Background
A growing body of evidence shows that basic care needs of nursing home residents are regularly neglected, and residents do not always receive qualitatively good care of basic human needs. Hence, these neglectful practices may include not providing sufficient basic care or ignoring residents’ needs related to nursing home residents’ physical, psychological, emotional, and social needs. Examples of this include omitting mouthcare on a regular basis, ignoring residents with challenging or aggressive behaviour, and lack of attention to a residents’ need for social stimuli. The literature presents different perspectives of what constitutes neglect of nursing home residents’ basic needs. In this paper we use neglective care practices given examples of above to address these practices regardless of the perspective taken [
1‐
7].
Not being able to provide sufficient care or observing colleagues providing compromised quality of care is found to be a major stressor for nursing staff [
8‐
12]. This may lead to physiological and emotional stress [
10], compassion fatigue [
13], troubled conscience [
14] and stress of conscience [
8], among other forms of pressure, all of which may potentially result in moral distress [
9,
11,
15‐
17]. Moral distress has been recognised as a major problem for health care staff in all care systems for over four decades [
18,
19]. The concept of moral distress was introduced by the philosopher Andrew Jameton in 1984 and has been further developed and enhanced by him and other scholars in recent decades [
18]. We lean toward Nathaniel’s definition of moral distress based on a synthesis of previous definitions by Jameton (1984), Wilkinson (1987-88) and Nathaniel (2004):
“Moral distress is pain affecting the mind, the body, or relationships that results from a patient care situation in which the nurse is aware of a moral problem, acknowledges moral responsibility, and makes a moral judgment about the correct action, yet, as a result of real or perceived constraints, participates, either by act or omission, in a manner he or she perceives to be morally wrong” (p. 421) [
20].
Moral distress occurs when nurses or other health care staff are unable to act in accordance with their personal values or/and professional judgement when it comes to external constraints, such as lack of resources, or internal characteristics related to moral judgement [
21].There is a high prevalence of moral distress in caring for people with dementia [
16,
22]. However, knowledge about moral distress in nursing homes in general is limited, and few studies relate this to compromised quality of care [
9,
11,
16,
17,
22]. Organisational, institutional or structural constraints, such as a lack of resources, which may contribute to compromised quality of care and suffering residents, are among the main reasons for moral distress among nursing home staff [
9,
11,
16]. In addition, individual and cultural obstacles like having to act in contradiction to personal knowledge, beliefs or values is a major stressor [
9]. Nursing staff may not only be troubled by what they have done, but also by what they have not done or should have done [
15].
Moral distress affect nursing staff negatively both psychologically and physically [
23]. Not being able to provide care, or providing compromised quality to the elderly contributes to staff reports of feeling emotionally drained or physically exhausted [
16]. This may lead to feelings of inadequacy, frustration, anger, powerlessness, helpless, heavy or troubled conscience, sadness, guilt and shame [
9,
11,
14,
22,
24], which over time can increase the risk of a person becoming cynical, bitter, callous and resigned [
25]. Physical symptoms of moral distress include fatigue, exhaustion, headaches, stomach pain, and sleeplessness [
15]. Furthermore, moral distress in nursing homes is associated with illness, decreased job-satisfaction, risk of burn-out, absence from work and increased intention to leave– all with the potentially negative impact on the quality of care [
11,
25‐
27].
Different ways of handling moral distress are presented in the literature, describing possible responses by caregivers to avoid or combat their moral distress: to acquiesce, maintaining a lack of awareness, to withdraw from distressing situations, to fight, or to reach a satisfactory resolution [
23,
28]. Cognitive dissonance reduction strategies are other ways caregivers handle moral distress. This can mitigate against distress through three different approaches: changing one’s appraisal, minimising the importance of dissonant thoughts, or creating new congruent ones [
10]. A theory of conformity has also been developed, whereby beliefs, attitudes and behaviours corresponding to group norms [
29] are nurtured as a way to manage moral distress related to providing substandard care [
30].
To our knowledge, no studies have explored the consequences of being a part of a neglectful work culture on nursing home staff, and how individuals manage this. In accordance with the constructivist grounded theory (CGT) approach guiding our work [
31], we have sought to understand the processes influencing a neglectful work culture in nursing homes. We wanted to investigate the social influences that shape staff members’ experiences of neglectful care practices and responses to them, focusing on the relation to moral distress. In this study we identify processes that shape staff members’ perceptions, experiences, and responses regarding neglectful care practices, and their relation to moral distress. The aim of this study was to investigate how nursing staff manage being a part of a neglectful work culture, based on the research question: “How do nursing home staff manage their moral distress related to neglectful care practices?”
Structure and organisation of Norwegian nursing homes
Norwegian nursing homes are 24- hours skilled nursing facilities providing a level of care between specialized care sector, such as hospital and home-based care. The average size of nursing homes in Norway is over 50 beds, but this varies considerably [
32]. The mean age for residents in Norwegian nursing homes is 85 years, and severe and complex comorbidities are highly prevalent. Consequently, polypharmacy is also common, requiring close follow-up, supervision, and support in activities of daily living. Almost 8 to 10% have dementia with accompanying neuropsychiatric symptoms such as agitation, aggression, anxiety, and depression [
33].
Norwegian nursing home care is delivered under the National Regulation of Quality of Care to ensure that residents’ basic needs including physical, psychological, and social needs are met, in addition to respect, security and independence [
32,
34]. The Ministry of Health and Care Services launched the Dignity Guarantee for elder persons in 2010, where healthcare services should work towards a “dignified, safe and meaningful life” for older persons [
35]. Norwegian nursing homes strive to promote resident-centred care (RCC) to meet the existing quality standards for care [
36]. RCC is influenced by a person-centred care (PCC) first introduced by Kitwood in 1997, and decades of practice and research confirms that person-centred care has become the gold standard to strive for in long-term care and dementia care. RCC facilitates a holistic view of the resident, recognising residents’ preferences and values, promotes autonomy, and right to self-determination. RCC emphasises partnerships between the health- carer and resident, in addition to care flexibility in attempt to contribute to meaningful lives and promote well-being for the residents [
37‐
39].
There is no mandatary staff-to resident ratio, standards for nursing staff´s qualifications or requirements regarding skill-mix [
40]. A high number of unskilled personnel are hired due to a shortage of registered nurses (RN), recruitment problems, and challenges of keeping nurses (RN) in nursing homes. Norwegian nursing homes are characterised by high physical and psychological workload and time pressure, high turnover among RN´s and licenced practical nurses (LPN´s), lack of competent personnel, high absence from work and intention to leave, all of which have a negative effect on quality of care [
26,
41].
Discussion
Nursing home staff find their work very meaningful and as having high standards for care provision and wanting to provide resident-centred care. However, existing work conditions and a neglectful work culture create a conflict between their ideals and the reality of care provision. Consequently, nursing staff find themselves becoming a part of a work culture challenging their professional and personal standards, and contributing to moral distress.
Our main findings are that participants acknowledge facilitating staff-centred and self-protecting care strategies to alleviate moral distress related to being a part of a neglectful work culture. These responses compromise the quality of care and enable the continuation of neglect in nursing homes.
Facilitating staff-centred care by adapting to and accepting neglect
To alleviate their moral distress, nursing home staff justify their practices by favouring efficiency to complete their care duties in sufficient time. This is a familiar approach, as the work culture in nursing homes traditionally promotes a strong focus on delivering routine physical care and completing task-based work efficiently and quickly [
48,
49]. This approach may resolve feelings of moral distress by achieving what appears to be a satisfactory resolution as basic (physical) care is provided [
23,
28]. Hence, the nursing staff can achieve a (temporarily) mitigation of their feelings of guilt, shame and frustration when resources and demands mismatches. However, while in the past Norwegian nursing home residents were typically frail and mostly bed-dependent, they are presently recognised as having complex medical conditions, cognitive deficits, and/or psychiatric illness, and challenging behaviours such as agitation and aggression [
33]. For this patient population, the availability of skilled staff with sufficient time for holistic care provision is crucial for sufficient quality of care.
Our study participants experienced meeting residents’ complex care needs when constantly pulled between “task and time” as challenging, which is confirmed in prior research [
49]. Favouring efficiency to get the job done makes the nursing staff´s workday liveable. This is in accordance with research demonstrating that nursing staff tend to reconcile their expectations for care as a way of adapting to the work culture, minimising their exposure to personal harm [
50]. Despite this emphasis on efficient, routine- and task-oriented provision of care, although intended to counter neglect, it nevertheless serves to promote neglectful care practices.
When staff adapt to the mismatch between resources and demands by working faster and in a more standardised way, care provision becomes quick and efficient, but also uncaring and dehumanizing [
50,
51]. This leaves little room for individualised and resident-centred care which is the gold standard for high quality of care for nursing home residents [
9,
22,
37,
38,
52,
53]. There may be limited opportunities for supporting and stimulating residents´ self-caring abilities, which further exacerbates functional and cognitive decline [
49,
54,
55]. Favouring efficiency is a problem-focused coping strategy aimed at solving neglectful care practices in nursing homes by regularising and normalising them. When staff are compromising nursing values and lower care standards to maintain efficiency, it further aggravates the carers’ moral distress, and a vicious cycle of neglect is established.
Our participants tolerated neglectful care to manage challenging working-conditions, including work overload and limited time for care. Acceptance of a difficult situation that is hard to change, and adapting by changing one’s expectations and behaviours, are well-established coping strategies [
56], like when trivializing morally challenging situations to mitigate moral distress [
57]. This finding can also be in line with the theory of conformity; tolerance of neglect may be explained by a tendency to conform to existing cultural norms, to minimise cognitive dissonance [
30]. Accordingly, simple acquiescence has been demonstrated as a response to moral distress. Nursing staff may be aware of the moral situation creating distress but accept the outcome without objecting [
28]. This acceptance may lead to staff becoming resigned, cold or blasé, eventually resulting in compromised quality of care [
25,
57,
58]. This is confirmed by our participants, who describe a reductionist care culture illustrated by terms such as
“care-factory” or
“finishing a packet” about morning care provision. In addition, the admonition
“just pee in the diaper” is illustrative of a cultural shift from resident-centred care to care provided at the convenience of nursing staff.
Participants tolerate neglectful activities such as omitting showering or social activities, which resonates with research demonstrating that staff “defend” their omissions by downplaying certain care activities to make them less relevant as examples of low care quality. This serves to retain their self-image as caring and compassionate nurses, in line with cognitive dissonance theory [
10]. Furthermore, here are practices reflecting ageistic attitudes, which might also confirm this theory in line with prior research finding that negative stereotypes of aging may affect the quality of care accordingly [
59]. Intentional or not, this handling of cognitive dissonance and moral distress, depicts neglectful behaviour as less severe, and thus easier for the staff to face in their everyday work. This is also indicated by previous research showing that nursing staff regularly fail to recognise their own practices as neglectful, normalising missed care as a way of legitimising neglect [
45]. Tolerating neglect may be a way of enabling existing and insufficient care practices. Intentional or not, tolerance of neglect will indisputably have a negative influence on the quality of care, as well as the well-being of both staff and residents in nursing homes [
22,
58,
60].
Self-protection through avoiding morally distressing situations
Participants further respond to the moral stress related to a neglectful work culture by disengaging emotionally from the caring process. This may reflect further efforts to manage moral distress related to neglectful care provision [
50]. Distancing is a well-known coping strategy, as when nursing staff disengage or become detached from a situation to minimise its significance. Not bothering too much enable some of our participants to continue working. This finding is corroborated by research demonstrating that withdrawing emotionally, distancing, and numbing of the conscience are approaches that helps staff to continue working in healthcare [
28,
57]. Nevertheless, this avoidance behaviour which initial is a way to mitigate their moral distress also becomes a source of guilt and despair, bringing the personal and professional long-term effects of this coping mechanism into question [
28].
Our participants have experienced colleagues who regularly disengage emotionally and physically from their care duties. We cannot know whether this observed behaviour is intentional or not. Distancing from direct patient care may, however, be an intentional way of avoiding morally distressing situations [
28]. It has also been shown that a lack of awareness of moral or ethical dilemmas may be a way of handling moral distress, as when staff do not recognise a moral event. This is confirmed in our study by examples of staff refusing to reflect or discuss their own care practices. This may be a way of protecting themselves from moral distress through distancing and/or hardening their emotions [
10]. Other research confirms that avoidance of discussion about situations causing moral distress can influence quality of care negatively [
25].
Heavy workloads and time pressure have been demonstrated to create emotional and physical stress among nursing staff [
16,
26,
50]. Distress, exhaustion, and avoidance (of care) have also been associated with absence from work [
57] and intention to quit [
16]. This raises concern at a time when there is an increased need for residential care for an increasingly aging population, and difficulties in recruiting skilled nursing staff in Norwegian nursing homes [
22]. It has previously been concluded that unfavourable working conditions are the strongest predictors of Norwegian nurses wishing to leave elderly care [
26]. Other researchers have found that work overload may not be directly linked to staff turnover and intention to quit, but to role-conflict and ambiguity leading to moral distress [
16]. However, this is compounded by research confirming that full withdrawal is a response to moral distress [
28]. Our participants verify both these outcomes when they have chosen to retreat from care as a way of protecting both themselves and residents from the burden of neglectful care. For some, this is directly related to the excessive workload, making working in accordance with their own values impossible.
A worrisome finding in our study is participants describing the quality of care in nursing homes as being locked in a “downward spiral” and their concern for the future of care provision. Other researchers have found that nursing staff are leaving their jobs to escape the increasing stress related to losing confidence in their ability to promote sufficient resident safety and quality of care [
61]. This may be intended as a constructive approach, to protect both themselves and the residents from neglectful care. On the other hand, the staff who stay, despite their dissatisfaction, may be confined to a role where they are unable to influence the neglectful work culture in a positive way [
62].
Strengths and limitations
The Covid-19 lockdown affected the recruitment process in this study, as nursing home staff were less available and gathering for focus group discussions was no longer an option. This reduced our ability to work towards a true theoretical sampling, to be able to saturate our categories and to provide a grounded theory. However, we managed to reach participants for member-checking, thus strengthening our results. We also managed to recruit a diverse sample of participants from a variety of nursing homes, and we were able to reach former staff who had quit working in nursing homes. Our research team consists of researchers from different disciplines, providing a broader perspective on the theme and possibilities for diverse interpretations of our results.
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