Recentering Moral Distress for Social Work Research: A Qualitative Investigation

Background and Purpose: Moral distress (MD) is generally defined as the psychological disequilibrium that arises when institutional constraints obligate an individual to carry out a task that violates their professional and/or personal ethics and values. Standardized tools to measure the frequency and severity of MD are created using this definition, supported by perspectives from nurses, physicians, and medical residents. However, the pandemic has demonstrated that healthcare social workers (HSWs) across fields of practice are also experiencing MD, seen through increased rates of burnout, fatigue, quiet quitting, and seeking new employment opportunities. Yet, there is limited empirical work on HSWs’ MD and whether the definition that has arisen in other professions and generally accepted across disciplines reflects HSWs’ lived experiences. A conceptualization of MD in HSW can assist in the implementation of relevant standardized tools of measure to accurately capture MD and inform interventions to ameliorate the negative sequala that arises.

Methods: This presentation will report qualitative findings from virtual semi-structured interviews (60-90 min) with HSWs across Texas prior to and during the pandemic. Interview questions asked participants to define MD and to draw on cases or encounters that they perceived as triggering MD. All interviews were audio-recorded and transcribed verbatim; all identifying information was redacted to protect participant confidentiality. Supported by conventional content analysis, the research team conducted an initial reading of all transcripts. Transcripts were then divided across the research team to identify emerging patterns that arose from the raw data. The research team met to reach consensus on final themes and resolve any disagreements.

Results: Three major themes arose from participant narratives. MD was defined as: 1) internalized moral conflict that arise from professional/personal values and ethics; 2) occupational challenges, such as disagreement with various organizational policies and practices; and 3) emotional burnout, fatigue, and self-doubt. Although many participants identified MD as a source of moral conflict and violation of one’s own values, participants also seemed to confuse MD with experiences of burnout, compassion fatigue, vicarious trauma, and psychological distress. Occupational challenges that did not comprise an ethical dilemma were also identified, showing that HSWs do not necessarily equate MD with ethical conflict but rather see this as reflective of general occupational hurdles. Findings suggest that there is a lack of universality regarding MD experiences and that HSWs use their own unique professional identities and experiences and organizational positionality to define how they perceive MD, perhaps showing discrepancy from other healthcare disciplines.

Conclusions and Implications: Research implications suggest an opportunity to create mechanisms to examine and assess MD in the context of HSW using new and innovative measures that do not stem directly from nursing or medicine. HSWs who are surveyed using standardized MD tools may not be responding accurately to questions given their diverse perspectives of MD, questioning the validity of prior findings that compare HSW with nursing. Scholarship ought to recenter MD definitions to integrate HSW experiences to support expanded empirical research that examines MD among HSWs to promote professional resilience and well-being.