"Do No Harm Can Get a Little Muddy": Social Workers' Experiences with Moral Distress

According to Jameton (1984), moral distress develops “when one knows the right thing to do, but institutional constraints make it nearly impossible to pursue the right course of action” (p. 6.). Research on moral distress has largely focused on this phenomenon among medical professionals (Jameton, 1984; Pauly et al., 2012;) however, scholarship examining moral distress in other disciplines such as social work is burgeoning (Epstein et al., 2019; Jameton, 1984; Pauly et al., 2012). This study was guided by two primary research questions: (1) What contributes to the development of moral distress among social workers? (2) What protects social workers from moral distress?

This study was grounded in phenomenology (Clarke & Braun, 2021; Crotty, 2015) and focused on understanding social workers’ experiences with moral distress. Qualitative data were collected via semi-structured interviews with 13 social workers. Participants were working in diverse professional contexts (e.g., child welfare, gerontology, mental health) and job roles including direct practice (n=6), supervising or educating social workers (n=3), and leading organizations (n=4). Participants included eight women and five men who identified their race as Black (n=2), Multiracial (n=1), Latinx (n=2), and White (n=8). The interviews were transcribed verbatim and were uploaded to Dedoose, a qualitative analysis program. Utilizing reflexive thematic analysis (Clarke & Braun, 2021), the study team engaged in several steps to code transcripts and develop themes. Rigor was enhanced through multiple read-throughs of the transcripts before coding, an iterative approach to code and theme development, reflexive memoing throughout the analysis, and maintaining a detailed audit trail.

This study generated three themes related to the guiding research questions. First, individual values, behaviors, and identities shape how social workers experience moral distress. At the individual level, participants named several factors (e.g., personal values aligning with organizational values; professional autonomy; and individual integrity) that seemed to buffer them from the deleterious effects of moral distress. Additionally, participants identified some characteristics that may increase their risk of moral distress. For example, participants identified that early career social workers and those with marginalized identities are disparately morally harmed in social work settings. Second, organizational contexts are bellwethers for moral distress. Participants described how organizational behaviors shape social workers’ experiences of moral distress, naming the importance of factors such as organizational climate, supervision, and colleague support in either amplifying or reducing moral distress. Third, harmful structural priorities and cultural norms breed moral distress in social work settings. Notably, participants described broader contextual factors and norms such as bureaucracy and fast capitalism (Agger, 2015) as foundational to how social workers experience moral distress.

This study offers an initial understanding of factors that may contribute to and protect social workers from moral distress. Importantly, results suggest a need for improved policies and practices to reduce the effects of moral distress among social workers. While participants identified multi-level factors contributing to moral distress, policies and practices addressing moral injury are needed primarily at organizational and structural levels.