Transcript: Moral distress in residential child care

Podcast Episode: Moral distress in residential child care

What follows is a transcription of the audio recording. Due to differences between spoken and written English, the transcript may contain quirks of grammar and syntax.

NM - Neil MacMillan
DJ - Dan Johnson

Dan Johnson, Clinical Director at Kibble, interviews Neil MacMillan: an Executive Director at Kibble on the topic of moral distress in residential childcare. The conversation defines the concept, provides examples of it and suggestions for how to support workers who experience moral distress. More broadly it explores the impact of the system and the practice of residential childcare.

NM Welcome, I’m Neil MacMillan, I’m an Executive Director at Kibble School in Paisley, in Scotland and I’m joined today by Dan Johnson: who some of you may know from last year in New Orleans, who presented ACRC conference on trauma informed care in early years. We are conscious that there is a lot of video content out there just now because of Covid as opposed to it being a monologue and me talking along on my own, I thought it might be interesting for Dan to come along and to chat with me about the subject that I wanted to talk to you about today. So, I suppose this is going to be more of an interview format rather than a dialogue from myself. I’m happy for Dan to introduce and welcome you as well.

DJ Pleased to meet everyone so, I’m Dan Johnson, I’m the Clinical Director here at Kibble and this is a subject that I don’t know much about so this is a good opportunity for us to find out more about it in a way that will hopefully be quite accessible to you. So, are we ready to go?

NM Absolutely.

DJ Right, so we’re here to talk about moral distress so could you give us like what that concept is in a real brief kind of sentence or summary?

NM Okay so, moral distress is basically the psychological or emotional experience that someone goes through when in the course of their work, usually morally based work or work which has some kind of moral value to it, where constraints either organisational, political, resource, or otherwise, prevent them from doing what’s morally right in their job, and that’s about as best as I can summarise it.

DJ Right, no that was good, that was brief. So, they’re at work, they’re doing a moral job, take it like residential childcare and because of political, resource, whatever it is, they’re prevented to do that and that causes some distress?

NM Yeah.

DJ So, interesting. How did you personally come to this concept? What’s your story with it?

NM Okay, so interestingly a few years ago, I was at university doing another course and I came across it while I was at university and the thing for me about it was that it really rung a bell for me, there was real resonance in relation to moral distress in residential childcare because interestingly the literature that exists and the research that exists around moral distress is primarily around about the nursing and medical field so I was surprised when I read it that in fact it had real meaning for me in residential care. So, I began to read a bit more about it and to try to understand what it was about and what were the themes and what was it that made me think about residential childcare. The most important thing I suppose, or one of the important things that drew me to it was that often in residential childcare we hear about staff burn out, we hear about how children might be mistreated or maltreated within the system historically and currently. We hear about how staff have burned out by the system, often by vicarious trauma and so the children and young people that we care for become the subject of difficult situations in residential care, the children become the cause of the burn out from staff through this vicarious trauma but very little is actually looked at in terms of what the organisation does to staff. So, what role does the organisation, the policies, and the system, for want of a better expression, have on the people who work there? We look, there’s lots of research about the impact of the system on children and what the system does to children, but there’s very little in terms of what the system does to staff. So, for that reason, I was very interested in it.

DJ Yeah, it’s a really good point. So, it’s acknowledging that this is a tough job, right, this is a hard thing to do. Often that’s looked at because of the young people we work with rather than, like you say, the system that we’re working with.

NM Yeah.

DJ Interesting, right. So, what’s the roots of the concept, like where’s the origin? It’s in nursing but has it got like a philosophical or medical or …?

NM Well, I think … and interestingly, Professor Andrew Jameton, who is an Emeritus Professor at the University of Nebraska, I think sometime in the 80’s … I’d need to check my reference but I think it was in the mid 80’s in the journal of nursing ethics that Andrew Jameton first wrote about this idea of moral distress and interestingly it’s no surprise that it comes from the medical field because if we think about it, the moral decisions that have to be made in the medical field, particularly in end-of-life care and in emergency care. Now, the difference between a moral dilemma and moral distress is in moral distress, there is no right answer, you know sometimes there is a right answer and a wrong answer, it’s about which one you choose, moral distress is usually caused by a situation where there are intractable constraints. So, for example someone has cancer and has to be treated and the nature of the treatment is that it’s really aggressive treatment which is affecting their quality of life and in fact it’s only going to prolong their life for a very short space of time so, question … do they have the treatment or not? Someone who’s on a life support machine and the family wish the life support machine to be kept on but it’s doing the person no good and only prolonging a poor outcome so, it’s where the … so, you can see why it’s emerged in medical care.

DJ Yeah.

NM It’s interesting because if you think again about more of the things it’s about organisational structure and resources and it might be argued that medicine, certainly in the UK, the health service has been subject to privatisation much earlier in social care and in residential care.

DJ It’s like what’s happening in medicine might happen to us at some point.

NM Yeah.

DJ So, what would be examples of moral distress in residential childcare then?

NM Okay so, I suppose the question is, is it more pervasive now than it used to be? I’ve been doing this for 30 years; you know is it different from what it used to be when I did it at the beginning? I believe it is.

DJ Right, right.

NM And that’s probably what’s drawn me to this notion or this idea about moral distress. I mean what we’ve seen in residential childcare has been a market, you know so there’s a rise in neo liberalism in terms of the politics of this country. Neo liberalism is basically a political idea in process where marketisation of the free market is valued, citizens are viewed as consumers, services become a marketplace, public services are privatised and become a marketplace so if you think about it, what we have is a marketplace in residential childcare, certainly in the UK. So, we have public sector, private sector and charity sector, even charities are rebranding themselves as social enterprises so, basically charities who operate their social mission using business principles. So, business principles have become applied to what is essentially a human task or a moral endeavour. That’s the issue, so when you begin to apply those principles then you see a number of different things happening so what you see is, you see … you know the watch words become economy and efficiency so, what you see is resource constraints, you see placements being squeezed in terms of cost and you see staff being squeezed in terms of their availability and numbers on the ground because what they’re trying to do is do more for less, you see placements being decided based on fiscal policy and not necessarily about need. So, what we have is resource led decisions as opposed to needs led decisions. So, all of those things begin to create a climate where people who have entered this work based on their residential care as a vocation, people would say, you know people come into this job because they want to make a difference, they have a strong sense of social justice and they care about children, some might say they love children.

DJ Yeah, yeah.

NM And interestingly, increasingly what we see is managerial culture and bureaucratization in residential care as a result of this liberalism which begins to change and strip away the moral face of the work.

DJ Yeah, so the organisation itself maybe trying to be moralistic and maybe trying to do the right thing but the system that that works with is subject to all this neoliberalism, professionalism, you know all that stuff that you listed which then forces on the ground decisions made about care that cause more distress. Could you give us some of those examples on the ground?

NM So, interestingly as I said if we look at some of the instruments for example for measuring moral distress so, many researchers have built on Jameton’s work so, Epstein and Hamrick have developed a moral distress scale which looks at the frequency with which morally distressing events take place and the rate at which people find them distressing, using Reichard scales. So, if you look at the items on this scale then you will see things like placements being driven by cost, working with people who are not qualified to do the job, being asked to do things by managers which are not morally okay and a whole range of other things. So, there’s maybe some 30 items on the moral distress scale so, certainly in my own research when I speak to people or when I’ve spoken to people about their experience of moral distress, they site many examples, particularly where they say, well I came to this job because I wanted to help children and one of the things that I find is that to become a manager, my business acumen is more important than my capacity to look after children. We have people who, certainly in my own research, numerous individuals who have said that they have found themselves in what they believe to be very morally comprising situations where they are primarily driven by resource issues so, it’s about, for example, in the medical field we might talk about providing aggressive care to a person which is only prolonging a poor outcome, people in residential care talk about children being placed inappropriately for longer periods than is necessary when clearly the placement is not working or making any difference but financial constraints result in the person remaining in placement. We hear about placements ending as a result of financial considerations as opposed to considerations about the child, we hear about staff working with other staff who are not competent to do the job, who are not experienced or not qualified to do the job, usually because they are cheaper to employ in some types of service for example, particularly the private sector.

DJ Yeah, I’m sure that’s going to be resonating with a lot of people listening to this. I’m guessing that, we’ll go into your research in detail later but, I’m guessing that’s what people across all different, private, charity …

NM Yeah, so this is … when I’ve spoken to people from the private sector, from the charity sector and from the public sector, yes, they all say the same things to a greater or lesser extent. And it’s interesting, you know, the research that exists around about moral distress indicates that people who are more qualified are less likely to experience moral distress and people who are less qualified are more likely to experience it. People who are more experienced are less likely to experience it, people who are … also the gender dimension if you look at some research so, in some research it says that women are more likely to experience it, more frequently or intensely than men so, there are a number of variables in relation to people’s experience of it. And some of that, in my own research, what has resonated so far in the data that I have collected from my own research.

DJ Do you want to tell us what your methodology was there?

NM Yeah, so as I said earlier on, it would be interesting for me to know how pervasive the notion of moral distress is in residential care but you would need a fairly large sample for that and there’s been a lot of … as is always the case in the social sciences, debate about the predictability of certain methods and measures but as I mentioned earlier there’s a moral distress scale which is basically a check list using a Reichard scale that measures frequency in which people experience moral distress and the level of distress that they experience from the events. So, I basically took this scale and I modified it slightly in terms of the language so, for example, where it might have said … because the language of the scale is because the scale has been developed for medical care, I mean there are some variations of the scale because it’s been used in other contexts but the language of the scale is primarily around medical care so, its been used in numerous occasions for various things, so I’ve changed it slightly, I’ve adapted it slightly basically so it fits with residential care so, where it talks about treatment, that’s doing no good and you know nobody is willing to stop the treatment then I’ve replaced that with, for example a placement, a child’s placement which is only prolonging a poor outcome for example, and nobody is prepared to stop the placement. So, slight changes like that. So, I’ve put this out using social media, Survey Monkey and I got people to respond so there were 100 respondents and the main thing for me was that people recognise this so, whilst the sample’s not big enough to measure the prevalence of moral distress across the sector that we work in, for me my research was about: does this have meaning to people? Can people see this?

DJ And to get 100 participants just from email shows that it does, right.

NM Emotionally, I mean I presented this before at national conferences and it’s been a sell out in terms of … because people are really interested and they recognise this so, what I did with the respondents was I put the data through SPSS and crunched the data and picked the 10 people who scored the highest in terms of the frequency with which they experienced these events and the intensity of the distress that it caused them and basically I met with them individually and interviewed them and talked to them about the items on the check list and they expanded on those experiences and talked about what happened in these instances, how they felt about it, how they coped with it and I have to say it was, the information was mind blowing and in terms of some of the ethical issues that people were bringing to the interviews, some of it was very concerning. Because of the timescale between which the information that the Survey Monkey was completed and the time of which I interviewed people, there was a bit of a gap in between that, I even found that some of the people had left completely.

DJ The whole sector?

NM The whole sector, yeah because they quite literally couldn’t take it anymore. Because, you know, one of the powerful and pervasive elements about moral distress and the way in which people talk about it, it’s a very traumatising experience for individuals and so a lot of them had left and gone on to jobs at different places, still in the sector, a couple of them had left altogether and I think again, the powerful nature of moral distress in terms of the emotional impact on people was within the interviews as well. And what I mean by that is at the most extreme I had one person completely break down in tears talking about and recounting the experience of these various events. Numerous people talked about periods of sick leave from work, based on their mental health and emotional well being in terms of dealing with these organisational constraints and morally questionable behaviour in the organisation and the morally questionable behaviour of their colleagues and managers and their inability to impact or do anything about that. There was a lot of shame that was around, I think for people as they recounted these events because what we know about moral distress as well within the literature is that it’s cumulative so, again Hamrick and Epstein talk about a thing called the Crescendo Effect in relation to moral distress so, they talk about a morally distressing event and more often or not the nature of it is that people cannot do anything about it so, they supress the feelings and what’s left is moral residue then the next morally challenging event comes and the same thing happens …

DJ And builds up.

NM … and it builds and it builds and it builds and so people simply can’t cope and so will often either go on sick leave or leave altogether. Some explained that they had been whistle-blowers, and that part of their lack of tolerance of what was going on meant that they had reported some of the events, so yeah, the interviews were very, very powerful in terms of people’s experiences.

DJ A few take-aways from your research then, the themes that have come out of that, what are they?

NM The main these is for me, the first and foremost is, this is not something that’s confined to the medical field. So, this is something that people recognise in residential care. The other thing is that people for the most part don’t know what to do about it because if we talk about coping mechanisms in relation to moral distress, and any events, as you’ll know yourself from your work is we talk about dysfunctional coping mechanism and we talk about more functional coping mechanisms and what was evident from the interviews is that for the most part people engaged in dysfunctional coping mechanisms and so the question is if people come to this work because a lot of the research around residential care indicates as well that people don’t come to this work for money, they come to it as I mentioned from a strong sense of social justice, wanting to do good, wanting to change people’s lives and from a moral stand point as well, so when that’s challenged, when the moral fabric of their work is stripped away, why is there not an outcry? Why is it supressed? What’s interesting, I think that from the interviews, what also emerged is that people engaged in this process of system justification so, there’s a process by which people … how do you deal with the cognitive dissidence of going into work every day and doing your moral work when the moral fabric of it is being stripped away? How do you cope with that? So, one of the dysfunctional methods which people reported although they didn’t describe it in these words, was about system justification. So, an acceptance that that’s just the system, that’s what we’re in and that’s how we get on with it.

DJ Yeah, this is the way the world is.

NM Yeah. Another coping mechanism which interestingly, I think Eric Bauman talks about is, adiaphorization which basically means the neutralisation of moral ideas. So, what happens is that things which are morally difficult, become morally neutralised. So, you take the moral question out of it – it’s a bit like system justification. So, interestingly in other research, some other research by Waurdhaugh and Wilding who looked at historical abuse. One of the areas that they identified as an area for concern is when an organisational culture begins to neutralise moral issues. So, it’s interesting so, not only are we talking about adiaphorization creating a climate where morally questionable practice might not happen or be neutralised … but it creates an opportunity for what we know historically has been institutional abuse to take place.

DJ Right.

NM What’s more concerning …

DJ Sorry, what’s that word, diaphorization?

NM Adiaphorization, I know it’s a bit of a mouthful.

DJ Just give an example of what that might …

NM So, basically, it’s literally about stripping the moral face from a morally difficult situation. So, it’s like system justification so, for example there’s no moral question about placements being driven by cost because the place has to be paid for.

DJ That’s the way the world is.

NM Yeah, so what we do is we rationalise it and it makes it okay but it’s not okay and that’s the difficulty.

DJ I know what you mean so, because of these retractable facts there’s nothing we can do so therefore we take the morality out of it.

NM Yeah, yeah so things become morally neutralised and then everything becomes okay so it starts off with the small things and then it becomes the bigger things and then everybody or most people become morally neutralised and we go along with … because what you need to remember as well, the proponents for moral distress or the proponents for neoliberalism particularly are extremely powerful so what we have, certainly in the UK, is systems of procurement, commissioning of services …

DJ Large government organisations.

NM … large government organisations, CEO’s of companies, large corporations who are running social care in this country funded by hedge funds, this is what people are up against so, as the social care worker coming into residential care every day, you know you can fight small battles but the fact of the matter is the pervasive nature of this, the government are engaged in it basically because they have commissioning and procurement systems for residential care so how do we drive costs down? Now they might say that how do we keep quality up but the bottom line is the double bottom line.

DJ Yeah, and it’s not what can we do for John here, it’s how can we get the cost of this placement down. So, I’m sure a lot of this is resonating with loads of people. We’ve got sort of different layers here. We’ve got the implications for the residential childcare work is starting to shift and feel moral distress and we’ve got it at the system (… unclear) level. So if this is resonating with residential care work, I feel this, I make these decisions, I’m part of the system, what can they do themselves to sort of alleviate this or change things?

NM I think that, well this for example, you know the fact that we are beginning to talk about it so that it’s not something that’s not talked about, something that’s not around, even if you think about neoliberalism, if you speak to most people about neoliberalism, most people will say, what do you mean? And it’s interesting because when you begin to talk about it, they know what you mean. But even that has become anonymised so, what we want to do I suppose in organisations is to create a better moral climate. So, we begin to have conversations about the moral climate of the organisation. We also begin to … and what we’ve seen in the sector, for example, is a bit of a return to ethics or to care ethics where people have an interest in care ethics. Certainly I remember it in the beginning of my career and people talked about the values of social care and the values of residential care unconditional positive regard for clients but nobody talked about organisations that were morally bankrupt or organisational behaviour that was morally corrupt or morally questionable or any of that so, the suggestion was that the organisation was fine, it was about individuals, I think that a recognition that the system, the superstructure that we are in, the political structure that we are in can be wrong is a starting point as well. So, again if you look at it in Scotland, what we have at the moment in Scotland is we’ve got a national review of residential care which is fantastic and it’s being led by the voices of children and young people, it’s being led by the voices of the care workers who work in these organisations so, some of these things can begin to be teased out so, keep a little bit of identity in politics that is playing into the national review but a conversation has to begin and it is there and I think one of the things as well is if you think about the rise in interest in social pedagogy in the residential childcare sector particularly in Scotland and the UK. Something that social pedagogy has been around for 100 years or more but we suddenly have this interest in it and I don’t think that that is by accident, I think that that is … it might be a covert backlash, against some of … the impact of neoliberal policies. And what I mean by that is that social pedagogy is concerned particularly with care ethics, so in social pedagogy what’s talked about a lot of the time is an ethic of care, (… unclear), your stance, your position, your moral position. Very strong theme in social pedagogy. And I don’t believe that that’s by accident that that’s been prominent in Scotland. You know so there is a body of individuals who want to question the way in which residential care is being done and I don’t just isolate this to Scotland or the UK, I think other parts of the world …

DJ Absolutely, it’s even more so.

NM … absolutely where privatisation of services is huge.

DJ So, one of the things we can do about it is talk about morality, talk about moral values.

NM Yeah.

DJ The social pedagogy does sound like something that could give folk some anchor or … what else can people be doing?

NM I think …

DJ There was functional or dysfunctional ways to cope?

NM Yeah, so I mean something like dysfunctional ways like morally neutralising which is not what we want to do. I think there’s a part of that’s about calling things out. I mean, that’s a dangerous road to go down and I’ve said to you that it’s powerful structures that we are talking about but one of the things that’s been written about recently is about moral outrage and quite literally saying we are outraged by … this is not acceptable within the field that we are in. Holding organisations, holding colleagues more accountable, having systems within the organisation that creates space for debate about the moral nature of our work and ensuring for example that some of the curriculum, I mean currently Strathclyde University, here in Scotland, run a fantastic masters degree in Advanced Residential Childcare which actually a lot of the curriculum picks up on this kind of thing. A lot of the content talks about an ethic of care and the ethic of care is something that’s really strong within the teaching, the curriculum. Another part of it is about so, I’ve come across this moral distress idea, people are experiencing it, it’s a phenomenon and what’s helpful is to have something to hang your hat on.

DJ Absolutely, yeah, yeah.

NM So, it’s a bit like, when you can begin to name a phenomenon then you can begin to do something about it so, I didn’t talk about moral distress when I was doing my research with these participants. I talked about a thing that they could all relate to so if we have a theoretical framework by which we can understand what’s happening to us that we can reflect and analysis on then that’s a starting point as well. It’s interesting because although I talked about system justification and you talked about what can we do. There are some research that would suggest that moral distress is actually a healthy thing and that it creates a barometer for the sector that we’re in. So, when we begin to see moral distress, we know that something’s not right so we can begin to do something about it. But people don’t report moral distress, you know people don’t say I’m experiencing moral distress and more often than not people say, I’m off work because I’m experiencing stress and have mental health problems and the assumption is usually it’s notionally to do about the work, probably about how difficult the kids are, it’s not about the system. So, we have to create opportunities where staff can talk about the system and where ethical debates can take place about the work that we are doing and people can be challenged. We need to stop people sleepwalking into the creation of morally neutral environments. So, it’s difficult to keep a check on it.

DJ There’s a few things I want to pick up on there. One is, when you say it could be a good thing in a sense of … and it could be a good thing because it drives us to do something, sometimes. I’m thinking moral distress can make you think oh, right well we need to change the system and we need to change the practices in an organisation. So, we’ve talked about what you can maybe do as a residential childcare worker but how can we change this system so we can vote different political parties or whatever but I can imagine, you know speaking from experience, some of these decisions that you make can feel really morally complex so do we accept a child into our organisation or not if we accept them, maybe they’re not perfectly placed with us, we’re not ideal to look after them but what’s the alternative, we’re in this kind of least worst, so is that some kind of … am I making the mistakes that you talked about already or …?

NM Well perhaps, you know, I mean one of the things that the national care review in Scotland has said is: we want to reimagine the care system because the system as it stands is dysfunctional … it doesn’t work, you know, so least worst is not okay. I suppose at the heart of this is a philosophical question that I always raise in which when you read some of the literature around about care ethics, is if you’re paying for it, is it care? Now that’s a complex and is a huge question. You know, my dad is elderly, he’s 84, he’s very frail and I’ll do whatever I can do for him because I love my dad and I care about him and there’s no question about whether I paid for it or whether I’m not paying for it or whatever you know, you do it out of a moral place or values or love or care for the person … but what it means right now is emotional labour. We trade our emotions for money basically …

DJ Buy some kind of emotional support, yeah.

NM Yeah, so that’s difficult because what’s happened is care has become monetised, you know, that’s the difficult situation we have this market of care but it can still operate more ethically I suppose is really what I’m trying to say.

DJ I’ve maybe listened to too many political interviews but I want to get into the nitty gritty here. So, just say there’s a scenario, just to sort of run this through in real life, and this happens all the time in residential care where a social worker or so, is seeking a placement for a child and says, please take this child because you’re the best option and the organisation might think, I’m not sure we could provide the best care for this child. We could provide a level of care but it’s maybe not fitting her exact purpose. And the social worker says but please because if not, they’re going to go to somewhere much worse. What should the practitioner in that position do? Should they say no? Because that’s more morally beneficial in the long term or should they say yes?

NM It’s a very good question, Dan, I think it’s a hugely difficult question. The problem is, where do you draw the line, is really a question that you’re asking and that’s down to an organisation. People are critical of the private sector but I have worked in a private sector organisation where the person who owned the place one month paid the salaries of all the staff from their own bank account because we made no money because we were doing the right thing by only taking the children who fitted the profile of the service. Now we could have ran bunk beds in the place, you know, but we didn’t. So, I’m not saying that you just turn every one away but it’s up to an organisation and its own values as an organisation and its own moral position to decide where they stand. If everyone constantly says, there’s no where else for the child, we’ll take the child, because it’s the best worst place, then do we become complicit in perpetuating a system that’s broken. Often what we’re talking about is brokers of care who tend to be local authorities or local government who in themselves run their own care services and we talk about providers of care who are sometimes private sector or the charity sector and we have a very different … so, there’s a purchaser/provider relationship between those two people and so we have a choice, I suppose, sometimes the local authority, as the provider as well as the purchaser doesn’t necessarily have a choice, they just manage kids within their own system but we do have a choice. If you’re in the private sector or if you’re in the charity sector, you do have a choice to make and so it’s up to the organisation really about what position they want to take. Whether they want to be complicit in a system that’s broken by frequently taking children in and having multiple placement breakdown because the placement’s never suitable for the child and the child goes around the system and this becomes one of the many placements that the child has and then that’s up to the organisation but it’s a difficult question.

DJ It is and there’s equally complex and difficult things, decisions like that that people are having to make on a daily basis in residential childcare, both in terms of, do I allow this child to see their family during Covid or not, all the way to … and hence why we’re experiencing … and that’s why there’s that level of distress, is that right?

NM Yeah.

DJ Okay.

NM I think the big challenge for people, and certainly from my own research, and everything that I’ve ready is the big challenge for people is to take the moral position. We talk about making a better moral climate in residential childcare provision or amongst providers, we also talk about, you hear people talking about professional courage but we also talk about moral courage as well, you know, so doing the right thing, even though it’s difficult. What we’re asking people to do is to challenge really powerful structures so, there’s this insidious narrative that comes from the top, when I say the top I mean the government, service providers are as much victims of this system or this process because we didn’t invent commissioning, we didn’t invent procurement, we didn’t introduce all of this so, we’re much as … well service providers whether you’re private service provider, a charity, we’re as much victims of this process as possible but what you’re actually doing is you’re challenging powerful systems, you are questioning powerful and sometimes insidious narratives and what we have seen from history is that careers for whistle-blowers don’t always end well or careers for people who try to take the moral high ground or question the morality of the things that organisations do, powerful organisations do: don’t always end well. Example of that that I would suggest where somebody tried to redress the balance around the narrative that was pervasive in residential care would be Professor Mark Smith at the University of Edinburgh who when the media, I mean there has been abuse in childcare, historically, there is no question about that, but when this became prominent in the media, rolled out a constant and some people might say blown out of all proportion at times, Mark Smith questioned that discourse of abuse in residential care and whilst he said, yeah, it’s happened, he questioned the extent to what happened. So, he questioned some of the morality around what people were saying and the consequence of that for him was that he was labelled as an abuse apologist which is perhaps one of the most difficult things for anybody who has a genuine interest and care for children in the way that Mark does so, the repercussions of trying to challenge powerful structures for individuals can be huge. That’s evidenced by the fact that many of the people that I interviewed in my own research, have said that they’ve walked away. You know, so they’ve gone somewhere else, they’ve left the organisation or they’ve left the profession altogether because it was easier to do that than to challenge some of the morally questionable behaviour.

DJ Is one of the problems and one of the things that keeps this going, the unethical work, if you like, is that there’s not always moral clarity, it’s not always black and white and if you’re almost anything sort of moral … it’s probably not the best analogy but where you’re like, well here’s my moral argument and someone counters it with, well here’s the moral against it and actually it’s hard to navigate with, what’s the truth here. I don’t really want to go into examples but you know, people can come up with moral justifications for why certain actions are taken. What’s your thoughts on that?

NM Well I think that what we know from our education in this field, I think we know the difference between what’s right and wrong that residential childcare, the care of the children, what we do, should be led by the best interests of the child. Not the best interests of the organisation, not the best interests of the person caring for the child, the best interests of the child and that’s a good starting point, I think for most or any decisions that we make, as organisations. It’s a good reference point, so if we come across morally questionable organisations, or organisational practice or individuals, then the question is, you know, is the organisation or the individual acting in the best interests of the child.

DJ Alright, so we’ve talked about the costs that it can have for individuals trying to challenge this but there’s costs if they don’t as well, in terms of the distress, the fear, they might end up leaving the sector and not doing good in that way so if there’s one sort of like take home that you want people to go away with and how they can navigate this, what would it be?

NM I think it’s having moral conscience, isn’t it? You know, so trying to preserve your moral conscience, to have an ongoing debate with your colleagues, to keep the debate alive about the ethic of care, to be true to the values that brought you to this work in the first instance, to question the things that instinctively … because usually it’s our gut that tells us that this isn’t right, we question the things that are not right, to work with the power structures, perhaps not work against them, because you know, it’s going to be very difficult but to try to work with the power structures and work with them as allies, to influence them and make some change. Yeah, yeah.

DJ If someone wants to learn more about this, where should they be heading to?

NM So, earlier in the year, in January, a special edition of the Journal of Social Work Ethics, I published an article which is called: Moral Distress in Residential Childcare, it’s got good information and some good references there however I’m specifically in residential care and to be honest there is very little of it at all and I was recently invited to edit an article that was being put forward for a publication around about this, so there is some, you know it is gathering some momentum and I hope to publish the results of my own research next year so there will be some more about it but to be honest the amount of literature that exists around this, particularly in the medical field, is huge. Especially in America and North America, interestingly, which is where Jameton is from, less so but gaining more prominence in Europe. Some literature around about moral distress in social work is beginning to emerge but primarily it continues to be in the medical field but I’m hopeful that we can gain some momentum, we can have a wider discourse about this, that more platforms like this can be created for people to discuss and begin to think about it and so as it gains momentum hopefully what we will see is an impact on the ground in organisations where it’s theme that is discussed more readily.

DJ Brilliant and if people are keen to continue this conversation with yourself?

NM So, I’m absolutely happy if people wish to email me or to contact me directly and yeah to have more of a discussion about it.

DJ Brilliant, thanks very much then.

NM Thank you.

DJ Cheers, thank you.

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