"Working within Broken Systems": A Qualitative Inquiry of Moral Injury Amongst Healthcare Social Workers Using Street-Level Bureaucracy

Background and Purpose: Healthcare social workers (HSWs) in the United States are integral to interdisciplinary teams and health services. HSWs, using their social work training, implement case management and clinical skills directly with patients and families. HSWs have a unique role in healthcare, as they care for their patients' psychosocial needs. There is a gap in understanding how HSWs are impacted by their healthcare work. Moral injury is a transgression, by oneself or someone in a position of power, in a high stakes situation, and the negative outcomes of those experiences. Specifically, this study contextualizes the experience of HSWs using street-level bureaucracy, highlighting the complex, community-serving, powerful impact their roles can have. This study aims to understand the experience of moral injury, a marker of well-being, amongst HSWs in one state in the United States.

Methodology: Qualitatively, using a phenomenological approach, semi-structured interviews were conducted in a Mountain West state at an academic hospital and federally qualified health center. Participants were recruited using convenience sampling, through presentations and email recruitment methods. The interviews were conducted by the principal investigator, who asked about moral injury, values, ethics, and additional well-being questions. Thematic analysis, with three coders, was used to understand the lived experience of moral injury for HSWs.

Results: In all, 24 participants engaged in interviews which lasted about 80 minutes each. Three primary themes resulted from this work. Theme one: HSWs’ experiences of moral injury, HSWs described moral injury as an experience that left a “yuck feeling”, made them feel “powerless”, “helpless”, and “not enough”. Theme two: HSWs are situated in the “in-between” of policy and practice. HSWs described themselves as the bridges between policy and practice, and they described this role as vulnerable, impossible, and stressful; therefore, causing risk for moral injury. Last, theme three: Upholding social work values within the medical model. HSWs shared that they often felt that they could not personally uphold or the medical system where they worked did not uphold social work values of social justice, dignity and worth of the person, and advocacy. Overall, HSWs described that they were experiencing moral injury, and it was often rooted in systems-level fractures.

Conclusions and Implications: These findings impact social work practice and policy, in delineating what falls within the bounds of social work, changing the workflow of health services, and creating further opportunities for interdisciplinary training, well-being initiatives, and systems-level changes. The findings from this work highlight the importance of understanding the moral impact of healthcare work on social workers. The future of social work hinges on the ability to integrate and retain a healthy social work workforce. The healthcare system is often a model for systems practices in general; therefore, supporting HSWs well-being is critical to shaping the future of the entire social work workforce.