Connecting Findings to Meaningful Change

Abstract

There is a symbiotic relationship between qualitative research and knowledge mobilization. However, there is often a significant lag between the conduct of research and the findings reaching the public (including those it impacts and those with the power to make change). In designing my study on ethics and policy in long-term care (LTC) with the aim of improving quality care, I sought a method that would not only generate broad data but data on which stakeholders would be able to more readily act and thus promote meaningful and timely change. With this goal in mind, I adopted an empirical ethics approach with the aim of consensus building and used an innovative qualitative Delphi method to explore ethics and ethical reasoning in LTC and the interaction between frontline practice and organizational and public policy. While the Delphi method is starting to gain more recognition alongside more well-known qualitative methods, it has yet to be used in the exploration of empirical ethics and policy in LTC. The rich findings from this study suggest it has the potential of expanding the breadth of qualitative inquiry, as it draws on real-world practice and decision-making to promote consensus in areas of organizational, policy, and practice change. There is a need for further research using a modified qualitative Delphi method in empirical ethics and policy research in LTC, as well as other areas. However, the results of this study suggest the suitability and benefits of the approach for qualitative inquiry and propose researchers seeking to expand research findings, knowledge mobilization, and to connect findings to meaningful and practical change should consider adopting the Delphi method.

What Is Already Known?

Qualitative Delphi method is gaining more recognition alongside more traditional qualitative methods.

The qualitative Delphi method has been used successfully in the areas of policy analysis, nursing, health services, and service-planning, though there are still a number of areas where it has yet to be used.

There is a symbiotic relationship between qualitative research and knowledge mobilization. However, there is often a significant lag between the conduct of research and the findings reaching the public.

What This Paper Add?

A theoretical justification for using qualitative Delphi method in the exploration of empirical ethics and policy in long-term care.

A brief demonstration of how qualitative Delphi can be used successfully in areas seldom explored qualitatively or empirically (such as ethics and policy in long-term care).

A discussion regarding the advantages and benefits to using qualitative Delphi, specifically the significant implications Delphi has on reducing the lag between the conduct of research and the findings reaching the public—highlighting the suitability and benefits of the approach for qualitative inquiry and propose researchers seeking to expand research findings, knowledge mobilization, and to connect findings to meaningful and practical change—should consider adopting the Delphi method.

Introduction

There is a symbiotic relationship between qualitative research and knowledge mobilization and dissemination. Seldom is qualitative research conducted without some form of mobilization taking place. Typically, however, knowledge mobilization/dissemination is perceived as a separate stage, occurring after the research has been completed; data are collected, analyzed, and summarized into findings that must be translated and then mobilized. As a result, there is often a significant lag between the conduct of research and the findings reaching the public (including those it impacts and those with the power to make change). In designing my study on ethics and policy in long-term care (LTC) with the aim of improving quality care, I sought a method that would not only generate broad data, but data on which stakeholders would be able to more readily act and thus promote meaningful change. With this goal in mind, I adopted an empirical ethics approach with the aim of consensus building (based on Habermas’ communicative ethics) among the array of stakeholders involved in frontline ethics and policy in LTC. Although various consensus building methods exist, I adopted an innovative qualitative Delphi method to explore ethics and ethical reasoning in LTC and the interaction between frontline practice and organizational and public policy. Using a qualitative Delphi approach to explore ethics and policy in LTC resulted in deeper, more rich findings on ethics, an area seldom empirically, or qualitatively, explored.

The purpose of this article is to discuss the benefits and ethics implications of using a qualitative Delphi method in empirical ethics and policy research. First, I will contextualize the study, providing a synopsis of the multistage research project. Second, I will provide an overview and rational for using an empirical ethics approach and consensus building method, followed by a brief overview of Delphi as a qualitative method, and finally, I will highlight the benefits of adopting this approach in this empirical ethics and policy research.

Contextualizing the Study

This is a two-stage research project, where the first stage informed the second. The first stage of the study aimed to explore the nature and extent of ethical issues in the provision of social care in LTC facilities and the ethical framework(s) deployed by LTC staff in making decisions as to the right thing to do in such situations. The goal of the first stage of the research was to gain a better understanding of how LTC staff reason ethically, in particular, addressing the following questions: (1) How does the ethical reasoning of LTC staff reflect, align with, or conflict with declared institutional approaches, policies, and procedures in managing ethical issues? (2) On which ethical frameworks do LTC staff draw in their ethical reasoning? and (3) How do LTC staff choose between competing or differing ethical values and frameworks?

In the first stage, seven interdisciplinary focus groups were conducted with 20 frontline care staff in four LTC facilities. Research Ethics Board permission was received prior to the commencement of the research, and written informed consent was sought and granted by each participant prior to beginning the focus groups. Participants were presented with one to two vignettes of complex ethical cases to discuss and deliberate. The findings revealed staff typically do not have difficulty determining the ethical thing to do and, in fact, draw on a number of ethical frameworks during the decision-making process. Despite this, the findings demonstrated staff frequently experience moral distress, defined as being aware of the ethical thing to do, but feeling powerless to act accordingly as a result of either real, or perceived, institutional constraints and thus engaging in perceived ethical wrongdoing (Austin, Lemermeyer, Goldberg, Bergum, & Johnson, 2005). Participants described a number of institutional constraints that impacted their ability to act in the ways they believed to be right and ethical. The dominant constraints included a hierarchy of power and lack of autonomy, staffing restrictions and task-oriented environment, concern about liability, family power, and financial inequality.

The majority of the reported constraints resulting in staff experiences of moral distress are structural. This means they could be solved, or at least reduced, by examining and addressing the larger sociopolitical factors influencing LTC organizational policies and procedures and thus the ethical decision-making environment of staff. To better understand these potential organizational constraints, I expanded the research inquiry by adding a second stage of the research to explore the interaction between public policy, LTC organizational policies, and procedures, and how these interactions impact frontline LTC staff’s ethical decisions and actions.

A qualitative Delphi method (more on this below) was used to engage 24 stakeholder experts from across the LTC sector, including residents, family members, LTC staff, professional bodies, policy makers, and organizations. In this Delphi study, participants were interviewed twice in an effort to reach relative consensus. Research Ethics Board permission was received prior to the commencement of the research, and written informed consent was sought and granted by each participant prior to beginning the interviews. In the first round of Delphi interviews, I explored what changes needed to occur in the LTC sector to encourage better alignment between policy and practice in an effort to minimize the moral distress experienced by frontline care staff (for details on the interview processes, including examples of open-ended interview questions, see Greason, 2017). The first round of interviews identified a number of barriers to change in LTC, and stakeholders suggested whether we want to see change and policy alignment, the sector needs to address the following four areas: (1) having the right workers, (2) having strong leadership (government and organization), (3) funding and budgeting (and the rigid policies flowing from this), and (4) divided sector. The dominant themes were collated into a 2,000-word summary, which highlighted areas of convergence and divergence in opinion on the topics. For example, under the theme “funding and budgeting,” some participants suggested increased funding would allow for improved ethical care in LTC. However, others believed better spending and allocation of current funding was necessary. The summary was circulated to participants and they were asked to carefully review the document, keeping the following in mind:

What do you agree with?

What do you disagree with?

Are there ideas/perspectives you had not considered before?

Have you changed your opinion on any points or themes since the first interview?

The goal of the second round of Delphi interviews was 2-fold. First, to identify how to overcome the identified barriers in order to see change, innovation, and positive ethical cultures in LTC. Second, to further explore how addressing these four areas would improve ethical environments, and thus ethical care, in LTC. Responding to, and working off of the summary of stakeholder opinions/suggestions, participants identified and reached consensus on a number of possible solutions and proposed changes during the second round of interviews. The suggested solutions and proposed changes included:

Establishing the right culture, leadership, and frontline staff;

Strategic hiring processes;

Ongoing and appropriate training;

Government leadership, focus, and policies;

Sector working collaboratively for change, innovation, and improved ethical environments.

The findings from the second and final round of interviews were collated and summarized into a 3,000-word summary, which included a number of participant quotes to provide greater detail and context. The summary was distributed to participants who were first encouraged to share the findings with their organizations, colleagues, and peers and, second, as part of the Delphi process, were further encouraged to act upon and implement the discussed and agreed upon necessary changes.

Now that the research has been broadly contextualized, I will provide an overview and rational for using an empirical ethics approach and consensus building method to explore ethics and policy in LTC.

Empirical Ethics

In this study, “empirical ethics” is understood as research approaches that “see a value in using empirical data to inform the ethical analysis of practical dilemmas” (p. 466) and which combine this empirical data with moral philosophical analysis (Dunn, Sheehan, Hope, & Parker, 2012, p. 467). The rise of empirical ethics is an example of interdisciplinary work, striving to go beyond traditional normative ethical principles (Molewijk & Widdershoven, 2012). Empirical ethics argues that theories cannot be arbitrarily developed outside of the practice context, for “the way in which people reason and act in actual practice can inform ethical theory by providing normative considerations and experiences” (van der Scheer & Widdershoven, 2004. p. 72).

Within undertheorized areas, such as the ethical practice in LTC facilities and the ethical reasoning deployed by LTC staff (Edwards et al., 2013; Hasselkus, 1997; Powers, 2000; van der Dam, Abma, Kardol, & Widdershoven, 2012), empirical research is opportune, as “clarity about social phenomena must precede the generation of hypotheses for the purposes of prediction” (Weinberg, 2004, p. 39). In this project, empirical research is relevant for ethics in that it can make clear what normative views LTC staff actually endorse rather than what ethicists theorize are normative guidelines (Widdershoven, Molewijk, & Abma, 2009). Further, with empirical ethics, the views and the reasoning staff actually use, rather than what the official philosophy of care is within the LTC facility, are clearer. The goal is to do research for LTC staff, rather than merely about LTC staff, and qualitative research and empirical ethics begin to bridge the theory–practice gap by allowing staff to inform and guide the research, rather than external researchers arbitrarily theorizing and making assumptions about LTC staff and their ethical reasoning processes. For this project, empirical ethics, along with the methodologies and methods adopted, allows for collaboration with those who have considerable experiential and practical knowledge of LTC (Lazar, 2007), further bridging the theory–practice gap by giving direct access to the reasoning process of LTC staff that is not necessarily available via the interview transcripts and is inaccessible in other ways for both practical and ethical reasons (e.g., observation; Barter & Renold, 2000; Hughes & Huby, 2004; Renold, 2002). Rather than using normative principles and theories alone to establish moral conclusions, the aim of adopting an empirical ethics approach in this research is to avoid the folly of assuming ethics begin from the “top-down” (philosophical theories), as described by Callahan (1999) and rather to begin at the bottom (experience and practice), where the people, practices, ethics, and concerns are, and build up.

There has been growing interest in empirical ethics and the “empirical turn” (see, e.g., Borry, Schotsmans, & Dierickx, 2005; Goldenberg, 2005; Willems & Pols, 2010), and empirical ethics has been examined in relation to a number of areas, for example, anorexia (Tan et al., 2006), caring for someone with dementia (Baldwin, 2008), and other areas of psychiatry (Widdershoven, MacMillan, & van der Scheer, 2008) and medicine (Hope, 1999). It is not, however, a popular approach to exploring frontline ethics and policy in LTC, and empirical ethicists often encounter a number of criticisms in the domain of practical ethics (Dunn et al., 2012). Dunn, Sheehan, Hope, and Parker (2012) suggest one of the reasons empirical ethics face criticism is a result of being used as a “catchall term to describe each and every approach to using empirical data within ethical analysis” (p. 466), resulting in diminished validity and distinctiveness. However, empirical ethics can be a distinguishable and valid approach if properly explicated, which requires a shift in focus from methods to methodologies (Dunn et al., 2012). The methodologies adopted are pivotal, as they must be able to facilitate the development of logically sound, carefully reasoned, and convincing arguments with respect to the practical ethical problems at hand that actually convince those in the position(s) to make changes to these practices (Dunn et al., 2012).

In this two-phase project, the adopted methodology, critical discourse analysis (CDA), guides and informs the research practices and methods used to integrate empirical and ethical analysis and to generate “practice-oriented” spaces to engage in critical reasoning and the co-development of sound arguments (Dunn et al., 2012). In order to better understand how, and why, staff make ethical decisions in social care the way they do and how public and organizational policy hinders and/or promotes ethical cultures in LTC, we must look at the discursive forces that influence and shape LTC organizational cultures and consequently the members in them. A CDA approach to empirical ethics acknowledges that the experiences and ethical decisions of LTC staff “are wholes that cannot be understood in isolation from their contexts” (Lincoln & Guba, 1985, p. 39) and therefore focuses on the contextual and personal perceptions and values of participants (Jamal, 2012) to allow for the “nuances of multiple realities” (Lincoln & Guba, 1985, p. 40). CDA methodology facilitates the required disentanglement of the interconnected and complex facts and ethical values of the LTC practice context, while also recognizing and encouraging the integration of empirical data (individuals’ experiences and attitudes) with normative arguments. CDA achieves this disentanglement through deconstruction,

a form of analysis which exposes the multiplicity of possible meanings, contradictions and assumptions underlying our understandings and ways of knowing—to question, who benefits, and how, from the assumptions about our social world embedded in those systems of thought. (MacNaughton, 2005, p. 78)

Guided by a CDA methodology, the research practices and methods of this project aim to explore how language, knowledge, discourses, social relations, and power/inequality are constructed, sustained, or reconstructed and how these elements impact ethics in LTC.

An empirical ethics study, rooted in CDA, recognizes the importance of language and conversation in the deconstruction and reconstruction of discourses and thus directly challenges the dominant discourses in LTC, offering direct access to the voices that are seldom heard, though most directly effected, by the complex and interconnected facts and ethic values in the LTC setting. It is in this way that we see the integration of the empirical and the normative, as “individual’s share their experiences and attitudes, which are then used to inform normative arguments about how one ought, and ought not, to act in specific domains of practice” (Dunn et al., 2012, p. 471). In this research, the empirically derived normative ethic claims (arguments) are established through interdisciplinary focus groups with frontline LTC staff through the use of vignettes. The vignette is a method which is particularly valuable when exploring attitudes, beliefs, values, perceptions, meanings, and behaviors and how these facets are situationally positioned (Finch, 1987). In the first phase of the research, open-ended questions were used to facilitate the critical exploration of staff experiences and attitudes—questions were used to challenge participants’ immediate responses and encourage participants to move beyond initial socially desirable responses, to responses more accurately reflective of the realities of practice.

Once empirically derived normative arguments are established, they should then be used in further research to help challenge, influence, and shape individual’s experiences and attitudes toward ethics, as well as further contributing to the broader understanding of “ethics.” Dunn et al. (2012) propose an iterative process of data collection and analysis during which the ethical reasoning of participants (practical and experiential knowledge) and relevant concepts and principles (theory) are interrogated repeatedly through multiple iterative cycles of participant interactions and analysis (of the empirical arguments derived from this process as well as the theoretical principles) in order to establish convincing empirical ethics claims/arguments. In this study, I adopted the notion of a cyclic approach to empirical ethics, though rather than interrogating participant reasoning with theory to establish empirical ethics claims, the first stage of the research aimed to empirically seek out what the ethics in practice are and then in an iterative cycle return these empirically derived normative ethic claims to the people involved in LTC practice to make a decision about how policy could potentially hinder/promote these claims. In so doing, this empirical ethics research strategy aims to make “normative ethics claims about practical situations” (p. 467) through the successful facilitation of a cyclic pattern of empirical ethics research (Dunn et al., 2012). The empirical ethics research cycle can be facilitated in a number of ways, however, being guided by a CDA lens, and in an attempt to establish and promote the flexible practice-oriented spaces for ethics researchers (me) and practitioners (participants) to co-construct relevant ethics claims, the second phase of this project adopted a consensus building approach for further exploration of the normative ethic claims made by frontline care staff in the first phase of the project and for further determining ethics in LTC.

Why Consensus Building?

Critical theory, such as CDA, has two goals: first, to identify the issues (diagnostic aim) and second, to use this knowledge to create environments of change and improvement (remedial aim; Finlayson, 2005). In this sense, critical theory aims to not only theorize and describe what the issues are but to also do something about the issues. Habermas (1984) is considered one of the leading critical theorists of the second generation of critical theory, and it is his theory of communicative action and social ontology which form the theoretical and philosophical basis for using a consensus building approach for further determining ethics and policy in LTC.

Habermas (1984) proposes that through socialization, individuals learn what is “right” and what is “not” based on punishment or affirmation and begin to identify with the collective moral consciousness of the society they are in (Finlayson, 2005). This, Habermas (1984) suggests, is accomplished through the use of language and “validity claims,” which serve to establish ethics through discourse (known as discourse or communicative ethics. Validity claims are commitments individuals make to justify her or his actions and words to others through sound reasoning and result in obligations (through commitment) toward other individuals and thus carry a moral status (Finlayson, 2005; Habermas, 1984). Validity claims “provide the invisible lines along which sequences of interaction unfold, and which guide agents away from conflict” (Finlayson, 2005, p. 27). Thus, we see how mutual agreement of sound reasoning, through language and interaction, “coordinates the actions of a plurality of individual agents” (p. 34) and results in conflict-free social order (Finlayson, 2005). Language is able to achieve this order because of its “inherent aim (or telos) of reaching understanding or bringing about consensus” (Finlayson, 2005, p. 34). Through validity claims, communicative action—where compliance of requests is attained on the basis of another accepting the reasons for the request—is possible rather than instrumental action—where individuals are coerced into complying with requests (Finlayson, 2005; Habermas, 1984). With communicative action, acceptance of requests and consensus is not forced but rather the result of inviting another to participate in a two-way dialogical process of agreement (Finlayson, 2005; Habermas, 1984).

In capitalist societies, there is a growing disregard and unimportance placed on participatory democracy practices such as communicative action (Frank, 2000). Communicative action, where individuals can talk about differences and come to a common understanding, is increasing replaced by the domination of certain individual(s) (or interests) because they have more money or power (Finlayson, 2005; Frank, 2000). Individuals have fewer spaces for communicative action (Frank, 2000). Without communicative practices, individuals’ validity claims are rejected (vs. having them accepted), and there is little (or no) opportunity to have a moral discussion and to reach mutual acceptance and understanding of the claim; that is, there is no room to establish and repair consensus (Finlayson, 2005). In terms of ethics, not having the opportunity to engage in communicative practices results in two areas of concern. First, it produces socialized moral agents who have learned what is “right” and how to act based on a framework of conflict and coercion, rather than truly agreeing with their actions, frequently resulting in experiences of moral distress. Second, without communicative action and discussion, ethics approaches often ignore the social factors, which create the contexts and limits of the moral decisions and actions individuals can make (Callahan, 1994), consequently separating ethics knowledge from the context of everyday life; thus, “the gap between what we know, and how we live, widens” (Finlayson, 2005, p. 65).

Adopting an analytical framework, as communitarian ethics suggests, which looks not only at the personal level of ethics (individual decisions) within a vacuum, but rather at the social dimensions of such individual decisions (the discursive forces influencing the context and “options”) allows for a better understanding of why people make ethical decisions in the ways they do. Similarly, such an approach to ethics expands the scope of analysis to include a multitude of voices within the community in an effort to blend individual judgment (personal judgment) and collective judgment (cultural/environmental/organizational judgment; Callahan, 1994). Blending individual and collective judgment within pluralistic environments such as LTC requires a common effort, for without this, individuals will continue to make decisions and take action based on coercion, flowing from those with the most money and power, and real change in ethics can never occur. Habermas emphasized, “all successful action in the real world depends on the capacity to reach consensus” (Finlayson, 2005, p. 49), and to reach consensus, we need to foster environments of dialogue exchange and communication. To see collective/organizational changes in ethics in LTC, all of the individuals involved in, and impacted by, this collective judgment should be invited to participate in the discussion (Habermas, 1984; Moody, 1984).

In discussing the “ethics of ambiguity” (p. 95) in dementia care, Moody (1984) proposes that the response to complex and ambiguous ethical contexts is communication, and while my research does not specifically focus on dementia, LTC environments are morally complex and ambiguous landscapes (Kuczewski, 1999). Using a communicative ethics approach to facilitate consensus building and establish ethics requires us to widen the scope of analysis to include more facets and interests than those typically included in ethics research and policy development (Moody, 1984). “Communicative ethics, in sum, offers a powerful alternative to the ethics of rules and principles so pervasive in contemporary thinking about ethical issues” (Moody, 1984, p. 99) and could be a transformative approach to ethics in LTC by offering a wider, and more empirically derived, perspective. When individual players reach a consensus, it creates an active participatory process, reduces the tension between groups, promotes ownership, fosters an environment supportive of change, and narrows the gap between philosophy and the daily lived experiences from where it draws its insights (Finlayson, 2005). Further, consensus building challenges and aims to rectify the oppressive effects of silencing and marginalization inherent to many of the dominant discourses in LTC, including the discourses of biomedicine (Estes & Binney, 1989), efficiency (Tonuma & Winbolt, 2000), risk (Clemens & Hayes, 1997), and ageism (Butler, 1975).

There are, of course, a number of methods to facilitate group research, consensus building, and establish communicative ethics. One such approach, and the approach adopted in this empirical ethics study, is a qualitative Delphi method.

Qualitative Delphi Method

The Delphi method originates from a Cold War study, “project DELPHI,” conducted by the RAND Corporation to forecast the impact of technology on warfare (Dalkey & Helmer, 1963). Since its inception, the Delphi method has expanded and more recently is beginning to gain more recognition and support as a qualitative method; the Delphi method has been used qualitatively to explore health leadership (Fletcher & Marchildon, 2014), community organizing (Brady, 2015), public policy (Alexander, 2004), and social justice and human rights issues (Jamal, 2014). As a quantitative method, Delphi is systematic and uses a series of controlled and preformulated questionnaires to reach statistical consensus among experts on a particular issue. Many modifications have been made to the original structured approach of the Delphi method to meet diverse research applications (Fletcher & Marchildon, 2014). Despite adaptations to the method, the fundamental purpose of using the Delphi method is to enable “structured communication” with the goal of reaching “convergence of opinion concerning real-world knowledge solicited from experts within certain topic areas” (Hsu & Sandford, 2007, p. 1). “Structured communication,” as described by Linstone and Turoff (2002), involves an iterative multistage process. As such, Delphi method requires (1) some feedback of individual contributions of information and knowledge, (2) assessment of the group judgment or view, (3) some opportunity for individuals to critically revise their personal views, and (4) some degree of anonymity for the individual responses (Hsu & Sandford, 2007, p. 3). While there is some disagreement on the “best way” to accomplish these aspects of Delphi (Linstone & Turoff, 1975, 2002), the emphasis is to ensure these criteria are met, in some way, in order to facilitate an iterative multistage process, which enables the transformation of individual perspectives into group consensus (Jamal, 2012).

As a qualitative method, this “structured communication” can take many forms; however, typically, Delphi involves multiple (at least two) rounds of interviews (Ziglio, 1995). During the first round of interviews, referred to as the “exploration phase” (Ziglio, 1995, p. 9), individual participants draw on their expertise to explore and contribute pertinent knowledge and insights relating to the subject under analysis (e.g., ethics and policy in LTC). Once the first round of interviews is completed with all participants, the responses are analyzed and coded thematically as to participants’ views, with emerging themes being collated and circulated to participants, prior to a second round of interviews, in which they are invited to comment on the themes from the first (Greason, 2017). Further exploration and evaluation of participants views occur in the second round of interviews, which Ziglio (1995) refers to as the “exploration phase” (p. 9). In the exploration phase, the researcher(s) pay close attention to areas of agreement or disagreement and invite individual participants to further explore and reevaluate their responses in relation to those of other participants. This multistage approach fosters an iterative process of knowledge production, reflection, and translation, as the findings from each Delphi round form the basis of discussions in the subsequent round (Brady, 2015; Fletcher & Marchildon, 2014; Linstone & Turoff, 1975; for more details on how the qualitative Delphi process operated in this project, see Greason 2017).

Panel members are considered “stakeholder experts,” not simply because they are the individuals in positions of power or superiority, but because they have knowledge and experience of the issues, are directly affected by the subject, or have specialist skills in the area under investigation (Adler & Ziglio, 1996; Gabb, Balen, Gibbs, Hall, & Teal, 2006; Greason, 2017; Jamal, 2012). Emphasizing the importance of including a diversity and multiplicity of voices, Linstone (1978) highlights Delphi method cannot be confined to only including “experts” in the traditional sense, but in matters of policy change, the greater public must be included; “…it is therefore important to include in the Delphi representatives of a large or wide spectrum of vested interests, ranging from bureaucrats to minority groups” (p. 294).

Hsu and Sandford (2007) suggest if your research aims to achieve any of the following objectives, Delphi is an appropriate method for your research (1) to determine or develop a range of possible program alternatives, (2) to explore or expose underlying assumptions or information leading to different judgments, (3) to seek out information that may generate a consensus on the part of the respondent group, (4) to correlate informed judgments on a topic spanning a wide range of disciplines, and (5) to educate the respondent group as to the diverse and interrelated aspects of the topic (p. 1). Despite having various applications and being modified over the years, the fundamental purpose for using the Delphi method “remains the collection of informed judgment on issues that are largely unexplored, difficult to define, highly context and expertise specific, or future-oriented” (Fletcher & Marchildon, 2014, p. 3).

Qualitative Delphi approaches have been adopted and successfully used in a number of areas, including policy analysis, medical, nursing, health services, and service planning (Gibson, 1998; Jamal, 2012; Williams & Webb, 1994). However, Delphi has not been used to explore ethics and policy in LTC, despite the many benefits of using such a method in this underexplored area of research (Fletcher & Marchildon, 2014; Ziglio, 1995).

Advantages and Benefits of Using Delphi in Empirical Ethics and Policy Research

Adopting a qualitative Delphi method to explore ethics and policy in LTC was extremely successful and resulted in deeper, more rich, findings on ethics and policy change in LTC that would not have been achieved if other consultative methods had been used. Below I will explore the promising advantages and benefits of using a qualitative Delphi method in empirical ethics and policy research specifically. However, the benefits are transferable to many other qualitative areas, and as this study suggests, adopting a qualitative Delphi approach has vast potential for both qualitative research findings and knowledge mobilization.

Broadly, Delphi method addresses some of the shortcomings of alternative consultation research methods: it starts from a position of openness, it allows participants to question the assumptions of other experts as to the issues, preferences, and ways forward, it aims toward consensus (and thus commitment to the outcome), it is comprehensive and inclusive, and it allows for the transfer of knowledge as part of the process (Powell, 2003). One of the benefits of Delphi is that through its communicative and inclusive approach, consensus can be reached in an area where there is a lack of empirical knowledge (Fletcher & Marchildon, 2014; Mead & Moseley, 2001; Murphy et al., 1998; Powell, 2003; Ziglio 1995, 1996) and where there are a number of diverse and invested individuals/groups. This makes it a particularly valuable and pertinent technique for achieving consensus building in terms of ethics and policy in LTC. The landscape of LTC is complex and ambiguous, thus the complexities of ethics, decision-making, and policy in LTC cannot, and will not, be resolved by any single group. Given the interconnected and interdisciplinary nature of LTC, adopting a qualitative Delphi method allowed for relative consensus to be reached among a vast array of players. In reaching consensus, the iterative nature of Delphi created an active participatory process, reduced tension between groups, promoted ownership, fostered an environment supportive of change, and narrowed the gap between philosophy and the daily lived experiences from where it draws its insights (Finlayson, 2005). The resulting consensus ultimately reflects a collective view rather than an individual view that would have resulted from using other consultation methods.

The resulting collective view also goes a long way in facilitating timely action toward meaningful change. While there is a growing body of literature on ethics in LTC, often the findings are philosophical in nature, making the translation into practice challenging, at best. A different approach to researching the ethical dilemmas and policy implications in LTC is needed if we want research in these areas to move beyond philosophies and research papers and into the realm of practice and change. Adopting an empirical ethics approach in conjunction with the Delphi method moves the research in this direction, allowing for more practical, tangible findings that can/should be acted on. Having a multitude of stakeholders participate in the research means those in positions of power to change policy at the LTC organizational and public levels are actively involved in the generation of knowledge, its evaluation, and assessment of its potential application. This is where Delphi moves beyond the typical “sharing of findings” that is standard in qualitative research. First, Delphi is an active research method, which goes further than merely seeking individual stakeholder opinions and perspectives. Delphi challenges stakeholders, asking them to reflect and reconsider their perspectives and opinions based on those shared by others in an effort to reach consensus. Second, by drawing on the views of various stakeholders, achieving consensus, and producing tangible practice/policy outcomes, Delphi inherently involves an array of knowledge mobilization activities including knowledge synthesis, transfer, exchange, and co-creation/production by researchers and knowledge users (Social Sciences and Humanities Research Council, 2018). Further, as Delphi iteratively aims to establish consensus on “ways forward” and produce tangible and applicable outcomes in underexplored areas, it involves up to stage three of the knowledge transition portion of Graham’s Knowledge to Action-Ethics cycle, which “represents the process of knowledge creation and its translation into practice and policy” (see Graham et al., 2006).

In addition, the final summary of findings, containing tangible and applicable solutions and/or directions needed for change, is circulated to all participants. Those in influential positions, or positions of power, are encouraged to act upon the findings, thus facilitating meaningful change. Circulation of the final summary to all of the diverse participants also means the findings reach a wider audience more quickly, as stakeholders are asked to circulate and share the results with their colleagues and within their organizations. Similarly, in this way, the lag between the conduct of the research and the findings reaching the public (including those most impacted by the results) is notably reduced.

Despite taking the research further than traditional ethics and policy exploration, there are still challenges to facilitating the translation of findings into policy and practical changes. Particularly, in this research, where the some of the findings identified ethical issues related to high-level policy and governmental operations. Although the Delphi method allowed for various stakeholders, including those at political and governmental levels, to discuss and explore these issues and propose possible avenues for change, instituting such changes will require significant policy and procedural changes at a systemic level.

For example, one of the main findings of the Delphi interviews was the need to have strong government leadership, focused on LTC, and the development of relevant LTC policies. Stakeholders expressed “…for nursing homes and long term care, there’s been very little investment in the sector outside of the bricks and mortar.” Many stakeholders demonstrated an appreciation and understanding that governments “are pulled in many directions.” However, also expressed minimal investment and focus on LTC and aging in the province has resulted in (1) no strategic plan for aging and LTC and (2) an outdated system made up of irrelevant and inflexible policies and models of care. Stakeholders suggested a number of possible reasons for the lack of investment/focus on LTC at a government level. Stakeholders shared that elected officials are afraid to make difficult decisions and “get turfed out of office” or “be on the front page of the paper” and are often more concerned with election/reelection than truly making change. Others suggested getting rid of fixed election dates and “allow[ing] governments to sit for five years” would make a big difference in what governments could accomplish, while others expressed that the frequent turnover of ministers does not allow for engagement and/or change. Further, stakeholders discussed how at a governmental level, the sector serving nursing homes and LTC is understaffed and has limited resources and autonomy, resulting in minimal space for discussions about change and innovation. Further, stakeholders overwhelmingly agreed that the majority of LTC policies are outdated and inflexible and need to be updated. When asked whether policy makers were aware of the realities of LTC, stakeholders all responded “no” or “I don’t think so.” Many stakeholders suggested that the lack of government/policy maker understanding and limited focus on LTC results in decision-making that negatively effects LTC staff and residents: “Government officials are…they’re focused on funding, licensing, and monitoring. They’re not focused on quality of life.” Stakeholders repeatedly said policy makers need to “come and spend a day here and really see, you know, what a real day is in the life of a resident,” and similarly, “those policy makers need to have a good understanding of each, what’s going on in the homes—they need to go and see what’s going on…to see what’s working and what’s not working.” Additionally, stakeholders expressed how “not one size fits all” in LTC, and that policies need to be developed with an understanding “that what works in one home might not work in another,” and that “not everything has to be carried out in every home.” Stakeholders also agreed that while there is a need for policies and regulation in LTC, current policies and inspection processes are rigid and do not provide an accurate report of residents’ experiences or the quality of care in homes. Stakeholders agreed that inspection processes need to change to include more holistic and resident-centered quality indicators.

While these suggested changes provide tangible solutions and reflect a collective view, the identified issues and proposed resolutions are multifaceted. Implementing such changes would require collaboration across sectors, political will, and significant investment (both personnel and financial). Further, instituting the proposed solutions would impact a number of systems and processes, including provincial budgeting and funding streams, employment regulation, political organization, and legislative procedures (to name a few). So while adopting a qualitative Delphi method to explore ethics and policy in LTC brought the findings further than typical methods used in this area of research and resulted in agreed upon solutions and ways forward, there can still be significant challenges to connecting the findings to meaningful change. However, not all of the proposed solutions from the collective view present such systemic hurdles. When asked what could be done to ensure the LTC sector was getting the “right” administrators, RN leaders, and frontline workers, stakeholders consistently discussed the significance of hiring practices, stressing the importance of adopting more strategic hiring processes. Stakeholders proposed a variety of strategic hiring process changes that are applicable at every level of staffing/hiring. Participants consistently expressed how potential staff, whether the administrator or frontline worker, need to be asked about their values and “why” they are interested in working in LTC. Some stakeholders suggested exploring values could be accomplished by conducting more purposeful interviews where individuals were asked specific questions about character and personality. Others proposed using a personality/psychometric test as a hiring tool to provide a more holistic understanding of the individual. Stakeholders also discussed how job descriptions are often vague and suggested that more specific descriptions, outlining qualifications, characteristics, and expectations of the role are necessary if we want to get the “right people” working in LTC. Finally, regarding all levels of staff hiring, the importance of involving peers, and in some cases residents, in the hiring process was suggested. As one stakeholder shared, “Because there’s been people hired and we’ve just went, “Pfft. Great. That’s just great now, isn’t it?” We could have told them a long time ago, you know, “No, this person was lazy as a [RA], do you think they’re going to be any better as an RN? I don’t think so. They’re going to be worse.” While the majority of stakeholders agreed that changes were needed in LTC for strategic hiring to take place, they also recognized and emphasized that once the “right” individuals were hired, they required continuing support and encouragement through ongoing and appropriate training.

Although these suggested solutions would require organizational will and commitment to change, there is minimal investment required to implement the proposed strategic hiring and ongoing training. Yes, there will always be the argument in LTC of staff availability and funding for training, however, there are a number of creative ways to incorporate free training and encourage staff to attend at minimal expense (e.g., lunch and learns where the education is provided by professional bodies, researchers, and/or students). Of course, for qualitative Delphi to be truly impactful, at least in this context, it also takes commitment from the researcher to follow-up with participants to see whether they have any questions regarding the final summary (and proposed ways forward) and to encourage the adoption of the suggested changes. This might require ongoing discussions, support, collaboration, and resource connection. However, given that the LTC sector continually expresses the barriers of limited staff and funding, and management being stretched thin, it is unlikely that without such follow-up and support, the changes will be implemented. Consequently, successful use of the qualitative Delphi method in the areas of ethics and policy in LTC requires, first for the researcher(s) to develop a trusting relationship with stakeholders, and second, serious commitment to the project and the translation of findings into meaningful change.

Another significant advantage to adopting a qualitative Delphi method in the exploration of ethics and policy in LTC is that through the iterative nature of Delphi, knowledge translation and mobilization are built into the method itself. As participants engage in multiple rounds of interviews, they are invited to reflect upon, discuss, and explore their own views and opinions in relationship to those of other participants, in a safe and anonymous context. Interacting with the findings in this way encourages an iterative process of knowledge production, reflection, and translation, which sets a strong foundation for further knowledge translation and mobilization. It is beneficial that within the research process, knowledge translation and mobilization can occur rather than waiting for a secondary stage of mobilization following the conduct of the research, as is typically the case.

Adopting a qualitative Delphi approach to ethics and policy in LTC may have been innovative, involving some reimagination of the approach, yet the successful use of the method in these areas of research is promising and suggests the applicability of qualitative Delphi in these, and other qualitative, areas. Here, Delphi allowed for deeper, more rich, findings on ethics and policy in LTC because the method inherently works from the bottom up, involving those most directly affected by the topics rather than a select few individuals arbitrarily theorizing about ways forward. In this way, the ethics practices and concerns staff truly endorse are explored and accounted for in the research. This results in practical and applicable research findings rather than arbitrary theories, thus promoting meaningful change.

Qualitative research is inherently exploratory, with the purpose of gaining insights into particular areas and/or developing hypotheses with respect to ways forward and toward change. While the Delphi method is just starting to gain more recognition alongside more well-known qualitative methods, it has the potential of taking qualitative and empirical research further, expanding the reach and depth of inquiry and findings, as it draws on real-world practice and decision-making to promote consensus in areas of organizational, policy, and practice change. There is a need for further research using a modified qualitative Delphi method in empirical ethics and policy research in LTC, as well as other areas. However, the results of this study, and those of others using Delphi in qualitative research (see, e.g., Brady, 2015; Fletcher & Marchildon, 2014; Jamal, 2016), suggest the suitability of the approach for qualitative inquiry and propose researchers seeking to increase the breadth of research findings, knowledge mobilization, and practical change should consider adopting the Delphi method.