Moral Stress and Moral Agency in Swedish Eldercare: A Study Protocol on a Participatory Action Research Project

Background : Ageing population, high levels of sick leave among eldercare personnel and financial constraints on municipal budgets impact eldercare. Daily care work is complex and ethical dilemmas are constantly present for eldercare personnel. This project aims to a) identify situations that give rise to moral stress, b) study the relationship between moral stress and moral agency c) explore how moral agency can be fostered in eldercare. The argument underpinning this research project is that ethical dilemmas in the work cause moral stress among staff in eldercare. While much research on moral stress highlights the connection between moral stress and negative effects on health and wellbeing, our focus is on the possible connection between moral stress and moral agency. Moral agency encompasses cognitive capacity, feelings, skills, and actions. Methods/Design: This project has a systemic approach to eldercare and interprets eldercare as an advanced system where a range of different skills is required. Participatory action research (PAR) will be used as an overall methodology. Focus-groups and research circles will be conducted with care workers, first line manages and needs assessors. Discussion: An ongoing discussion on relevant knowledge production in research, stresses the importance of participation. This is expressed by concepts such as deliberative democracy, user participation, empowerment, collaboration, follow-up research and citizen dialogue. In our research project we refer to robust knowledge as relevant knowledge that is valid in the eyes of care workers, care municipal needs assessors and first line managers. As the research is performed in collaboration with these three vocational groups, local politicians, and trade unions in three municipalities as well as two educational settings, different sorts of knowledge will be present. This unique stand will show how moral agency, as a response to moral stress, can be the ground for social changes and improve quality of care.


Background
Swedish welfare systems are facing several challenges, for example demographic changes, high sickness rates and weak economy. One of the most topical areas of the welfare systems is eldercare. In eldercare, some of these challenges are more properly described as failures; failure Social Science Protocols, January 2022, 1-10. http://dx.doi.org/10.7565/ssp.v5.6618 2 to respond to the needs of older people, and the needs of the staff (on both an organizational and individual level). Working conditions are irrefutably poor within many parts of the eldercare (cf. Forsberg Kankkunen, 2009;Strandell, 2019;Rydenfält et al., 2020) and as a welfare system, eldercare has been in the politically backwater for decades. However, during the last year, the consequences of the Coronavirus pandemic has given new fuel to the debate, and the since long existing shortcomings within eldercare have been highlighted (Szebehely, 2020).
The organization of Swedish eldercare has changed in line with the political development towards a more restrictive deliverance of care services. The principle of 'ageing in place' stipulates that older people should receive care in their own homes rather than in care homes (Schön et al., 2016). As a consequence, only the very frail older people with extensive care needs are granted places in care homes. For the personnel, these changes have made both needs assessments and daily care work more complex and ethics have increasingly become a required component of eldercare practice at different levels. In addition, being a first line manager in the eldercare sector means a constant struggle to find and recruit qualified personnel. Considering this, it is not surprising that many health care professionals suffer from stressrelated health problems. Stress due to ethical dilemmas can be referred to as moral stress (Pfeilstetter, 2017). With the conviction that working conditions matter, the research project will build on the theoretical concepts of moral stress and moral agency. Moral stress signifies welfare workers experiences of having no control over the situation, external factors preventing them from doing what is perceived to be the "right thing to do" (Lützén et al., 2003). To perceive and feel the moral implications of a situation can lead to passivity, not doing anything. However, moral stress can also lead to action; thus, implying increased agency.
It is on agency as a response to moral stress this project will focus and build further knowledge. While much research on moral stress highlights the connection between moral stress and ill-health, our focus is on a possible positive outcome of moral stress; moral agency. Moral agency encompasses cognitive capacities, feelings, skills, and actions that take place in a given situation. Taking responsibility comprises acting on what is believed to be the right thing to do and being able to justify these actions in a moral terminology (Lützén & Ewalds Kvist, 2012). Thus, a central question is: how can moral stress generate moral agency rather than passivity and tacit acceptance? In our view, moral stress and the moral agency that possibly follows from it, must be understood in the light of the political and structural context of the current ethical dilemma occur (cf. Kälvemark et al., 2004;Pfeilstetter, 2017). Hence, those political and structural obstacles that hinder moral stress from causing moral action must be identified and tackled. This project is unique as it interconnects three different vocational groups within eldercare with educational settings. Moreover, it is grounded in our experiences not only as researchers in social work and social policy, but also as teachers. Problems reported by students after one semester of practical field placement within eldercare almost always include misunderstandings and distrust stemming from lack of knowledge about the different vocational groups within eldercare. In addition, local politicians and trade unions are invited in the research project as partners in the research, as change processes are more likely to succeed if all relevant stakeholders are involved at an early stage.

Aim and research questions
The project postulates a solid link connecting high quality care of older people, decent working conditions, and moral agency among different categories of female-dominated occupations in Swedish eldercare. Without neglecting the aspect of conflict of interests, it takes the value of solidarity between different vocational categories, as a guiding principle. For Social Science Protocols, January 2022, 1-10. http://dx.doi.org/10.7565/ssp.v5.6618 3 solidarity between vocational groups to arise, mutual understanding of each other's 'everyday life at work' and 'vocational core' is crucial.
The aim of the study is to: 1) map out moral stress and possible paths to moral agency among vocational groups in the sector of eldercare. 2) use this map to create mutual understanding of each other's' 'everyday lives at work' and 'vocational core', including abstract features such as perceived vocational identities and roles as well as concrete work tasks.
By posing the following questions to different vocational groups: What situations give rise to moral stress? And Under which circumstances does moral stress become a catalyst for moral agency? we will uncover ethical challenges faced by different vocational groups involved in eldercare. This map will be used to build a common understanding of the 'everyday lives at work' and 'vocational cores' among the vocational groups. Mutual understanding and solidarity are loadstars.

Scientific as well as financial investment in eldercare
The project is based on knowledge concerning organizational conditions affecting the ability of care staff to provide good care (Sverke et al., 2016;Szebehely et al., 2017). The value of care workers' legal and administrative skills for being able to reassure that older people's rights are met, is recognized in the project. Previous research (Lagercrantz All, 2017; Hultqvist & Hollertz, 2019) show that education is not only about acquiring a professional competence, but also about establishing a social network, finding out how the labor market works and gaining knowledge of civil rights and societal obligations in the broadest sense. The fact that eldercare as a part of the labor market since long suffers from labor shortage has led to a scenario where municipalities have tailor-made vocational training programs to attract individuals who have difficulties to find employment to this specific sector. As a consequence, an already complex sector with a range of different vocational groups involved (auxiliary nurses, nurses, physiotherapists, vocational therapists, social workers) is getting even more complicated as the competence of the personnel differs a lot between and within municipalities.
The lack of formal education among eldercare workers is not a new problem (Ahnlund & Johansson, 2011;Kommunal, 2015), but has now been put on the political agenda (SOU, 2019:20). The Covid-19 pandemic has been a catalyst for political action and significant financial resources has recently been offered by the Swedish government: Äldreomsorgslyftet (in English, the eldercare-lift), includes 3,3 billion Swedish crowns to be invested during the period 2020-2023 [1]. Since our project in its design links practice with education, the research project can, in fact, be seen as one way of contributing to this financial investment in eldercare but with another kind of resources; updated research-based knowledge.

Moral Stress and Moral Agency as Theoretical Tools
The theoretical basis for this project is an understanding of the importance of good working conditions for being able to provide good care for older people. Moral stress most common describes negative aspects of work (Mänttäri-van der Kuip, 2020), but can also constitute a positive force in relation to taking a moral responsibility. However, this is closely linked to organizational conditionsand when organizational conditions needed are not there, it constitutes a problem for moral responsibility. From a social policy perspective, this point of view emphasizes the importance of decent working conditions and moral agency for personnel to be able to protect and secure older people's rights (Kälvemark et al., 2004).
Our approach combines critical perspectives on the care of older people, working life research and theories on moral stress and moral agency. Studying different vocational groups' experiences of moral stress and moral agency is one way of identifying under which circumstances moral stress is harmful and hinders practitioners to fulfil their duties, and under which circumstances moral stress can strengthen the inclination towards moral agency. Identifying ethical dilemma will be a key method to learn more on moral stress and moral agency (cf. Pfeilstetter, 2017).

Methods/Design
This project has a systemic approach to eldercare. Rather than focusing on a certain organizational level, eldercare is seen as an advanced system where a range of different skills is required. In fact, the explorative object of this project is to lay bare the actions taken in order to expose the 'whole picture' forming eldercare. In our understanding, eldercare reform needs to be anchored in those vocational and academic educations fostering care workers, first line managers and needs assessors of tomorrow. Furthermore, the belief that formal education is a key for being able to provide good care for older people underpins this project. From a social policy perspective, it emphasizes the importance of formal education to be able to protect and secure older people's rights. The design and methods reflect this belief, as the project interconnects practice research in the eldercare sector with the education of welfare workers.
In addition to formal education, workplace learning is another crucial process on this project. The leap from stress to agency might seem brave, almost daring in the context of eldercare, where circumstances like poor working conditions and lack of skilled personnel undoubtedly restrain eldercare personnel in different vocational categories to 'do a good job' according to their vocational ethos. However, based on the assumptions that 1) negative emotions like disappointment, frustration and fear are often ascenders to reflection (Dewey, 1910) and 2) if policy imperatives are to be successfully implemented, those who are supposed to realize those imperatives must see themselves as actors of change. The project has been ethically approved by the Swedish ethical review board (dnr: 2021-04462).

Participatory action research
We will use Participatory action research (PAR) as an overall methodology. As concrete methods, focus-groups and research circles will be used. Data will be co-created in communicative spaces (Habermas, 1978). In such spaces participants feel safe, open towards transformational learning and stimulated towards creativity. Transformational learning is based on mutual recognition, reciprocal perspective taking and a shared willingness to learn from each other (Abma et al., 2019). The first communicative space set-up will consist of digital focus groups on Zoom, where the three respective vocational groups (care workers, needs assessors and first line managers) in three municipalities will be offered a 'room of their own' (Woolf, 1929). Led by the researchers, the purpose of the focus-group session is to describe everyday life at work, pinpoint situations linked with moral stress and highlight preconditions necessary for moral agency to occur. The collective nature of the focus-groups will empower the participants and validate the views and experiences of the participants. Negative opinions are more easily expressed in the presence of peers and the participants are selected because they possess vocational/professional competence and vast concerning the topic of interest. To be considered an 'expert' can per se be an empowering experience. Another important aspect for this project is that focus groups can create awareness; the participants become aware of things they have not thought about before when they reflect on their common 'everyday life at work'. They can find out that their problems are not just individual but structural and shared. They learn from each other and re-evaluate their own understanding (Ivanoff &  ). This phase in the study builds on newly gained experiences from arranging workshops on digital platforms. The focus-groups will provide explorative data as the everyday lives at work and the vocational core in three different categories of personnel in eldercare will be mapped out. It will also empower the respective vocational group as it provides an opportunity for care workers/first line managers/needs assessors from three municipalities to reflect upon the own vocational role and how work tasks are organized in the own municipality, in comparison to other municipalities. On a general level, it will contribute to the development of computer-assisted focus group interviews as a research method.
We will use the format of the research circle to create the second communicative space. Research circles will take place in each of the three municipalities and at this stage the different vocational groups get to know each other's' vocational cores, experiences of moral stress and moral agency. The research circle is partly a way of revitalizing an old tradition of Volksbildung, as it stems from courses arranged by Swedish trade union half a century ago, and partly something radically different from this tradition with its strong connection to scientific research (Holmstrand et al., 2008). One of the strengths of this methods is that it interconnects research with personal experience, education and working life. Representatives from the trade unions (Kommunal, Vision, SSR) will be invited to contribute to the research circles with expertise asked for, concerning labor law and work environment issues. PAR as an overall approach to knowledge creation can result in interaction by means of inclusive dialogue, reconsideration of responsibilities and assuming a new role within the community (Bendien et al., 2020). The creation of mutual understanding among different vocational categories involved in eldercare, is used as tool for placing these groups in the front-seat in the carrying out of the necessary reformation of the sector.

Plan
In line with the PAR-approach, the research project will be performed in close collaboration with involved participants. Eldercare personnel representing the three vocational groups (care workers, first line manages and needs assessors) in three municipalities are the central actors. Representatives from trade-unions, NGOs and local politicians form an outer circle of participants in the project. The executive work group consists of SH, ME and KH, located at different universities (Linnaeus, Södertörn, Göteborg). The executive work group will be responsible for: • Monitoring the project daily • Reviewing budgets • Secure the quality and relevance of the output • Management of possible conflicts among the different participants • Management of unforeseen events Four experienced professors, each of them engaged as expert in a specific theme, will support the executive group with guidance when needed.
The project includes two different kinds of societal institutions: municipal eldercare and educational settings providing this sector with personnel. Hence, the project will take place in three municipalities and four educations together with (and partly in) these organizations. Grimslöv folk high school will be our partner in this planned project. Together with the social work education at our own departments the folk high school will function as educational living labs. Also, we plan to engage master students in social work in the project, as they will be offered to do their master thesis project as part of the project.

WP 1 Exploration and self-reflection
This initial, explorative phase consists of online focus-group interviews where each vocational group meets separately. 7-9 care workers/first line managers/needs assessors from three different municipalities meet online for a focused interview, facilitated by researchers. Depending on the numbers of participants and on evolving group dynamics, the possibility to split the group into smaller units might be used. The principal aim of this phase is to map out moral stress and possible paths to moral agency within each vocational group. This will require a thorough review of central work tasks, role in the organization and collective self-reflection concerning the own 'vocational core'. Expected outcome: A stronger sense of one's own vocational identity. Expected output: a map for each vocational group describing its 'vocational core', situations associated with moral stress and tentative suggestions regarding how moral stress could be led to moral agency. Seen from the perspective of one's own vocation, what are the necessary conditions for moral agency to occur?
Professor Synneve Dahlin-Ivanoff, with vast experience of conducting focus-groups in eldercare will methodologically guide this phase with her expertise.

WP 2 Education and innovation
A compilation of the maps will be used as a discussion material when setting up living labs with students studying to become auxiliary nurse and social worker at Grimslöv folk high school, Linnaeus university, university of Gothenburg and Södertörn university. Using vignettes, students will be encouraged to critically discuss "who does what and why?" within eldercare. The principal aim of this phase is to provide students with a 'systemic gaze'. With a broader understanding of the sector of eldercare as part of the Swedish welfare state, students will be empowered to question the prevailing order and reflect on their own future vocational role as moral agents in such a reformation. Also, these discussions will fertilize the following research circles with innovative ideas and visionary suggestions on how to (re)organize eldercare. Expected outcome: a broader understanding of the 'everyday life at work' for other vocational categories within eldercare than the own. Expected output: A report with visionary suggestions on how to organize eldercare in the future.

WP 3 Implementation and revitalization
The concluding phase consists of place-based research circles. The aim is to convert the aggregated knowledge from WP1 and WP2 into local action. Research circles including 3-4 physical meetings will take place in each of the three partaking municipalities. Approx. 15 persons participate in each circle. In these circles, the different vocational groups get an opportunity to translate and adapt gained knowledge documented in maps and reports of visionary suggestions as to fit into local settings. The central actors in the research circles are representatives for the three vocational groups. Depending on the kind of conditions pinpointed for moral agency to take place, other actors will be involved. Accordingly, trade unions, politicians and NGOs representing senior citizens in Sweden will be invited to the research circles. Expected outcome: organizational learning and solidarity reaching above the own vocational group. Expected output: a white paper stating the necessary conditions for moral agency to arise in the sector of eldercare in the respective municipalities.
Professor Gunilla Härnsten, with extensive experience of conducting research circles will methodologically guide this this phase with her expertise.

Discussion
In the field of eldercare, there is a lack of scientific knowledge about the relationship between organizational conditions, moral stress and moral agency. While there are set-up systems for measuring the scientific impact of research, reliable and broadly accepted indicator for measuring societal impact are not available (Spaapen & Van Drooge, 2011). We subscribe to an epistemological view where socially robust knowledge (Nowotny et al., 2013) is desirable. Robustness refers to knowledge that is relevant and accepted by actors in the context of its Social Science Protocols, January 2022, 1-10. http://dx.doi.org/10.7565/ssp.v5.6618 8 application. In this project, our conclusions must be valid in the eyes of care workers, care municipal needs assessors and first line managers. There is an ongoing discussion of the importance of increased participation for robust knowledge. This is expressed by concepts such as deliberative democracy, user participation, empowerment, collaboration, follow-up research, and citizen dialogue (Kasperowski & Kullenberg, 2018;Hultqvist & Salonen, 2016;Krogstrup, 2006). Robustness refers to knowledge that is relevant and accepted by actors in the context of its application. Thus, conclusions drawn in this research project must be valid in the eyes of the personnel within eldercare. Societal impact is therefore a question for both practice and education.
Our approach concerning societal relevance and social impact stresses interaction and mutual learning, crossing vocational boundaries. By extending the conception of expertise from its common sense meaning, we look upon expertise as an iterative process, a knowledge bank (Bammer, 2020) that is shared by many and under continual development. Given the emergence of academic programs turning more vocational and some vocational programs turning more academic, the pragmatist outlook of this project is that a more systemic understanding of eldercare practice must lead to coordinated educational trajectories for those categories leaning to become first line managers and needs assessors of tomorrow. As social workers and researchers in social work, our focus is on 'the social categories'. Aware of these vocational categories only being part of the vocations necessary for this advanced system to function, robust knowledge will be vital for future eldercare and future vocational education.
The project is unique as the research is performed in collaboration with three vocational groups, local politicians, and trade unions in three municipalities as well two educational settings. The project will lead to increased knowledge about how to support moral agency for those working in eldercare and thereby improving the quality of eldercare. Implementation within the field of eldercare can be described as processes of social changes, both affected by and affecting a range of actors and factors. Taking as a premise a link between high quality care of older people in a comprehensive welfare state such as the Swedish, mutual understanding and solidarity among different vocational groups in eldercare and an enhanced capacity for moral agency, the project sets up an arena where different forms of knowledge (academic, professional, lived experience) circulate to achieve certain goals (cf Spaapen & van Drooge, 2011).

Declarations
Competing interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.