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Aims: The aim of this narrative synthesis was to explore the necessary and sufficient conditions required to define moral distress. Background: Moral distress is said to occur when one has made a moral judgement but is unable to act upon it. However, problems with this narrow conception have led to multiple redefinitions in the empirical and conceptual literature. As a consequence, much of the research exploring moral distress has lacked conceptual clarity, complicating attempts to study the phenomenon. Design: Systematic literature review and narrative synthesis (November 2015–March 2016). Data sources: Ovid MEDLINE ® In-Process & Other Non-Indexed Citations 1946–Present, PsycINFO ® 1967–Present, CINAHL ® Plus 1937–Present, EMBASE 1974–24 February 2016, British Nursing Index 1994–Present, Social Care Online, Social Policy and Practice Database (1890–Present), ERIC (EBSCO) 1966–Present and Education Abstracts. Review methods: Literature relating to moral distress was systematically retrieved and subjected to relevance assessment. Narrative synthesis was the overarching framework that guided quality assessment, data analysis and synthesis. Results: In all, 152 papers underwent initial data extraction and 34 were chosen for inclusion in the narrative synthesis based on both quality and relevance. Analysis revealed different proposed conditions for the occurrence of moral distress: moral judgement, psychological and physical effects, moral dilemmas, moral uncertainty, external and internal constraints and threats to moral integrity. Conclusion: We suggest the combination of (1) the experience of a moral event, (2) the experience of ‘psychological distress’ and (3) a direct causal relation between (1) and (2) together are necessary and sufficient conditions for moral distress.

Supplemental Material, NEJ_Supplementary_Material_(Table_4) for What is ‘moral distress’? A narrative synthesis of the literature by Georgina Morley, Jonathan Ives, Caroline Bradbury-Jones and Fiona Irvine in Nursing Ethics

Aim.: This paper is a report of a study exploring the empowerment of nursing students in clinical practice. Background.: There is a great deal of literature regarding empowerment in nursing but most focuses on the empowerment of patients and registered nurses. There is very little regarding the empowerment of nursing students. Of the limited available studies, most explore empowerment in an academic, rather than a clinical context. Methods.: This longitudinal study was underpinned by hermeneutic phenomenology. Thirteen first-year nursing students were recruited using a purposive sampling strategy. Annual, in-depth interviews were conducted with the students on their trajectory from the first to third year of the undergraduate programme. Data were collected between 2007 and 2009. Findings.: By the end of the study, most students felt more empowered than they had at the beginning. They attributed this to increased knowledge and confidence. Empowerment of nursing students in clinical practice can be represented in the form of 'spheres of influence'. Intrinsic, essential structures of having knowledge and confidence are at the core. External spheres influence the extent to which nursing students are likely to experience increased knowledge and confidence, and thus empowerment. However, nursing students use a number of strategies to promote their own empowerment in clinical practice. Conclusion.: Efforts to promote the empowerment of nursing students in clinical practice need to be multi-layered and targeted at each of the spheres of influence. © 2010 Blackwell Publishing Ltd.

The study focused on the evaluation of capacity building strategies, as implemented by Merseyside Health Action Zones (MHAZ). The aim was to determine whether capacity building activities constitute as appropriate tools to tackle the underlying causes of poor health, including unemployment, and social exclusion especially amongst young people. This study also determined the MHAZ contributions towards increasing the employability towards enhancing the quality of life for young people, aged between16-25 in the Merseyside areas. The Health Action Zones (HAZs), including MHAZ, were a government programme for action in local communities to tackle the root causes of ill health in other to reduce health inequalities. The qualitative evaluation methodology adopted for this study provided in-depth understanding of participants' experiences of both the processes and the impacts of the projects. 20 project workers and 18 beneficiaries from 5 local authorities in Merseyside were involved as respondents. Data collection involved semi-structured interviews, a focus group meeting, case studies, and an evaluation workshop using the 'theory of change' (TOC) approach to evaluation. The TOC enabled the project workers identify their programmes‘ logic models as well as enabled the assessment of complex community-based activities of capacity building that operated at many levels. A review of projects‘ reports and relevant literature provided an overview of project structure.\ud \ud The study was carried out in three phases: the first phase explored the MHAZ project workers‘ perception and understanding of the term 'capacity building' in the context of HAZ. The second phase focused on identifying the MHAZ logic models and assessing MHAZ process, focusing on what worked what did not work so well and what could be done differently for better practice in the future learning and development. The third and final phase assessed the impact of capacity building on the project‘s participants, in relation to enhanced learning (knowledge, experiences, attitudes or skill) and improved conditions, including increased employability and behavioural changes.\ud \ud Key findings revealed that the MHAZ project workers characterised the activities of capacity building using a more community-friendly terminology such as 'personal development', 're-training-to reactivate-potential', and 'social capital', as their values seemed more in line with what they do. However, the term 'social capital' arguably seemed to have suffered the same fate as the term 'capacity building' at the project level as it seemed - not only is it jargonistic, it is a complex concept as well. Meanwhile the term capacity-building was viewed negatively by most project workers as its philosophy could not easily relate to what they do in the community. This indicates that capacity building can act to marginalize people rather than enhance skills.\ud \ud Efforts were made to address social exclusion and many projects recorded successes in terms of increased self-confidence, personal qualities and enhanced social skills for both the project workers and beneficiaries. The relationship of trust and respect between the project workers and the young people was obviously very vital to the success of the MHAZ programmes, as positive changes were noted in attitudes and interaction with different groups of people.\ud \ud The weakness of the MHAZ programmes was attributed to the short term nature of the projects and the uncertainty in the funding system, which had huge negative impacts on both the project workers and the young people. It was therefore not possible to determine on the shorter-term objectives if MHAZ achieved the reduction of health inequality status. Also the absence of a support structure with an inbuilt transitional period meant that the young people were left independently to find their own jobs with little or no confidence. Government could do more to address the real problems of social exclusion amongst young people. Perhaps, the Coalition government 'Big Society' agenda comprising of integrated provisions where parental education, social and health care support provided to vulnerable families should be seen as crucial in addressing health inequality status while improving young people‘s wider wellbeing. This approach will enable young people to have a sense of belonging within a community network, even after the programmes and projects have drawn to an end.\ud \ud Suggestions for improvement included: the need for increased funding to extend the life of the projects, and the development of a workable post support structure for the transition period to enable young people prepare their mind-set for employment as well as establishing education, and life skills programmes to gain employment at the end of project‘s duration.