Moral distress among social workers in long term care facilities for older adults

The primary obligation of social workers is to their clients. Yet, there might be occasions in which social workers have difficulty acting in a way that they perceive as moral and professional due to rules, regulations and bureaucratic considerations, as well as the organization’s commercial and reputational interests.

A theoretical and empirical concept, which is taken from the nursing literature and relates to these dilemmas, is called "moral distress".  Accordingly, moral distress occurs in situations where a nurse has trouble acting in accordance with professional morals due to institutional constraints and restrictions. Despite the significance of ethical issues faced by social workers, research on moral distress among social workers has been extremely limited. The aim of this series of studies was to explore moral distress among social workers who are employed in long term care facilities (LTCFs) for the older population in Israel.

The first study described the development of a unique questionnaire to measure moral distress among social workers in Israeli LTCFs for the older adults. The construction of the questionnaire was based on a secondary analysis of a qualitative study that addressed the moral dilemma of social workers in nursing homes in Israel. The items on the questionnaire were extracted from the qualitative study and were adapted based on the theoretical and empirical definitions of moral distress. The initial questionnaire consisted of 25 items and included two scales measuring both the frequency of morally loaded events and the intensity of distress that followed them.

The aim of the second study was to describe the content validation of the moral distress questionnaire. The content validation included review and evaluation by two experts, a cognitive interview with a nursing home social worker and three focus groups of experts and the target population. In its final version, the questionnaire consisted of 17 items.

The third study described the quantitative validation of a unique questionnaire to measure moral distress among social workers in long term care facilities in Israel. Overall, 216 LTCF social workers took part in the pilot study, which included psychometric evaluation and construct validation. Moral distress was examined by two scales, measuring the frequency and the intensity of morally loaded events. A third scale was created representing the product of the frequency and intensity scores for each item, separately.

Two items with high floor effect were removed. The internal reliability of each of the three moral distress scales was 0.92. An exploratory factor analysis suggested a single factor solution, supporting a broad definition of moral distress which includes a violation of an obligation to either the clients or the management. The construct validity was approved, and, in its final version, the questionnaire consisted of 15 items.

Finally, the purpose of the fourth study was to identify whether unique types of social workers exist inLTCFs for older adults in Israel, and whether these variants are differentially associated with moral distress. Overall, 216 LTCF social workers took part in the study. A two-step cluster analysis was conducted in order to identify different profiles of the social workers based on environmental and personal features (ethical environment, support in workplace, mastery and resilience). The variance of the identified clusters and their association to moral distress were examined.

Four clusters of LTCF social workers were identified. The clusters varied significantly from each other in relation to their personal and environmental features: Cluster 1 was characterized by high environmental resources and low personal resources. Cluster 2, was characterized by low environmental and personal resources. Cluster 3 was characterized by low environmental resources and high personal resources. Finally, Cluster 4 was characterized by high environmental and personal resources. The clusters varied significantly from each other in relation to their experience of moral distress, while the clusters with low environmental resources (Clusters 2 and 3) were characterized by significantly higher levels of moral distress than the clusters with high environmental resources (Clusters 1 and 4).

The four clusters that were found in the present study are parallel to the four prototypes of nursing home social workers that were found in a qualitative study which has served as the basis for the present study. The resemblance between these two studies represents a triangulation of the findings and increases their validity.

 To sum, we believe that this pioneering series of studies can contribute by broadening and deepening the ethics research and discourse with regard to social workers' obligational dilemmas and conflicts. In addition, the findings of the studies indicate the importance of adequate ethical environment, as well as the importance of developing programs for LTCF social workers that provide support and enhancement of personal resources.