Editorial

As I write this editorial the seasons have changed in the UK from summer to autumn – the holiday season has morphed into party-political conferences, the public-service purse-strings have been drawn in to match our shrinking daylight and the focus of our readings has switched from summer relaxation to work-related reports, papers and emails. All of these things we expect by autumn. What we don’t expect is for healthcare workers to feel so morally distressed that they are threatening strike action.

This autumn in England we may experience more strikes by junior doctors as they remain concerned about patient safety, insufficient funding for the instigation of a 7-day NHS, contract imposition and elements of inequality. Their predicament, one of moral distress ‘when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action’ (Jameton, 1984: 6), cannot be ignored. Their distress is further sharpened not only by the apparent compassionless carelessness with which negotiations for an ultimately better service have been handled, but also because of the moral dilemmas that healthcare strikes bring. As the only group of NHS professionals who can be sure that their work will be competently covered by others, their consultant bosses, they sometimes claim that they are striking on behalf of the rest of the service who do not have that assurance. But other health and social care workers also experience moral distress in their work every day in different ways. The Perspective in this issue of JRN details the debate Georgina Morley convened in May to develop a better understanding of this concept in preparation for research to find solutions to moral distress. In this issue we have collected together a set of papers and reviews that offer some food for thought.

Finding ways to ameliorate moral distress is complex but necessary, especially as it is not restricted to the workforce. It can also affect patients’ families and friends as they balance their expectations of the system with what it (or they) can provide. All of us, whether involved in healthcare as patients/clients, friends, lay or professional carers, managers, educators, politicians or policy makers need to concentrate on resolving, or at least reducing, moral distress. Neither can researchers shy away from this area of work because it is difficult; rather they need to undertake research that, through both methodological style and attainable consequences, offers ways to make a difference.

One such study (Andrews et al., 2015) used participatory methods alongside appreciative facilitative techniques to bring together older people who used health and social services, their families and friends, practitioners, managers and policy-makers to solve everyday problems that caused – among other things – moral distress. The moral distress resulted from multiple organisational factors, from the seemingly simple, for example residents unable to do things they were capable of in case they breached ‘health and safety regulations’ (pouring tea being one notable example), to the complex, for example over-documentation, befriending and travel outside their residence. In all of these examples the key to minimising distress was to bring people from all parts of the system together to talk, listen and respectfully develop joint actions. This resulted in shared understandings and changes to the daily lives of all involved: care became truly person-centred, with relationships dominating where previously documentation and professional distance had dictated practice. Welsh national and local policies similarly changed and regulations were altered to suit the needs of people rather than being a blanket application of generic rules. Ultimately, people were freer to use their judgement and as a result were happier about their work and their care. In a nutshell, moral distress was diminished.

The papers and reviews in this issue offer more ideas. The paper by Kristiansen et al. is a stark reminder of the unintended consequences of altering the shape of nurses’ work without consultation with the workforce – something nurses are perennially subjected to. In this case an increase in nurse leaders’ managerial tasks weakened their ability to lead and influence care at the point of delivery. This shift caused them to have feelings of moral distress as their professional values were compromised. At the other end of the spectrum Eriksson and Salzmann-Erikson’s paper catapults us into the extraordinary world of cyber-nursing. Reading this paper made me see possibilities around virtual self-care and online caring that I’d never dreamt of, and it left me wondering if cyber-nursing and robotics (Laitinen et al., 2016) could diminish moral distress and enhance care. Clearly, the feasibility of cyber-nursing needs assessing and this will undoubtedly need to be done by researchers able to exercise nursing’s imagination while keeping nursing’s feet firmly on the ground. Being able to do both, as Rolfe reminds us in his paper, is a matter of intellectual craftsmanship rather than mere research paper production.

Fixing our research imaginations on scholarship that stays close to the business of care will minimise moral distress not only in practitioners but also in researchers who sometimes find themselves, as Rolfe suggests, undertaking research to fill their institutions’ publication coffers rather than improve practice. One shining example of a researcher who fixed practice change firmly in his sights, Professor Jack Hayward, has died this summer. He is best known for his seminal work on the value of information in promoting patients’ welfare (Hayward, 1975), which even then showed dissonance among organisations, professional practice and patient welfare as seen in one of the closing paragraphs of his monograph … ‘The majority of doctors and nurses encountered during this investigation agreed in principle that patients should receive as much information as possible, but felt that without extensive reorganization the idea was unrealistic’ (Hayward, 1975: 117). He was one of the first people to hold, from 1976, a professorship in nursing in the UK. Both Jack and his research were inspirational to his students and nurses around the world.

The two final papers by Koeberich, and by O'Neill and Moore, are reminders that patients and potential patients/carers, need to be creatively encouraged to understand and identify symptoms in themselves and others. Doing this enables them to educate their families and friends about their needs and wishes surrounding care, thereby potentially diminishing the moral distress associated with dashed expectations as they engage with health and social care systems.

Celebrating nursing success is also an antidote to moral distress and it is with great pleasure that all of us at JRN congratulate the winners and runners up of the 2016 ‘Veronica Bishop Paper of the Year’ award. The 2016 winners are Sören Augustinsson and Pia Petersson for their paper entitled ‘On discharge planning: dynamic complex processes – uncertainty, surprise and standardisation’, and the 2016 runners up are Catherine Paterson, Martyn Jones, Janice Rattray, and William Lauder for their paper ‘Identifying the self-management behaviours performed by prostate cancer survivors: a systematic review of the evidence’. Both of these papers are accessible on the JRN web-page: http://jrn.sagepub.com/site/misc/Prize/prizewinners.xhtml.

Finally, another JRN celebration, for which we send our congratulations to our editorial assistant Liz Ryan and her husband on the birth of their first daughter, Lily.