TABLE 1.

Steps required for reflexive balancing and steps taken in this project

Steps required for RBL*	Steps taken in this project
1 Identification of a moral problem: the problem could be rooted in practical experience, engagement with empirical literature or from theoretical considerations.	1The issue of MD was first identified through GM’s experiences in practice and key questions regarding the concept raised through engagement with the empirical and theoretical literature.
2 Disciplinary naïve inquiry into the problem: this can be achieved either by data gathering, engaging with social science literature, philosophical theoretical literature, legal cases, politics and policy, and must be undertaken reflexively. Aims are twofold: To uncover and explore from multiple perspectives, all the values that operate on the problem and try to find some basic value propositions which act as quasi‐foundational boundary principles. To fully understand both micro and macro context of the problem, the way it is broadly conceived by the stakeholders, with the aim of uncovering recalcitrant experience.	2Inquiry begins by systematically searching and reviewing the social science and theoretical/conceptual literature. Data gathered from stakeholders regarding their ethical experiences using feminist interpretive phenomenology. Reflexivity maintained throughout using a reflexive research diary. Systematic literature review conducted, and a hypotheses definition of MD generated to be used as a boundary principle. Stakeholders asked to describe ethical challenges and experiences of moral distress (micro), and how systems could support them (macro). Data analysed using Van Manen’s six steps and quasi‐foundational boundary principles determined (i.e. beliefs about what MD is and what causes it). Data analysed individually and collectively to uncover both shared and recalcitrant experiences.
3 Reflexive balancing: identification of boundary principles (from 2a), followed by systematically challenging those principles by actively searching for disconfirming data. If disconfirming data is found, the new boundary principle must be coherent with the others to be justified.	3Hypothesis definition of MD derived from systematic review used as a starting point (boundary principle 1), and developed to make coherent with empirically identified beliefs about MD (boundary principles 2). This hypothesis account of MD was then exposed to systemic challenge from our commitment to ‘core feminism’ and other disconfirming/recalcitrant data, data from previous studies and theoretical literature. The data and theory that survives systematic challenges is used to form a coherent account of MD in UK nursing and how we ought to respond to it.

^*Steps required for RBL is taken from Ives, op. cit. note 10.‘Reflexive balancing’.