Theory Building Using Qualitative System Dynamics: The Vicious Cycle of Moral Distress in Child Welfare Casework

Background and Purpose

Child welfare (CW) caseworkers frequently act in ways that are inconsistent with their values due to constraints in their work environments, resulting in feelings of guilt, anxiety, and self-blame--referred to as moral distress. The conceptual basis for moral distress was developed in the nursing context, leaving a theoretical gap in how this phenomenon plays out in CW work. This study aimed to clarify the conceptualization of moral distress in CW casework by developing a dynamic theory that explains how levels of moral distress build and decrease over time. Specifically, we sought to: 1) determine what values caseworkers hold, 2) identify the conditions and experiences that violate these values and cause moral distress, 3) determine how factors in the CW context interrelate through feedback to cause the growth and decline of moral distress over time, and 4) illustrate the theory as a causal loop diagram (CLD), or systems map.

Methods

Data came from 25 caseworker focus groups (n=192 participants) conducted in 2019 as part of a multisite public CW workforce improvement project. Data were analyzed using Kim and Andersen’s (2012) method for creating system dynamics model from text data. Inductive coding was used to break text into smaller segments, categorize them by theme, and assign each a code. The data segments were then further analyzed to identify causal structures composed of two variables. The structures were transformed into links indicated by an arrow between variables with a polarity indicating the direction of the relationship. The links were then connected according to common variables and reassembled into the CLD.

Results

Although caseworkers strongly valued helping children and families, they reported that work constraints often prevented them from providing needed services, which violated their values. These violations led to common and widespread moral distress, depicted as a stock that accumulates according to the rate values are violated. The rate was directly impacted by time constraints, which prevented caseworkers from helping clients and from properly caring for their own children. Participants reported using coping strategies (“checking out” and quitting) to reduce moral distress, forming balancing feedback loops. However, both strategies had the unintended consequence of perpetuating moral distress. Several reinforcing loops operating as vicious cycles also emerged. Not only did these feedback loops reinforce the growth of moral distress, they also reinforced turnover, workload, burnout, and time constraints.

Conclusions

This study’s dynamic theory provides a framework that illustrates the stock (accumulation) and flow (release) of moral distress in CW caseworkers and sheds light on the psychological distress and conflict experienced in this profession. System constraints appear to be cyclical and interconnected in nature, suggesting multi-directionality rather than linear relationships between constraining conditions and moral distress. More research is needed to develop interventions that slow the growth of moral distress and speed its release, thereby breaking vicious morally distressing cycles. Additionally, approaches that help caseworkers incorporate alternative coping strategies and build moral efficacy, courage, and resilience could help alleviate the impact of moral distress.