the interview period. After the interviews, a development work of this study project was initiated. For this reason, a diverse sample of interviewees was sought to avoid overemphasizing any single group (e.g., region, work unit). Two researchers (T.K, N.O) selected the interviewees, taking into account diversity (e.g., different health care district, type of working unit, profession, education, occupation, work experience).

The data were from 40 semi-structured interviews, but one interview was excluded from the analysis because the interviewee was not a nurse. The interviewees included nurses (n = 23) and supervisors (n = 17) from home care services, long-term care facility, and institutional services (hospital ward) from four different regions. There were 7–13 interviewees from the same region. Finland’s healthcare is divided into 21 regions. This article is based on interviews of nurses (n = 23) and supervisors (n = 16) in elderly care. All interviewees were nurses, although some held positions as supervisors.

Data collection

The interviews were semi-structured. Semi-structured interviews are standardized, flexible, unique, and personal, based on open ended questions (Gilham, 2000). In semi-structured interviews, the questions are prepared as per the interview guide prior to the interview based on previous knowledge (Mason, 2004; Rubin & Rubin, 2011). The list of questions helps the interviewer to be certain that all relevant questions were asked (Runeson & Höst, 2009).

A semi-structured interview guide was formulated based on extensive literature review and survey results on the well-being of social and healthcare workers in Finland. Those working in elderly care experienced significantly more ethical distress and less supportive leadership from supervisors compared to other professionals in HSS. The work ability of those working in elderly care was also weaker compared to other professionals in the social and healthcare sector (WHO, 2023).

The interview guide included following themes: occupation and well-being at work (work duties, work-related resources, stress factors and recovery), cooperation with colleagues (peer support, peer learning, experiences of workplace bullying), nurse—supervisor interaction (leadership, opportunities to influence one’s work, job performance, education), organizational ethics (ethical principles, ethically challenging situations, ethical conduct, patient`s right of self-determination), and changes in eldercare work (change scenarios, attraction factors of elderly care work). The interviews were recorded and transcribed and their length varied between 45 and 58 minutes and the transcriptions ranged from 14 to 27 pages.

The interview guide was pilot tested (Naz et al., 2022) Two researcher (T.K, N.O) made individually two interviews and the guide was re-assessed based on the findings of the pilot interviews by three researchers (T.K, N.O, E.K). There were no major changes made to the interview guide.

The interviews were conducted via Teams because of COVID-19 restrictions, by three researchers (T.K, N.O, E.K). Each researcher conducted the interview alone, but before the interviews, the researchers discussed the themes and related questions together to find a common understanding. It was important to discuss about these thoroughly before the interviews because it was possible that interviewees will ask something corrective. This allows the interviewees more freedom in expressing meaningful opinions and perceptions, while still allowing the interview to maintain focus the topic on hand.

In this study interviewees' answers were mainly focused on the themes cooperation with colleagues and organizational ethics. The questions were for example: How are challenging ethical situations handled in your work unit? Could you describe situations where you felt uncertain about the right way to act? What kind of support did you receive in those situations? The interviews were recorded and transcribed. The number of transcriptions used on these themes in this study varied between 0.5 and 3 pages in the interviews. Thus, the total length used in this study was 56 pages (Calibri 12, line spacing 1.15).

Data analysis

The qualitative interview data were examined using two-stage content analysis. Firstly, the data were analysed inductively, and secondly, the results from inductive analysis were classified according to the results from the scoping review by Nikunlaakso et al (McCarthy & Monteverde, 2018). Content analysis is a base method for presenting a synthesis of results (Elo & Kyngäs, 2008; Elo et al., 2014) (Graneheim & Lundman, 2004).

Inductive content analysis. During the first stage, we read the data several times and gained a comprehensive understanding of the content. After this, we analysed the data inductively and selected every utterance that described strategies to mitigate moral distress. We then categorized them according to similarities and differences. We used inductive content analysis in order to ensure that every described strategy to mitigate moral distress would be analysed. This was important step before the second stage when we used deductive content analysis, since without the first step there would have been a possibility to miss something. The finding of this first stage was that main categories corroborated the findings of the previous systematic literature review (Nikunlaakso et al., 2022). The subcategories (Table II) were based on inductive content analysis. A scoping review is a type of evidence synthesis that has the objective of identifying and mapping relevant evidence regarding the topic, field, context, concept or issue under review (Peters et al., 2021). We utilized the findings as it had synthesized the key findings from recent research, which are scarce.

During the second stage, we categorized the results from the inductive analysis using deductive content analysis to compare the first stage results and the main categories followed the formed classification recognized in a recent scoping review (Nikunlaakso et al., 2022). The four main categories were 1) organizational support and education, 2) collegial/peer support, 3) nurses’ self-care and competence, and 4) strategies chosen to defend the patient’s viewpoint.

The researchers (T.K, M.P) conducted the whole analysis process together, evaluated the categories and content together and discussed the difficult parts in order to reach consensus. Later, the reliability was reassessed by four researchers (T.K, N.O, M.P, E.K). Table I presents an example of the analysis process (main categories, subcategories, and original utterances).

Table I. Example of analysis process (main category peer support).

Quote	Subcategory	Main category
“It’s a case of just going to chat, a quick meeting in the doorway. We talk, voice our concerns, and take measurements if needed and so on. We say how we feel right now, that this patient isn’t doing so well, can you go and see them and assess the situation. (…). This works for us [for me and my colleagues] usually, this type of discussion, we’re able to get things taken care of on both sides.” (10) “I’ve probably faced these situations, in which I’m not 100% sure (…) I usually call a colleague, so I’m not left, I don’t like being left alone to think and guess, so if I don’t know what to do, I call a colleague and ask them ‘Hey, what have you done in this situation, what’s the right way?’” (35)	Informal forums to resolve situations	Peer support
“They’re open groups, a few of us (…) we have closed groups and open groups. Now it’s these open groups about every other xxday. (…), it’s voluntary. People really like to go [to these groups].” (28) We have job coaching at the moment, as we asked for it, and we talk about (…) respecting colleagues and that each of us has our own way of working, and giving and receiving feedback … (1)	External support for groups discussion to deal with difficult situations
“We’ve kind of tried to, like when new employees arrive, old or young, that the new employee has two mentors, that is, one of them is someone who has just arrived, maybe even just graduated if possible, and the other is someone more experienced, on old-timer and then this new employee would get both perspectives.” (26) “I’d say the younger ones adapt more quickly to changes and (…) learn programs and accept changes more quickly and so on. Of course, those who have been here longer and are maybe older have good instincts, or they maybe … (…) They see and experience and are able to observe things and draw conclusions differently, which of course comes from the professional experience they’ve gained. The younger ones maybe go more according to the tasks … .Work life is like a checklist, more could be said.” .(33)	Young and experienced nurses working together to strengthen professional skills

Research ethics

The research was conducted in accordance with the Hyvä veto study (an implementation project of the age programme) in Finland in 2021, and permission to collect the data was obtained from the Ethics Committee of FIOH (ethical approval (12/2020). Informed, written consent was obtained from all interviewees before recording the interviews. They were also advised that they could withdraw their consent at any point during the data collection. All names and other details that could enable identification of the interviewees have been removed or altered in the text and data excerpts.

Trustworthiness

The transcriptions of the interviews were read multiple times by at least two different researchers to form an overall understanding. All expressions relevant to the research questions were extracted from the data. It could be a word, sentence, or part of a sentence, or a combination of several sentences. Condensed expressions with the same content were categorized into subcategories. The subcategories with the same content were grouped into main categories. The reliability of the study was examined through credibility, transferability, and confirmability (Elo et al., 2014; Graneheim & Lundman, 2004).

The position of the interviewees (nurse vs. supervisor), years of work experience, workplace (home care services, long-term care facility, and institutional services), and geographical area were considered in the analysis, but the results did not differ by background factors.

The interviewees expressed their willingness to participate, and the researchers selected them in a way that the data represented a diverse range of backgrounds. It is possible that those who volunteered for the interviews had already been reflecting more on these themes related to elderly care. Limitation of this study might be that target group was relatively small (N = 39). However, the four regions/organizations were well represented in the interviews, and both supervisors and nurses were sufficiently interviewed. Further, during the second stage of the analysis, our main categories followed the former classification recognized in a recent scoping review (Nikunlaakso et al., 2022). Although a scoping review is a systematic review of previous research and its aim is to describe what has been previously studied on a topic, it is possible that the scoping review classification may not be comprehensive enough. Also, nurses got information on a possibility to participate to interviews directly from working units and management of participated elder care organizations. Thus, the researchers had no possibility to influence that.

To conclude the trustworthiness of the data and the analysis are good, as the interviews were recorded, transcribed, anonymized, and systematically analysed. Multiple researchers read the material to ensure a consistent understanding of the themes. The data allowed for diverse and reliable answers to the research questions presented.

Results

The interviewees reported different ways of managing moral distress, which were grouped into four main categories. The main categories were organizational support and education, peer support, improving self-care and competence, nursing and defending patients (Table II). The results of the study support those of previous research but are described in more detail. Next, we describe the practices that were created from the interviews of nurses and supervisors, by their main categories.

Table II. Main categories and subcategories of moral distress management tools in four health and social service organizations.

Organizational support and education	Workplace guidelines and instructions of organization
	Workplace guidelines more recognized by work unit
	Official forums to discuss ethically challenging situations
	Professional competence through education to act in ethically challenging situations
Peer support	Unofficial discussions in work unit
	External support for groups discussions to deal with difficult situations
	More experienced people and young people sharing their skills
Improving nurses’ self-care and competence	Controlling emotions in work situations
	Psychological recovery from work
Defending patients	Immediate contact with work community to resolve situation when concern emerges
	Nurse respects patient’s right to self-determination
	Nurse has ways to seek agreement with the patient when their views differ

Organizational support and education

The guidelines and instructions created by organizations and work units formed a morally normative framework for decision-making, action and evaluation. Ethical decision-making and the quality of care were also supported through official joint discussions and by encouraging nurses to improve their professional competence. Interviewees felt that these practices decreased moral uncertainty and helped them to act according to professional values.

Workplace guidelines and instructions of organization

The interviews revealed that the common guidelines and policies of the organization helped supervisors deal with and resolve ethically charged situations. As one interviewee said:

Of course, we have a specific mobile system, to report problems. There are work safety-related problems, our employees report exactly these kinds of situations involving violence […] then when the employees report these things, we discuss them in our meetings and think what could help to resolve the situation and to prevent it from happening again. Of course, we have guidelines for situations involving violence and challenging behaviour and so on. So, we have instructions and we try to go over them now and then. (9)

According to interviewees the guidelines were used as a reference point for supervisors in challenging patient-related situations. The common guidelines also ensured consistency in the supervisors’ decisions. This reinforced the nurses’ perceived fairness of the supervisor’s actions. Common guidelines also help line managers support supervisors in ethically difficult and stressful situations. If their own organization has no guidelines for the situation, line managers can find out what kind of guidelines have been drawn up in other health and social service organizations.

Workplace guidelines more recognized by work unit

The second practice that was described was the use of practices jointly developed and agreed upon by the work unit. The work of an individual nurse in challenging situations was made easier when all nurses in the unit knew how to deal with situations and how to report them. This meant that the challenging situations were recorded and made visible and could be resolved in joint meetings. As one interviewee described:

So, let’s talk about, what can I say, the use of the alarm system, what does it mean from the perspective of the client, and how can we describe the text, like, for the self-monitoring plan. So that the members of every team think about it together and think how to write it in the same way, how the employee takes part in thinking about it and recording it in that way. (21)

The interviewees felt that common organizational guidelines helped set up the policies. The key was to open up the organizational policy to the work unit level and to develop the policy together in a participatory way with the nurses. Participation could take the form of multi-professional working groups, small group discussions or asking for everyone’s opinion at a meeting. In this way, policies were created that supported everyone’s daily work. In addition, the interviewees found that the involvement of nurses enabled a discussion about the principles of the policy and why it was important for everyone to be committed to it.

Official forums to discuss ethically challenging situations

The third way we identified in the interviews was regular discussion forums and agreed ways of discussing ethically challenging situations within the work unit.

These included weekly and monthly meetings during which, in addition to current issues, changes in client care and challenging client and family situations were regularly discussed and solutions to these situations were considered together. As on interviewee said:

Well, I suppose just that, what’s the best way to deal with difficult customers, I feel like we can never talk about it too much. (35)

In order to ensure that the meetings helped employees handle situations, interviewees reported that it was important that the work unit had agreed on common discussion methods and ground rules for interaction. This ensured that the atmosphere of the discussion was perceived as safe and that interviewees dared raise even difficult issues.

Professional competence through education to act in ethically challenging situations

According to interviewees education was one of the practices that supported the management of moral distress. Strengthening their own professional skills gave the nurses the tools and confidence to deal with challenging situations. The importance given to training and the provision of training alongside work encouraged the nurses to develop/learn their own skills. As one interviewee said:

[…] we have two tutors for each student, so there’s always one or the other tutor working […] each tutor has ones own way of teaching and the student is not left alone. Except for the tasks that we check that they are able to complete, they do them alone, but the supervisor is still present nearby. Somewhere a few steps away or behind a wall, so that they are not left alone to wander around (30).

Some nurses asked about moral distress during their performance appraisals, and together with their supervisors, reflected on the skills they felt they needed to deal with difficult situations. Together, the supervisor and the nurse considered what kind of training would strengthen the nurse’s ethical competence. As one interviewee put it:

[…] in my performance appraisal with my supervisor, exactly this came up, that now that I’m going to have my own areas of responsibility then I’ll be able to freely look for relevant training and sign up for it […] my supervisor has a really positive attitude to training. (13)

Peer support

Peer support was described as an absolute necessity for mitigating moral distress. Nurses shared knowledge and skills and provided emotional support for each other to cope with feelings raised by challenging ethical situations.

Unofficial discussions in work unit

Informal forums to discuss and resolve situations while working were one form of peer support that came up in the interviews. As one interviewee said:

Well, we do sometimes share our experiences [of violence]in the staff room and talk about them. Maybe also share tips […] (16)

The nurses held quick meetings outside of work. In these discussions, they worked together to resolve serious patient situations and at the same time agreed on how to deal with such situations. These discussions were not recorded or formally noted but agreed on among those present. They helped the individual nurse to deal with a situation; a decision was taken together, and the discussion enabled different approaches and solutions to be considered. Informal discussions were held with supervisors if the situation was considered demanding and required higher decision-making power. Interviewees also explained that in the workplace, nurses were debriefed afterwards challenging situations and decisions were discussed with colleagues. Unravelling situations together helped the nurses detach themselves from the moral distress that the situations created.

External support to groups discussions to deal with difficult situations

Another means of peer support that interviewees described was group sessions run by an external facilitator (e.g., psychologist) to help resolve situations. Nurses were offered the opportunity to participate in group sessions led by an outsider, during which they could reflect on situations and solutions with their peers. As one interviewee put it:

[.] the priest holds a meeting every two or three weeks we have these kind of wellbeing groups. They’re open groups, small groups […] And they are things that the employees feel they can benefit from. They are good. (31)

These included job coaching, and open and closed groups. The groups met regularly and participation was voluntary. The role of the external facilitator was perceived to be effective, as an outsider ensures a safe atmosphere for discussion and can guide the discussion from different perspectives.

More experienced people and young people sharing their skills

According to the interviewees professional skills could also be built through peer learning on the job. This form of peer learning was combined especially in collaboration between experienced and young nurses. Both sides had knowledge to share and both benefitted from learning from each other at work. As one interviewee indicated:

about improving old nurses’ professional confidence, because it’s also that we partly feel a kind of insecurity about our own old-fashioned education, when the younger ones, they often have these ideas when they come, and of course sometimes they’re a bit high-flying because they don’t yet know what everyday life here is like, but still, I’ve always tried to, like, say that this is great, that the younger ones have the most recent knowledge, and that brings us again to job circulation and training, so that if the older nurses had the energy and interest in their own field and to learn new things and see new things it would be easier to like, tolerate the younger nurses’ differentness. (3)

Interviewees described that novice and experienced nurses had different levels of knowledge, but orientation was important for both. According to interviewees even an experienced nurse needed to be trained if they moved to a different type of work unit in eldercare, for example, from home care to assisted living facilities. In a busy environment, there were fewer opportunities for discussion and other work tasks took time away from orientation. Interviewees described that cooperation between young and experienced people could be promoted by, for example, pairing them up.

Nurses also explained in the interview that joint discussion offered an important means of sharing knowledge. Experienced nurses had many tasks, for which they also had orientation responsibilities. In a safe atmosphere, young people dared to share experiences and ideas, which increased the cooperation between them and more experienced people in everyday life.

According to the interviewees work experience strengthened skills for patient encounters and caring and empathetic interaction. Experienced nurses had tacit knowledge and a holistic understanding of patient encounters that could be passed on to early-career nurses over time. Experienced nurses could advise novice nurses on how to deal with an elderly person or a relative in a challenging care-related situation. Young people also needed guidance on work life skills when starting out in their careers.

According to interviewees those at the beginning of their careers had the latest professional knowledge from education. It was therefore important that young people had the opportunity to use this knowledge in their work. They also often had excellent digital skills. As one interviewee said:

[…]the younger people are very well informed and very good at these IT things and they’re very interested in metres and all the equipment and so on. Then again, this older generation, they know how to use the basics, of course, but they are alienated from those things and they long for something more old-fashioned, that everything would be open and on paper and clear instructions. (8).

Early-career nurses had a great enthusiasm for learning and developing their work, which should be better exploited in the eldercare sector.

Improving nurses’ self-care and competence

In addition to the organizational and workplace level, nurses also had different ways of preventing and managing moral distress at the individual level. During work shifts, the importance of the nurses’ own emotional regulation skills was emphasized, while during leisure time, stress was managed by investing in psychological recovery.

Controlling emotions in work situations

Interviewees felt that the demanding situations they encountered at work sometimes aroused strong emotions in the nurses. Recognizing and regulating their emotions was seen as a professional skill that helped them cope with stressful situations. For example, they managed feeling rushed by taking a consciously calm, holistic approach to client encounters. The skill of self-soothing was also emphasized in terms of tolerating aggression from patients. As one interviewee put it: “Personally, I’ve always tried to stay calm, it’s no good starting to shout and rage yourself too, it’s better to sit quietly for a while or stay there next to the person, or just leave if the situation looks like that, and ask other nurses to come or get help.” (7)

Uncertainty and feelings of inadequacy were managed by “playing it safe” and examining the limits of one’s own abilities. Rather than trying to internalize all the information needed for their work, the nurses considered confirming their chosen behaviours as a more reliable way in which to ensure the safety of care. Accepting the limits of their own capabilities made it easier to cope with a heavy workload and incompleteness. In practice, this meant being able to identify the situations that they could influence by their own actions and to do their best in these situations.

On the other hand, they described a desire not to completely limit the experience and expression of the emotions aroused by the work. Tensions arising from stressful situations were defused through humour among the nurses and with the patients. Creating a caring, warm atmosphere was a way of maintaining a trusting relationship with the patients, and showing compassion was seen as a key element of successful end-of-life care.

Psychological recovery from work

The nurses described their ability to cope with the moral distress of work by investing in psychological recovery outside of work. The means mentioned included doing things that bring pleasure and leaving work matters at work, i.e., avoiding thinking about work-related issues. As one interviewee indicated : “Like when I leave work, I usually go through the patient list for the last minute and think have I done everything, then I don’t ever have to think that I’ve left something unfinished. And then when I clock out, I start thinking about home stuff and on the way home I really shift my thoughts to the evening and what’s ahead, what I’m going to do.” (24)

However, spending leisure time with colleagues was also mentioned as a way of strengthening the team spirit of the work unit as well as peer support. A good team spirit was perceived to protect nurses from work stress and made it easier to bring difficult moral issues into the decision making process.

Defending patients

Defending patients’ interests through personal action was identified as the fourth main category in the interviews. The goal of care was seen as promoting the patient’s well-being. Advocacy for the patient was a kind of yardstick against which nurses assessed the fulfilment of their own responsibilities. The promotion of the patient’s welfare required nurses to have a broad range of professional skills to identify and resolve situations in which the patient’s best interests might be at risk.

Immediate contact with the work community to resolve situation when concern emerges

Interviewees described that in order to be able to immediately resolve morally stressful situations, it is essential that nurses bring the problems to a common discussion within their work community as soon as possible. The nurses also explained that they had to identify situations that required the support of the work community to resolve. If they suspected that the patient’s interests were at risk, they managed the situation by bringing the problem to the attention of the rest of the work community as soon as possible. For example, in home care, even minor doubts about a patient’s capacity to function were readily brought to the attention of the rest of the work community. Continuity of care was ensured by communicating openly with colleagues about unfinished tasks. Problems could also be related to the behaviour of colleagues or the work community. For example, concerns about a colleague’s outdated working practices or inappropriate behaviour could be raised directly with the colleague concerned or by referring the matter to a supervisor nurse. As on interviewee put it: “And if you think about it, if you don’t address it now, then it’ll just continue in the same way and nothing will change, you can complain about it at home, why didn’t I do that at the time, why didn’t I say anything, it’s better to get it out in the open immediately and say how it feels, how you feel.”(7) The nurses’ efforts did not always lead to the desired outcome, but even attempting to intervene in a situation that threatened the patient’s interests could alleviate a conflict of values.

According to interviewees, in a multi-professional working community, decisions and policies on patient care need to be justified and understandable for everyone. The nurses discussed care goals and their implementation with older people, relatives, colleagues, and other professional groups. Conflicting views regarding the implementation of care were inevitable. When opinions differed, solutions that best served the interests of the elderly person had to be found. The tension caused by these conflicts could be reduced by discussing care decisions and policies openly so that the solutions behind the decisions were understood by all. In-depth discussion at different stages of the decision-making process was a practice that facilitated cooperation between different professions.

Nurse respects patient’s right to self-determination

Nurses described that exercising patient autonomy was a crucial means of ensuring the quality of care. As one interviewee said:

Well I for one can say, hand on heart, that it’s what I strive for all the time when I’m at work, that I give them the chance, that at least those who are able in some way to decide for themselves what should be done and for instance what table they want to sit at and what they want to watch on tv and so on, that really, even if some situations are difficult and you feel that there’s no time and there should be, but anyway, you take the time to do the work, because we’re here for them, and that seems to be forgotten, that at the end of the day we’re in their home. (7)

They also explained that autonomy was sought by actively listening to and asking about the patient’s wishes, desires, fears, or physical sensations, and by describing in advance the care activities on the to-do list. In the case of patients with memory problems, it was sometimes challenging to implement the patient’s own will. However, this could be achieved through, for example, discussion with relatives and by recording the things that the elderly person in their care and service plan enjoyed. At times, exercising autonomy meant that the nurse had to respect the patient’s decision, even if it differed from their expert opinion and was potentially harmful to the patient. Internalizing the importance of autonomy seemed to protect nurses from this conflict of values.

Nurse has ways to seek agreement with the patient when their views differ

Interviewees felt that the issues of patient compliance with care are a key part of nurses’ work. Although autonomy was considered one of the most important principles guiding care, the nurses also reported encountering situations in which it was impossible to implement patient autonomy in a straightforward way.

These situations included cases of the patient completely refusing to eat, take medication, or look after their basic hygiene. In such cases, the nurses had to be skilled in seeking agreement through negotiation with the patient. As one interviewee indicated: “If only we could always see the bigger picture in these problems. And maybe that it’s easy for a nurse to come from the outside and give orders. We should take more time to get to know what the client is able to take on and what they are prepared to accept. That somehow the client’s level and their perspective would be the starting point, and that we don’t just dictate things. That the client could be involved in their own care. I feel that this would get the best results and that their compliance would be much better that way than if the nurse just comes along and says, right, this is the way we’re going to do it. Of course, there are situations when it has to be that way. But generally, that we take time to negotiate these things with the client.” (16). Nurses described that agreement on the necessary treatment was sought by justifying their own views constructively and in consultation with the patient. This behaviour was intended to communicate a sense of urgency and respect, which was felt to improve patients’ willingness to cooperate and respect the right to self-determination.

Discussion

The key finding of this study was that strategies to mitigate moral distress can be found at all levels of eldercare service organizations: organizational, workplace and individual. The tools that were created from the interviews fell into four main categories: 1) organizational support and education 2) peer support, 3) improving self-care and competence, and 4) defending patients. The main identified categories confirmed the earlier findings of the scoping literature review (Nikunlaakso et al., 2022), and the qualitative, rich research interview data provided new insights into a little-studied topic. The obtained results can be used in developing solutions and practices to mitigate moral distress in eldercare.

In the first main category—“organizational support and education”–that was created from the interview material, common ethical principles and structures defined at the organizational level provided the basis for an ethical culture. This in turn helped supervisors establish practical ground rules and guided them to use and strengthen the nurses’ professional skills. It was essential that the principles and their application to moral situations were discussed collectively and regularly. In this way, the study confirms previous research findings that the management and the employer organization provide the structures for developing ethical competence and moral action in work units and among individual nurses (Laukkanen et al., 2022; Numminen et al., 2015; Woods, 2020) (Huang et al., 2012). Ethical structures are not strong enough in Finnish health and social service organizations and management lacks the competence to create an ethical organizational culture (Laukkanen et al., 2022). Thus, the management of moral distress is not about the abilities or characteristics of individual nurses, but about the ethical structures of the organization that create opportunities to act morally. The study also confirmed the earlier finding that rules based on organizational values, practical guidelines, and permanent channels for dealing with moral problems help manage moral distress [see e.g (Corley et al., 2005; Rego et al., 2022)].

In the second main category, different forms of peer support and education for nurses acted as a management tool at the work unit level. The importance of nurses’ mutual support in addressing and solving ethical issues has also been observed in previous studies (Kangasniemi et al., 2017; Ventovaara et al., 2021). Team support and shared reflection help nurses cope with and endure difficult moral situations and the related uncertainties. The importance of peer learning was particularly emphasized in the interviews concerning the cooperation between novices and experienced nurses, both parties having complementary and beneficial professional competences. Our findings show that peer learning can strengthen novices’ competences and support their ability to view ethical situations holistically and empathetically. This is important because nurses just beginning their careers report experiencing higher levels of moral distress than experts (Corley et al., 2005), and young people’s experience of inadequate professional competence is associated with a propensity to change fields (Numminen et al., 2015; Ulrich et al., 2010). Nurses’ professional competence can be defined as the ability to integrate and apply the necessary knowledge, skills, and values to each care situation (Numminen et al., 2015). Application skills are especially important when it comes to ethical issues. Ethical situations can be very complex and subtle, making it impossible to create direct guidelines to cover them all (Eriksson et al., 2007). In our view, strengthening peer mentoring is an important way to reinforce ethical competence and to influence the attractiveness of the eldercare sector to young nurses.

The third and fourth main categories contained individual-level means, confirming previous research evidence. In particular, moral distress was managed through self-regulation skills and by investing in psychological recovery during leisure time. The nurses’ assessment of the ethicality of their own actions by mirroring them with the defence of patients’ rights can also be seen as an individual-level tool. The importance of defending patients’ rights and tolerating moral tensions has also been indicated in previous studies [see e.g (Abbasinia et al., 2020; Atabay et al., 2015; Rushton et al., 2021; Vaclavik et al., 2018)]. For example, it has been noted (Rushton et al., 2021) that nursing work inevitably involves emotionally and cognitively demanding moral conflict situations. In order to be able to deal with stressful situations in a professional, analytical, and empathic manner, nurses need to possess self-awareness and self-regulatory skills. These skills can be learned, and thus health care organizations should actively support nurses in maintaining and developing them.

Our main conclusion is that moral distress management tools can be found at organizational, workplace, and individual levels in eldercare services. As moral distress is experienced more in eldercare than in other social and health sectors (Selander et al., 2022), and distress factors cannot be completely eliminated, it is important to have all management tools in place. By strengthening ethical competence at all levels of eldercare organizations (Amos & Epstein, 2022), moral problems can be more easily identified and thus more often prevented and solved (Lützén & Kvist, 2012).

Our findings suggest that some of the moral distress management measures identified seem to be linked to general work organization and the development of well-being at work. Therefore, our second conclusion is that the development skills of nurses and supervisors in eldercare should be strengthened and ethical perspectives should be permanently integrated into the long-term development of work and well-being at work. Strengthening the ethical competence of supervisors is not sufficient in itself if they have no practical means to help their subordinates manage moral situations or experience in developing the competences of subordinates. Awareness and understanding of ethics can help motivate supervisors to find time for development, even in the midst of hectic daily life.

The already existing shortage of nurses creates growing pressure to support current nurses’ work ability and to attract new workers. Today’s improved longevity has increased the need for care, while less people are entering the workforce and the retirement rates of nurses are growing rapidly (Petersen & Melzer, 2023; Sousa-Ribeiro et al., 2022). Moreover, eldercare work also suffers from traction and grip problems (Korkiakangas et al., 2022). The ethical aspects of eldercare should be given serious consideration when addressing the care crisis.

Our research deepened our understanding of moral distress management in eldercare. The inadequacy of governance may partly explain the fact that eldercare nurses are so overburdened. The prevalence and importance of ethical issues and moral distress in eldercare should be taken more seriously, and the development of skills in the field should be strengthened. Further research is needed on the impact of strengthening moral distress management tools on a practical level. It is also important to determine in more detail how well these management tools are used in eldercare organizations in the future.

Conclusions

We conclude firstly that resolving moral issues and ethical situations in eldercare daily work demands special professional skills. Strengthening the professional knowledge of nurses and supervisors in eldercare is the main strategy to mitigate moral distress and therefore it is important to strengthen ethical competence at all levels of eldercare organizations.

Secondly, common organizational guidelines and policies for ethical issues decrease moral distress. Jointly developed practices and opportunities to discuss and share feelings about ethical issues are important for mitigating moral distress. Thus, organizational policies and practices for mitigating moral distress need to be strengthened in eldercare organizations.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

Our project “Ensuring the availability of staff and the attractiveness of the sector in elderly care services” (2020-2023), was funded by the Ministry of Social Affairs and Health and Finnish Institute for Health and Welfare.

Notes on contributors

Tiina Koivisto

Tiina Koivisto (Ph.D.) (Licentiate of Arts, Psychology) works as Senior Specialist in Finnish Institute of Occupational Health. Her current research interests relate to psychological resilience, digital agency and moral distress among social and health care workers.

Maria Paavolainen

Maria Paavolainen (MTh) is a researcher in the Finnish Institute of Occupational Health. She specializes in social ethics and her current research interest lie in the ethical aspects of elder care work.

Nina Olin

Nina Olin is senior consultant at the Institute of Occupation Health, Finland. Previous appointments include researcher, Turku University of Economics and researcher, University of Turku, Finland. She received her Master of Social Sciences (sociology) in 1998.

Eveliina Korkiakangas

Eveliina Korkiakangas, Ph.D. works as specialist researcher in Finnish Institute of Occupational Health. Her current research interests relate to employee and entrepreneurial well-being, recovery from work, job strain and moral distress among social and health care workers. https://orcid.org/0000-0002-7939-8749

Jaana Laitinen

Jaana Laitinen is responsible leader of several R&D projects on the promotion of well-being and work ability among health and social service employees. She is specialized on health promotion at workplaces. She has about 200 peer-reviewed publications.