i

HOW HEALTHCARE SOCIAL WORKERS CREATE
MEANING FROM THEIR EXPERIENCES
WITH MORAL DISTRESS

By
Hali Miller
Bachelor of Social Work, University College of the Fraser Valley, 2000
MAJOR PAPER SUBMITTED IN PARTIAL FULFILLMENT OF THE
REQUIREMENTS FOR THE DEGREE OF
MASTER OF SOCIAL WORK
In the School of Social Work and Human Services
© Hali Miller 2015

UNIVERSITY OF THE FRASER VALLEY
Spring 2015

All rights reserved. This work may not be reproduced in whole or in part, by photocopy or other means, without
permission of the author.

ii

Name:

Hali Miller

Degree:

Master of Social Work

Title of thesis:

How healthcare social workers create meaning from their
experiences with moral distress.

Examining Committee:
Glen Paddock, BSW, MSW, PhD, LMFT
Chair
Faculty, School of Social Work and Human Services

Leah Douglas, BSW, MSW, PhD, RSW
Senior Supervisor
Faculty, School of Social Work and Human Services

Margaret Coombes, BA, BSW, MSW, PhD, LMSW
2nd Supervisor
Faculty, School of Social Work and Human Services

Date Approved:

March 10th, 2016

iii

University of the Fraser Valley Declaration of Partial Copyright License
The author, whose copyright is declared on the title page of this work, has granted
to the University of the Fraser Valley the right to lend this major paper or project,
or graduate thesis to users of the University of the Fraser Valley Library, and to
make partial or single copies only for such users or in response to a request from
the library of any other university, or other educational institution, on its own
behalf or for one of its users.
The author has further granted permission to the University of the Fraser Valley to
keep or make a digital copy for use in its circulating collection, and, without
changing the content, to translate the major paper or project, or graduate thesis, if
technically possible, to any medium or format for the purpose or preservation of
the digital work.
The author has further agreed that permission for multiple copying of this work for
scholarly purposes may be granted by either the author or the Associate Vice‐
President, Research, Engagement and Graduate Studies.
It is understood that copying or publication of this work for financial gain shall not
be allowed without the author’s written permission.
Permission for public performance, or limited permission for private scholarly use,
of any multimedia materials forming part of this work, may have been granted by
the author. This information may be found on the separately catalogued
multimedia material and in the signed Partial Copyright License.
The original Partial Copyright License attesting to these terms, and signed by this
author, may be found at the University of the Fraser Valley Library.

University of the Fraser Valley Abbotsford, B.C.

iv

The author, whose copyright is declared on the title page of this work, has granted
to the University of the Fraser Valley the right to lend this major paper, thesis,
project or extended essay to users of the University of the Fraser Valley Library,
and to make partial or single copies only for such users or in response to a request
from the library of any other university, or other educational institution, on its own
behalf or for one of its users.
The author has further granted permission to the University of the Fraser Valley to
keep or make a digital copy for use in its circulating collection, and, without
changing the content, to translate the major paper/thesis/project or extended essay,
if technically possible, to any medium or format for the purpose or preservation of
the digital work.
The author has further agreed that permission for multiple copying of this work for
scholarly purposes may be granted by either the author or the Associate Vice‐
President, Research and Graduate Studies.
It is understood that copying or publication of this work for financial gain shall not
be allowed without the author’s written permission.
Permission for public performance, or limited permission for private scholarly use,
of any multimedia materials forming part of this work, may have been granted by
the author. This information may be found on the separately catalogued
multimedia material and in the signed Partial Copyright License.
The original Partial Copyright License attesting to these terms, and signed by this
author, may be found in the original bound copy of this work, retained by the
University of the Fraser Valley Heritage Collection.

University of the Fraser Valley Abbotsford, B.C.

v
Abstract

Social workers employed in healthcare are often present for clients during times of heightened
stress and emotion. They are called upon to diffuse tensions that frequently exist between
competing interests that involve clients, colleagues, external resources, and agency interests.
Moral distress arises when value conflicts exist, and create implications to the social worker or
client. In pursuit of core values that honor social justice, social workers in healthcare are often
caught within conflicts as they pursue advocacy for marginalized clients. Using an ethics of care
perspective within a feminist framework, this study uses a cross-sectional exploratory design to
examine the ways in which social workers in healthcare make meaning from their experiences
with moral distress. Eight social workers employed with the Fraser Health Authority were
interviewed and offered their experiences with moral distress within a healthcare setting. They
revealed their perspectives on the origins and outcomes of their moral distress, means of resolve
and the transformations that have occurred. Implications for practice and possibilities for future
research are discussed.

vi

Acknowledgement

My deepest thanks to the social workers who participated in this project and
shared their time, experiences and insights. Each of you is a credit to this
profession and without your participation, this research would not have been
possible. I want to acknowledge the faculty at the University of the Fraser Valley
who reminded me of my purpose as a practitioner and guided me in this journey.
In particular, my thanks to Dr. Leah Douglas who cultivated a learning
environment that was challenging and enriching. Your accessibility, your ability to
recognize my study interests and simplify the research process is a testament to
your skills as an instructor.

vii

Dedication

The ability for people to endure exceptional adversity is what inspires my journey
for continued learning and social work practice. During my career, I have come to
recognize that within the course of an average day, many of my fellow social
workers experience adversity in the form of moral distress. This research has
enriched my regard for these dedicated professionals.
I want to acknowledge my parents, who nurtured the confidence I needed to pursue
higher education. To my husband Norm, who offered unwavering support,
encouragement, and laughter when needed. To my children, Kayla, Daniel and
Denise, who center me, and remind me of what is important in my life…I thank
you.

viii

TABLE OF CONTENTS
Abstract…………………………………………………………………………v
Acknowledgement……………………………………………………………..vi
Dedication……………………………………………………………………..vii
Introduction.……………………………………………………………………1
Literature Review……………………………………………………………..3
What is the issue?.....................................................................................3
Features of moral distress........................................................................5
Outcomes of moral distress......................................................................6
Contributing factors.................................................................................7
Suggestions to reduce moral distress.....................................................11
Gaps in literature....................................................................................13
Theoretical Framework……………………………………………………..16
Design and Methodology.................................................................................20
Type of research design….......................................................................20
Recruitment…..........................................................................................21
Sample…..................................................................................................22
Data collection........................................................................................23
Ethical considerations.............................................................................24
Findings…………………………………………………………………….25
Value conflicts that create moral distress…........................................25
Fairness and justice............................................................................25
Autonomy..............................................................................................30

ix

Outcomes of moral distress…...............................................................32
Support with the moral burden.............................................................34
Creating meaning.…............................................................................36
Limitations to research.........................................................................41
Discussion and implications for practice…………………………………42
Conclusion.....................................................................................................46
References………………………………………………………………….48
Appendix A....................................................................................................54
Appendix B………………………………………………………………….55
Appendix C………………………………………………………………….56
Appendix D.…………………………………………………………………58
Appendix E.…………………………………………………………………63

1
Introduction
Little is known about the subject of moral distress as it applies to social workers in
healthcare, and even less is understood about the approaches used to heal or make meaning from
these experiences. Social workers in healthcare are engaged with clients during periods of
heightened stress and emotion. Moral distress can manifest when practitioners are obligated to
perform work duties that are in conflict with personal values based on external factors including
policy expectations, organizational pressures, and client expectations. In their role as advocates,
social workers frequently interface with opposing opinions and are called to diffuse the tensions
that exist, at times, at a compromise to their own values. It is expected that practitioners will
experience value conflicts during the course of their careers. “Through research and anecdotal
reports, moral distress is a reality of clinical practice” (Rushton, Kaszniak, & Halifax, 2013, p.
1074).
Moral distress was originally defined approximately thirty years ago by nursing ethicist,
Andrew Jameton (1984) who described it as a state of conflict between knowing the right thing
to do but being restrained by organizational structures (p.6). Moral distress has been researched
from a narrow lens, primarily with studies aimed at nursing. Thus, it has a limited application to
social work because of the variance in core competencies, job requirements and political
perspectives. There is a need to examine moral distress within the local landscape in order to
account for unique features that may arise within the regional political climate.
The presence of moral distress can influence a professional’s sense of well-being and job
performance. Research has shown moral distress can have short and long term consequences and
create implications on the delivery of patient care, retention and job satisfaction (Pauly, Varcoe,
& Storch, 2012, p.1). Complex care situations within a stressful work environment are shown to

2
contribute to moral distress among healthcare professionals, and the current political climate
requires that healthcare social workers respond to increasingly complex situations with fewer
resources. At times, it may seem the worker is focused more on the agency objectives versus the
client who is in receipt of care. Social workers follow a professional code of ethics, which may
conflict with opposing forces when a lack of understanding about ethical frameworks exists.
Compassion for others contributed to my fit with the social work profession but overriding this
was my instinct for fairness and justice. At times, it is challenging to work in a way that honours
both values.

There is value in learning more about moral distress in order to mitigate consequences
that may extend to the practitioner, organization and recipients of care. The burden of care is
linked with moral distress. “All too often, providers feel completely responsible for whether a
client succeeds or fails, lives or dies, and they can become emotionally overwhelmed by this
heavy burden” (Teixeira, Ribeiro, Fonesca, Cervalho, 2014, p. 98). Compromising care to
clients, avoidance of certain situations, anxiety and depression, and withdrawal from practice are
unfortunate outcomes of moral distress and may lead to employee turnover and burnout. It is
important to learn more about the strategies employed for resolving value conflict and whether
positive outcomes can formulate from experiences with moral distress. If managed effectively
with individual and organizational structures, moral distress “can be an opportunity for
transformation and growth” (Hanna, 2004; as cited in Pauly et al., 2012, p. 4). My interest in the
topic of moral distress has evolved from my experiences as a social worker in healthcare over
fifteen years. Circumstances abound that involved conflict between professional values and job
expectations and I was curious about the immediate and cumulative effect of these experiences
for social workers in healthcare. I have witnessed the erosion of caring responses among

3
colleagues and their clients and this led me to research the possibilities to interrupt the frequency
and intensity of moral distress. The intent of this study is that it may inform opportunities for
support and education for healthcare social workers, leading to professional growth and
retention. These outcomes may then improve the delivery of care within healthcare and the
experiences for social workers and consumers.

Literature Review

What is the Issue?

Moral distress was originally defined in the 1980s with significant information about the
outcomes and contributing factors becoming more available during the past five to ten years.
This allows for reflection of current social and political influences. Performing mainstream
social work within the current conservative climate was a theme that did arise in the research.
Social workers often tend to task-oriented work and avoid an advocacy role. Social workers
frequently resist taking a stand against the social injustices that present for clients (Musil,
Kubalı ́kova, Hubı ́kova ́, and Neasova ́, 2004, Papadaki & Papadaki, 2008; Stanford, 2010; as
cited in Fine & Teram, 2013). Clarity surrounding the rationale behind these practices may offer
relevant insight regarding the prevalence of moral distress for healthcare social workers

Within the published literature, there is limited material on the subject of moral distress
within a healthcare setting. To date, what is available is primarily tailored to nursing practice but
there has been evolving recognition towards the impact moral distress will have for a broader
base of healthcare providers. “Through research and anecdotal reports, moral distress is a reality
of clinical practice” (Rushton, Kaszniak, & Halifax, 2013, p. 1074). Complex care situations

4
within a stressful work environment are shown to contribute to moral distress among healthcare
professionals. Research has shown moral distress can have short and long term consequences and
create implications on the delivery of patient care, retention and job satisfaction (Pauly, Varcoe,
& Storch, 2012, p.1). The presence of moral distress can influence a professional’s sense of wellbeing and job performance. Patient care may also be affected in situations where the social
worker cannot do what they believe to be right due to lack of confidence, level of training or
limited resources (Grady, Danis, Soeken, O’Donnell, Taylor, Farrar, & Ulrich; 2008, p. 7). Neoliberalism is instrumental in the distribution of resources in society and has influenced a decline
in social welfare programs (Raphael, 2011, p. 354). The current political climate requires
healthcare social workers respond to increasingly complex situations with fewer resources.
Social workers follow a professional code of ethics, which may come into conflict with
organizational constraints (BC College of Social Workers, 2009). As a result of these factors,
ethical dilemmas may occur. The lack of understanding about ethical dilemmas within
multidisciplinary teams frequently places social work at the center of controversy. Ethics are
frequently discussed in relation to moral distress, though information related to the interactions
between ethics education, ethical practice and moral distress for healthcare social workers is
inconsistent and sparse.

Research on moral distress has been primarily tailored towards nursing, however, there is
growing interest on the topic as it relates to healthcare social workers. A healthy working
environment is suggested for fostering safe, competent, and ethical care (Pauly et al., 2012, p. 7).
It is important to learn more about the strategies employed for resolving moral conflict and
whether positive outcomes can formulate from experiences with moral distress. If managed

5
effectively with individual and organizational structures, moral distress “can be an opportunity
for transformation and growth” (Hanna, 2004; as cited in Pauly et al., 2012, p. 4).

Features of Moral Distress

Moral distress can manifest when practitioners are obligated to perform work duties that
are in conflict with personal values based on external factors, including policy expectations or
organizational pressures. “Moral distress is often described as psychological disequilibrium
associated with knowing the morally right course of action to take in a situation but failing to
follow through with that action because of institutional constraints” (Bell & Breslin, 2008, p. 94).
“The feeling of discomfort arising from the conflict between professional values and job tasks is
referred to as professional dissonance” (Taylor, 2005, p. 89). Kalvemark, Hoglund, Hannsson,
Westerholm, and Arnetz (2004) define moral distress as a symptom of stress, which arises when
“the health providers feel she/he is not able to preserve all the interests and values at stake”
(p.1082).
Values that define what is important to an individual are frequently discussed in research
and act as a contributing force to sources of conflict. A value is held dearly and is informed by
environmental factors that can affect one’s attitudes, behaviours and task performance (Horne,
2014, p. 52). It is critical to be self-aware of values in order to know your fit with a job, a client
group, and agency because positive alignment of personal and organizational values can foster
job satisfaction.

6
Outcomes of Moral Distress

All professionals working in healthcare can experience moral distress (Bell & Breslin,
2008, p. 95). Among social workers, moral distress has been correlated with a sense of
powerlessness and feeling undermined by others (Openshaw, 2011, p. 4). Moral distress may
manifest into “feelings of anger, frustration, guilt, depression, nightmares, anxiety, helplessness,
powerlessness, compromised integrity, dread and anguish” (Bell & Breslin, 2008, p. 95). Moral
distress can also weaken the social worker’s ability to offer empathy and compassion to the
client. The burden of care is linked with moral distress. “All too often, providers feel completely
responsible for whether a client succeeds or fails, lives or dies, and they can become emotionally
overwhelmed by this heavy burden” (Teixeira, Ribeiro, Fonesca, Cervalho, 2014, p. 98).
Compromising care to clients, avoidance of certain situations, anxiety and depression, and
withdrawal from practice are unfortunate outcomes of moral distress and may lead to employee
turnover and burnout. Symptoms of burnout include depersonalization, emotional exhaustion and
overall dissatisfaction with work and with one’s personal life. According to a literature review
completed by Epp (2011), there is no standard definition of burnout, however, common features
include emotional exhaustion or detachment, or lack of job satisfaction (p. 25). Feeling
ineffective and lacking a sense of accomplishment is linked to burnout and can be compounded
when there is a lack of support from supervisors (Epp, 2011, p. 28).
Research indicates that a high percentage of nurses leave the profession due to moral
distress (Bell & Breslin, 2008). Shared features in burnout and moral distress include the
presence of ethical dilemmas, feelings of powerlessness, power imbalances within the work
environment, workload issues, perception of inadequate care and communication styles
(Dalmolin, Lunardi, Lunardi, Barlem, & de Silverman 2014, p. 36). Results from the study by

7
Dalmolin et al. (2014), revealed a low level correlation in the association of moral distress and
burnout between most groupings explored. However, there was a relation between the two where
futile medical interventions were the focus. While there were intersecting features between
burnout and moral distress, there was limited evidence to support a strong correlation outside of
issues involving lifesaving treatment.
Contributing Factors
There is an increased risk of burnout among healthcare workers if they perceive
incongruence between agency policy, professional values and ethical standards. “When a
situation arises that contains moral reasons both for and against a certain action, and that
challenges one’s ethical beliefs, the result is an ethical dilemma” (Davis, Schrader, & Belcher,
2012, p. 738). “Moral distress is specifically associated with ethical dimensions of practice and
concerns related to difficulties navigating practice while upholding professional values,
responsibilities and duties” (Epstein & Hamric, 2009; Hardingham, 2004; Kalvemark, Höglund,
Hansson, Westerholm, & Arnetz, 2004; Kalvemark Sporrong, Hoglund, Hansson, & Arnetz,
2006; as cited in Pauly et al., 2012, p. 2). Ethicist, Jameton, distinguishes ethical dilemmas and
moral distress by suggesting that the ethical dilemma is identified but not yet resolved whereas
moral distress arises when the worker defies the right course of action as a result of institutional
restraints (Jameton, 1984; as cited in Pauly et al., 2012, p. 3). “Staff burnout and emotional
exhaustion are a common response to ethical problems in providing patient care services” (Bell
& Breslin, 2008, p. 95).
Professional ethical standards influence the response to a situation. The Social Work
Code of Ethics suggests that practitioners promote fairness and the equitable distribution of
resources and act in a way to reduce barriers and expand choices for all persons (Canadian

8
Association of Social Workers, 2005, p. 5; as cited in Fine & Teram, 2013, p. 1313). Where
ethical differences exist, it is important to engage in conflict resolution to reduce the perceived
value incongruence and prevent burnout that may be fostered through competing values (Gabel,
2011, p. 424). It is illogical to suggest social workers stand up to every injustice that may be
produced out of policy, but a better framework for ethical practice may be valuable to reducing
the incidence of moral distress (Fine & Teram, 2013). Facilitating, maintaining and promoting
ethical practice require agency commitment. “A 2007 study that included nurses and social
workers, found that half of 1215 respondents felt frustration and fatigue when they could not
resolve ethical questions” (Bell & Breslin, 2008, p. 95). Recognizing an ethical conflict but
feeling unqualified to respond or taking no action increases the susceptibility to moral distress
(Grady, Danis, Soeken, O'Donnell, Taylor, Farrar, & Ulrich, 2008, p. 6). There is a lack of
consensus about the content and delivery of ethics training for health providers but in one study
by Grady et al. (2008), it was identified that social workers have more education overall, more
ethics training and use ethics resources more often than their nursing colleagues (p. 7).
Moral distress is influenced by the political climate and allocation of resources. The
current social-political climate does not favor social work clients and has created a growing
emphasis on the marketplace and personal autonomy, thus reducing its responsibility for
establishing and maintaining equity for those who need it most. Neo-liberal ideals emphasis on
self-sufficiency combined with a residual government state has resulted in shifts to resource
allocation (Raphael, 2011). The distribution of resources influences a social worker’s ability to
link clients to supports that could improve quality of life. Healthcare social workers often work
with marginalized population groups who do not have reasonable access to resources. Research
participants have identified feelings of helplessness and powerlessness when interfaced with the

9
political climate (Pauly et al., 2012, p. 7) while workload constraints interfere with the resolution
of moral distress.
Social work is involved at the micro and macro levels of practice. Social workers may
operate in direct practice assisting individuals in need of immediate service while social reform
and social justice are addressed at a macro level (Bransford, 2011, p. 933). Ferguson and Layette
suggest there has been a shift within social work that favors the needs of the marketplace above
the needs of the public (2006). Critical consciousness encourages social work to link private
troubles and public issues, but agency priorities often conflict with this practice. Social work in
healthcare has taken an increasing responsibility towards managing resources and mitigating
risks to clients, leading to an increase on administrative tasks and less time for client-centered
engagement and building rapport (Oliver, 2013, p. 211). The limited research available related to
moral distress and social workers suggests workers “choose not to address injustices in their
places of work” (Musil, Kubalı ́kova, Hubı ́kova ́, and Neasova ́, 2004, Papadaki & Papadaki,
2008; as cited in Fine & Teram, 2013, p. 1314) and because of a neo-liberal ideology, many
social workers have “adopted a more defensive and morally timid position in response to the
pervasive and insidious political and moral conservatism of neo-liberal risk society” (Stanford,
2010, p. 1067).
Life and death decisions are frequently related to ethical dilemmas and contribute to
moral distress amongst healthcare workers. Research has found that intensive care nurses are
vulnerable to moral distress because they are often powerless to make decisions, and instead are
required to execute physician orders (Epp, 2012, p. 26). Moral distress is frequently present in
situations where families want to continue life-sustaining treatments deemed futile. Information
is lacking in reference to how moral distress translates to other professions outside of nursing

10
(Oliver, 2013). Research that utilized the participation of nurses, social workers, respiratory
therapists and doctors revealed that the triggers to moral distress varied between disciplines. In
one study that reviewed the causes of moral distress among physicians and nurses, a high
incidence of moral distress associated with life-saving treatments was present, specifically in
situations related to prolonging life and subjecting patients to invasive treatment that were
deemed inappropriate (Allen, Judkins-Cohn, deValasco, Forgers, Lee, Clark, & Procunier, 2013,
p. 116). This same study by Allen et al. (2013), suggests that providing less than optimum care
was the primary trigger of moral distress for social workers while patient suffering due to poor
continuity of care ranked second and life-saving treatment issues was the third leading source of
moral distress (p. 116). Research is available which uncovers other contributing factors to moral
distress among multidisciplinary teams, including workload and time pressures that interfere
with patient care, changes in the health system including advanced policy and legal parameters,
and issues related to treatment decisions. Those organizational values and constraints that may be
contrary to professional values in healthcare include discharging patients too soon, lack of
information sharing between healthcare providers and clients, insufficient time allowances for
patients, and disregard or avoidance of less desirable patients (Gabel, 2011, p. 422).
Moral distress then, can be conceptualized as a by-product of the interaction between
internal and external forces (Pauly et al., 2009; Varcoe, Pauly, Webster, & Storch, 2012; Webster
& Baylis, 2000; as cited in Oliver, 2013, p. 206). An approach to practice is influenced by the
social worker’s individual values and its interface with client values as well as agency goals. The
combination does not always align and a person’s beliefs about right and wrong may at times
come into conflict with organizational expectations and philosophies. Some of those internal
constraints which have been correlated to moral distress include a fear of speaking up, being

11
perceived as imperfect, fear of conflict, socialization towards compliance, lack of courage, fear
of job loss and self-doubt (Oliver, 2013, p. 206).
A commitment to social work ethics may also contribute to moral distress. The social
work code of ethics endorses a set of values to guide practice but does not offer support to
practitioners when their values are in conflict with agency policy (Openshaw, 2011, p. 5). Over
the past ten years, there has been increasing attention to ethics and encouraging moral sensitivity
as part of student education (Oliver, 2013, p. 205). Education systems are promoting the concept
of moral sensitivity leading to heightened awareness of incongruent moral frameworks within
agency settings and feeling “unsupported in their moral burden” (Oliver, 2013, p. 211). From this
perspective, there is suggestion that moral sensitivity correlates with moral distress (Austin,
Rankel, Kagan, Bergum, & Lemermeyer, 2005; Lutzen, Blom, Ewalts-Kuist & Winch, 2010;
Lutzen, Dahlquist, Eriksson & Norberg, 2006; as cited in Oliver, 2013, p. 205).
Suggestions to Reduce Moral Distress
Management participation on the frontline and increased attunement on moral distress is
suggested (Epp, 2011, p. 29). The combined approach of frontline social workers and their
supervisors may influence the frequency and intensity of moral distress. When social workers
feel supported by their employer, there is less moral distress (Corley, Minick, Elswick, & Jacobs,
2005; Pauly et al., 2009; as cited in Oliver, 2013, p. 210). Supervision over the span of a career is
suggested as a potential strategy to prevent professional dissonance. Supervisors may stimulate
dissonant discussion by exploring anxieties and illuminating sources of the inner and outer
conflict (Taylor, 2007, p. 97). Encouraging practitioners to identify and process moral issues
may decrease the prevalence of employee turnover and promote collective solutions (Schluter,
Winch, Holzhauser, & Henderson, 2008).

12
There has been increasing attention towards problem solving through ethical dilemmas to
prevent distress. Research suggests that leaders have a responsibility for promoting ethical
climates, but available information does not convey the leadership role in addressing staff moral
distress (Bell & Breslin, 2008, p. 96). Many agencies do not promote a climate towards ethical
decision-making and little is known about the outcomes within those agencies that do.
Advocating for one’s values and beliefs and encouraging change within one’s agency are
suggested in literature. Noteworthy is that standing up against a system may come with a cost
and seem ineffective to enact change, and an agency’s climate can influence the courage it takes
to address policy. People may act based on the climate and the perceptions of others around them
(Openshaw, 2011, p. 8). “Acting with moral courage involves bringing the internal or external
constraints that are prohibiting appropriate action into the light so they can be recognized and
then dealt with appropriately” (Openshaw, 2011, p. 10). Promoting an ethical climate does not
necessarily address the presence of moral distress amongst care providers. The ethical climate
should be expanded to include “strategies to recognize and name the experience of moral
distress, critical stress, debriefings, ethic committees, grief counseling, and protocols for end of
life care” (Bell & Breslin, 2008, p. 96). Ethics education specifically designed to address moral
distress may be useful to reducing its prevalence particularly if provided within a climate that
promotes discussion about ethical dilemmas. Moral distress could arise throughout the span of
one’s career and therefore, information related to the ingredients surrounding the dilemma and
improving self-awareness is imperative to mitigating the risk. Through a process of education,
experience and reflexivity, social workers are able to formulate their “ethical selves” (Oliver,
2013, p. 213). One study found participants felt more confident to address ethical dilemmas after
receiving weekly sessions with supervisors who had ethics training (Bell & Breslin, 2008, p. 96).

13
Gaps in Research

Moral distress illuminates the complexities within social work practice and the conflicts
that exist, but further knowledge is required. Moral distress has been researched from a narrow
lens, primarily within the nursing profession. This restricted view is often directed towards lifesaving treatments within the intensive care units. In September, 2011, a search for the term,
moral distress, within academic databases for nursing produced approximately 550 hits while
two main social work databases, social work abstracts, and social service abstracts produced a
collective seven articles using the same term (Oliver, 2013, p. 204). Research has highlighted
negative outcomes of moral distress for nurses (Bell & Breslin, 2008; Dalmolin et al., 2014; Epp,
2011; Oliver, 2013; Texeira et al., 2014). Nurses provide physical care to their patients and
develop bonds that stem from intimate and frequent contact. The study that Epp (2011)
completed was done with nurses in Alberta, and was very focused on the stressors within nursing
practice including high acuity of patients, job responsibilities, advances in technology and caring
for families. With its application towards nursing, it is understood that moral distress is often
related to carrying out physician orders that involve invasive tests or treatments deemed to be
unethical. The hierarchy of nurses within the healthcare system may also have an influence on
their experiences with moral distress and may not be transferrable to other disciplines.
Quantitative studies have been used to measure moral distress using a moral distress scale,
primarily with nurses (Oliver, 2013 & Pauly et al., 2012). Qualitative studies directed at social
workers in health could offer distinctions in the experiences between them and their nursing
counterparts. A multidisciplinary approach was considered in a small amount of studies and
revealed shared psychological experiences of moral distress amongst professions. Grady et al.
(2008), considered a multidisciplinary approach in their research while Pauly et al. (2012)

14
focused on nursing, but acknowledged that other professions would also be impacted by moral
distress. Findings that are focused on nursing have a limited application to social work because
of the variance in core competencies, job requirements and political perspectives.

Moral distress and its consequences are well defined in literature but its application to
healthcare social workers is lacking. The concept of moral distress is extending beyond the
nursing profession to include other health providers including psychologists, pharmacists, and
doctors and its relevance to social work has only just begun (Weinberg, 2009; as cited in Oliver,
2013, p. 204). “There is a need to expand research on moral distress in disciplines other than
nursing and/or approach research on moral distress from an interdisciplinary perspective” (Pauly
et al., 2012, p. 6). Social workers are often the only member of an interdisciplinary team who can
speak to the social determinants of health but research has not identified the potential linkage
between this area of knowledge and the incidence of moral distress.

Most information on the subject of moral distress is from North America and the United
States of America in particular. International studies were available but avoided due to potential
disparities in concepts and structural influences. Information from Pauly et al., (2012) was
gathered from a forum presented in British Columbia, which considered information from an
international lens, but again, with a focus towards nursing. There is a need for more local
information in order to examine unique features of moral distress that may arise within the
regional political climate.

Most articles lacked information regarding gender and age. Participants from research by
Grady et al. (2008) were over 80% female and primarily Caucasian. Studies conducted by Fine
& Teram (2013) sampled fifty-one women and twenty men and 15% of participants identified

15
themselves as minorities. This would account for the higher representation of females working in
the social work profession. Differences in the experiences of moral distress between men and
women and race are not addressed.
Moral distress seems to be “understood differently in different studies” (Pauly et al.,
2012, p. 2). At times, the concept of moral distress and burnout were interchangeably used in the
literature. The interactions of ethics and moral distress were reported differently. Some
information presents ethical dilemmas and moral distress with similar definitions while other
information was distinctly different. Also, the importance for cultivating ethical climates is
clearly outlined but its effectiveness to reduce moral distress is again divided. Bell & Breslin
(2008) suggest a positive ethical climate does not address moral distress (p. 96) whereas Grady et
al. (2008) suggest ethics education is correlated with moral distress. “Not feeling qualified or
responding to an ethical conflict by feeling concerned but taking no further action makes one
susceptible to moral distress – distress resulting from a discrepancy between what one thinks
ought to be done and what is actually done” (Grady et al., 2008, p. 7). The existence of moral
distress among healthcare social workers has been established but the outcomes of effective
strategies to reduce the prevalence are needed. Attention toward positive outcomes forming from
moral distress and how this may influence job satisfaction and retention could be valuable. It
could be useful to explore whether the frequency or intensity of moral distress is influenced by
specific social work traits, practice situations or job experiences. Actual outcomes surrounding
the impact of supervisory support to reduce moral distress has been suggested but the outcomes
are unclear. A review of the supervisor’s role to reduce moral distress was divided and not
specific to social workers in healthcare. Bell & Breslin (2008) were not able to correlate
leadership’s role to reduce moral distress, however other studies could articulate some benefit

16
(Epp, 2011; Oliver, 2013; & Taylor, 2007). Peer supervision may also alleviate moral distress.
The importance of peers for resolving moral distress is noted in the studies (McAuliffe &
Sudbery, 2005; Pauly et al., 2012). However, limitations exist in the analyses by McAuliffe &
Sudbery (2005), which was completed in Australia within social services agencies using a small
number of participants.

Theoretical Framework

Social work practice is guided by theory and principles, unique to each clinician. For the
purpose of this research, moral distress among healthcare social workers will be discussed from
an ethics of care perspective. Ethics of care prescribes an emphasis on relationships and
highlights the need for care that every individual requires at various points within their life
(Held, 2006, p. 10). The ethics of care is rooted in feminist theory and provides a framework for
understanding that the basis of moral action is caring relations. The need for care is intrinsic.
Moral tendencies do not arise from a sense of duty but rather from a natural tendency for
reciprocal relationships. Feminist theory suggests ethical behavior stems from a sense of
compassion rather than obligation and stresses the importance of interactions and meanings
within relationships (Gray, 2010, p. 1804). Ethics of care is interested in the issues that manifest
from ability, class, gender and race (Meagher, 2004, p. 22). Social workers consistently advocate
for patients and families and frequently interface with opposing opinions, which can occur
interchangeably between clients and medical providers and/or between patients and their
families. It is the social workers role to identify and diffuse the tensions that may exist within
these systems, regardless of internal beliefs. Their interest in the person within the environment
offers a broad perspective of the individual’s psychosocial situation and the interplay with

17
presenting medical issues. The relationship between the client and therapist forms the foundation
for uncovering needs.
Social work aligns with feminist theories through their mutual interest in justice,
compassion, empowerment and emancipation of patriarchal oppressions. Feminist theories
consider oppressions that are perpetuated by patriarchal systems (Machold, Pervaiz, &
Farquahar, 2008, p. 670). Acts of caring within formal or informal systems is largely
unrecognized in society because women often perform in the capacity of care. An ethics of care
perspective describes social work as a caring occupation, devalued within patriarchal societies
(Payne, 2005, p. 255). Its reference as a soft profession with an emphasis on caring is even more
disregarded when positioned next to other healthcare professionals that demonstrate measurable
outcomes. In a quest for justice, social work is often perceived as the profession that creates
barriers against desired outcomes. Virginia Held is a contributor to ethics of care theory and
stresses her thoughts that justice should be secondary to care in the formation of a moral
framework (2006, p. 71-2). Justice and care should be considered together in order to foster a fair
and just society. “Justice says everyone is entitled to the same treatment but an ethics of care
may lead to differential treatment as it may dictate that some people are needier of care than
others based on situational and subjective judgments” (Gray, 2006, p. 1806). Healthcare is a
rationed service, which creates barriers to service access especially among vulnerable
individuals. Social workers are required to advocate and seek justice for marginalized individuals
with complex care needs within a system that does not necessarily endorse the cause.
The medical system can be daunting to consumers. The jargon, chaos, frequent
breakdowns in communication, and emotion can create significant distress for patients and their
families. Healthcare consumers are often vulnerable and may not be equipped to stand against

18
systemic barriers and unfair practice. Furthermore, the medical model frequently ignores the
specialized needs of marginalized individuals. “The political approach to the ethics of care
explores how the ethics of care can illuminate problems of power and difference in existing
social arrangements (including arrangements for the giving and receiving of care) and can help
overcome some of the characteristic problems and dilemmas of care that unequal power
engenders” (Meagher, 2004, p. 17). An ethic of care is interested in empowerment within a
framework of caring and recognition of unequal relationships (Machold et al., 2008, p. 673). The
theory considers the power that is manifested through social norms, laws and values. Important
in its application to moral distress, ethics of care acknowledges, “every aspect of practice takes
on a moral dimension as the ethical self negotiates with the wider environment” (Hugman, 2003,
as cited in Oliver, 2013, p. 209). Utilizing a concerned, fair-minded approach, social workers are
in a position to assist people to navigate the complex systems. However, moral distress can arise
when “health providers feel she/he is not able to preserve all the interests and values at stake”
(Kalvemark, Hannson, Westerhold, & Arnetz, 2004; p.1082). Moral distress is an outcome of
“competing values within power dynamics” (Varcoe, Pauly, Webster, & Storch, 2012, p. 51).
The political arena influences the interactions between client and agency. There are
macro-level influences in the formation of moral distress, which include economic factors and
resource allocation. Within a capitalist marketplace, there is value toward economic savings, and
workdays are often defined by rules versus client needs. The political climate has left social work
with less time for client-centered engagement in order to concentrate on gate-keeping resources,
managing client behaviours and mitigating risks (Oliver, 2013, p. 210). Neo-liberal Canadian
policies typically inform strategies that will reduce risks of ethical dilemmas and engage in topdown decision-making (Oliver, 2013, p. 205). Those social workers that are able to follow

19
procedure and detach from moral sensitivity are less susceptible to moral distress but may
compromise authentic, caring relationships with clients (Oliver, 2013, p. 208). Social service
work has a tendency to “undermine moral concepts, because of their contradictory nature: their
stated goal is to help clients, yet their actual operation serves the interest of preserving the
bureaucracy. When this conflict is not recognized, workers often function as if the bureaucratic
decisions do not have moral dimensions” (Rhodes, 1986, p. 134). Social work is sensitive to the
barriers that agency priorities create for clients. Neo-liberalism fosters oppression by enforcing
autonomy and individualism and disallowing structures to support people who are frail, sick, and
in greater need of care. “Unless society places value on caring for others, we will not care
whether their rights are respected or not, especially in the case of people who are too weak to
make serious trouble for us, as the history of domination, exploitation, and indifference makes
evident (Held, 2006, p. 89). Varcoe et al. suggest that the current socio-political climate, which
blames the individual for the health and social issues, also blames the health provider for their
own distress (2012, p. 51). Moral distress has become an increasing reality of the profession’s
discourse. The emotional issue has been defined as “the state experienced when moral choices
are thwarted by constraints” (Austin, Bergum, & Goldberg, 2003; as cited in Oliver, 2013, p.
204). Resource shortages can interfere with an ability to provide adequate care to patients, and
health providers are frequently asked to follow standardized formulas to address identified
issues. A focus on managerialism decreases the caring relationship (Meagher, 2004).
Professional codes of conduct may assist social workers to navigate the external conflicts that
may exist but this may not address internal value conflicts. The shortcomings of systematic
reasoning have led to increased interest in relational ethics approaches to address one’s sense of

20
moral responsibility (Oliver, 2013, p. 205). Ethics of care draws attention to the internal conflict
that can occur within conflicted or value-laden situations (Oliver, 2013, p. 204).
I am drawn to the ethics of care and its emphasis on caring relations and social justice.
These concepts align with social work values and also aide in the explanation of moral distress.
Moral distress would not exist in absence of caring practitioners who are invested in the
professional relationship and interested in preserving social justice. Individuals depend on social
workers to advocate for services on their behalf, to act as a liaison with medical providers and to
ensure their dignity and rights are preserved. However, the care and justice that is provided by
social workers in health continues to be devalued, especially for those people who are seen as a
burden to the system. The current socio-political system placed high regard on individualism and
autonomy and blames the victim for their circumstances. “If through the process of caring
systems, structures and institutions that oppress men and women are maintained and perpetuated,
it easily deteriorates into an ethics of suffering within is antithetical to feminist ethics” (Machold
et al., 2008, p. 671).
Design and Methodology
Research Design
The research question: How healthcare social workers create meaning from their
experiences with moral distress.
Type of Research Design
This was an exploratory study using qualitative methods, intended to offer a rich
understanding of the topic pertaining to healthcare social work. Qualitative research can promote
an understanding about the incidents of moral distress within a “larger social context” (Dudley,
2011, p. 26). Utilizing a design that was flexible was important for data collection in order to

21
explore meaning, context and provide opportunity for participants to expand on open-ended
interview questions. This was a cross-sectional study, collecting data at one point in time
(Dudley, 2011, p. 126). A level of measurement was used to capture data such as education level
and years of experience as a social worker. Moral distress was considered using a feminist lens.
According to Dudley (2011), feminist research typically wants to create benefits for participants
(p. 31). The intention from this research is to inform education and practice within the Fraser
Health Authority. The Fraser Health Authority is one of six health authorities in British
Columbia (BC) dependent on the Ministry of Health for funding and is registered as a charity
organization that represents health regions in BC, spanning from Burnaby to Hope.
Recruitment
Approval to conduct research was received from the Ethics Board at the University of the
Fraser Valley on March 11, 2015 (Appendix A) and from Fraser Health Authority on April 10,
2015 (Appendix B). As part of the ethics application, Fraser Health also required confirmation of
experience and qualifications to carry out this research. This was obtained from the principal
investigator’s manager, Jan Olsen. For the purpose of the study, a convenience sample was
obtained through invitation to social workers currently employed with the Fraser Health
Authority on a full time, part time or casual basis. The sample was solicited through email
request by the Regional Social Work Practice Leader, Terry Brock, on April 13, 2015. An
invitation explaining the research study, its purpose and criteria for participation was included
within the email (Appendix C). Fraser Health social workers, who self-identified as having
experienced moral distress, were invited to participate in the study. Interested participants were
asked to contact the principal investigator, ask questions and arrange for an interview at a time
and place that was convenient, outside of work hours. Thirteen social workers responded to the

22
invitation and received a consent form to review (Appendix D). Of those thirteen people who
expressed interest, one person cancelled prior to the interview, two were excluded because they
did not fit the employment and/or qualification criteria, and two others did not follow through to
schedule interviews. Eight social workers met the criteria and participated in the study.
Pseudonyms were assigned alphabetically in the order that contact was made with participants.
Sample
In-person interviews took place with eight healthcare social workers between April 25
and May 29, 2015. Semi-structured interviews offered the benefit to clarify questions and
introduce prompts for further exploration as new information arose. These interviews lasted
between forty-two to ninety-seven minutes, with an average of seventy-six minutes. Three
interviews took place on Fraser Health property, three were completed in public areas, and two
were conducted in someone’s home. All interviews were audio recorded and then later
transcribed by the principal investigator. Some notes were written to highlight salient points.
Demographic information was obtained at the beginning of the interview and participants were
invited to share information about their social location at their own discretion. Three people did
not disclose features of their social location. Among the other participants, one person identified
as South Asian, three identified as Caucasian, two people identified as heterosexual and one
person identified as middle class. One person stated having no fixed religion. Four participants
had a Bachelors degree in Social Work and four had a Masters Degree in Social Work. One
person was working in a casual position at the time of the interview, three were part time and
four were full time employees. Five participants worked in an outpatient services while three
worked in acute care. It should be noted that participants drew upon their experiences as
healthcare social workers within acute, chronic care and outpatient services and did not

23
necessarily refer to experiences within their current job positions. Seven participants were female
and one person was male. Their age range was as follows: two people were in the 51-60 year age
range; four people fit within the 41-50 year age range; two people in the 31-40 year age category.
Participants’ experience working as healthcare social workers ranged from 2.5 years to over 20
years. Five people had nine to twelve years of experience as healthcare social workers.
Data Collection
To ensure clarity of terms, moral distress was explained to participants in the consent
form and at the beginning of interviews. A series of open-ended questions were used as a guide
to collect data (Appendix E). Participants were invited to share their experiences with moral
distress at work. Moral distress was described as a conflict that arises when the worker’s values
and perceived obligations diverge with the work environment (Epstein & Delgado, 2010, p. 1).
The value conflicts may exist between worker and client or agency. Causation of distress was
explored including value conflicts involving client, policy and agency expectations.
Organizational influences that involved operational restraints, case complexities, and task
centered work that is prioritized above counseling and advocacy services were discussed.
Implications on job satisfaction and retention were addressed as well as motivating factors that
support or hinder the social worker’s ability to preserve his or her values. The participants were
asked about ethics training and their practice in seeking consultation when faced with moral
dilemmas. Important to the study was the participant’s perception of positive outcomes
secondary to their moral distress. How the social worker has created meaning and healed from
moral distress was a principal component to the study.

24
Ethical Considerations
Approval to conduct research was obtained from the ethics boards at Fraser Health
Authority and the University of the Fraser Valley. Participants were advised of my qualifications
and relationship with Fraser Health. A consent form explaining the nature and purpose of the
study was given to participants to sign. Each participant received a copy of the consent. The
study explored interactions with the organizations, and findings of the research will be made
available to Fraser Health. These results could foster negative perceptions on the profession.
Some participants expressed concern about sharing information about their experiences with
moral distress. Because findings will be shared with members of the organization, it was
imperative to reinforce the parameters of confidentiality with participants. Furthermore, the
option to withdraw from the study at any time was discussed prior to every interview and
participants were advised they could decline to answer any questions during the interview
process. Confidentiality was discussed within the recruitment letter and consent form. Some
participants expressed relief to hear that their own identity and the identity of the client groups
they referred to within their narrative would be protected.
The potential for a psychological impact was reviewed within the consent. It was
important to monitor the “effects of participation and extend support to participants when
needed” (Dudley, 2011, p. 42). Dialogue related to experiences of moral distress did prompt an
emotional response for some participants and interviews were paused when this occurred.
Participants were then reminded of the option to discontinue the interview or withdraw from the
study, but each interview continued. Counselling support through Fraser Health’s employee
assistance program and extended health services were discussed.

25
Findings

During this study, interviews revealed two major sources of moral distress that result
from issues of fairness and justice and preserving client autonomy. Throughout the interview
process, participants talked about strategies used to relieve distress as well as the factors that
hinder resolve. Outcomes of their moral distress were also reviewed. Central to the research
findings were the circumstances in which participants make meaning from their experience.
Research focused on what moral distress signifies to the participant’s practice; how did
participants process their experiences and move forward. There was interest afforded to the
purpose that participants could identify with these dilemmas, and whether these incidents
strengthened or changed the social worker’s approach to value conflicts.

Value Conflicts That Create Moral Distress

Obligations to perform work functions that directly conflict with personal and
professional values contribute to moral distress. These value conflicts often stem from external
issues that rest outside of the social worker’s control and may involve systemic influences.

Fairness and justice. As demonstrated in research and practice, social workers are
involved with marginalized people and act as advocates for individuals who are unable to
navigate complex health systems. As advocates for clients who are misunderstood or mistreated,
social workers often experience moral distress. Interviewees revealed that the injustices that
triggered distress was often linked to the availability and response of resources and services,
stigma, systemic issues, internal conflicts, role ambiguity and communication issues.

26
Resources and services. The challenge to link clients to resources was an identified
source of moral distress for all research participants. According to one participant, “it was the
lack of resources and not feeling like you can be helpful. And that’s why I went into this field, to
be helpful, not to be useless” (Participant A). Within health settings, social workers facilitate
transitions for clients, but the lack of appropriate resources poses barriers and creates moral
distress. “Home health could be more flexible….people who really need it (home health
services) but they don’t fit the criteria or the resource doesn’t exist or the resource is inflexible,
then that creates distress” (Participant F). According to participants, many gaps exist which
interfere with access to services including age restrictions or residential location. Services may
not adequately support the individual and there could be expectations that informal supports fill
the gaps that exist. A lack of resources and inequitable distribution of services impacts the
client’s quality of life. “I’m not able to provide all the resources I would like to my clients in
order for them to have the best quality of life that they need” (Participant C). Some respondents
thought services were lacking for those individuals who are less valued in society, such as the
aged and disabled.
“I’m not convinced that we’re using our resources in the best possible way. I think there
is room to open more continuing care beds and room to increase mental health support in
the community. And if that’s not happening, then should the patient be caught in the
middle? Its not their fault” (Participant H).

Discharges are a priority in acute care but limited community resources is a persistent
source of distress for social workers. “Where the moral distress comes in for me is where I’m
being asked to discharge someone and I don’t think its safe and there isn’t adequate resources to

27
support the person” (Participant H). Research respondents emphasized sentiments of respect and
understanding towards the constraints and mandates that other systems must follow. However,
moral distress may still be aroused if there is uncertainty about another agency’s commitment to
assume responsibility for the safety and care for a vulnerable individual “It’s a lack of faith in the
resources that are there” (Participant A).

Some patients or clients have strong advocates who can navigate the healthcare system
and are willing to engage in formal complaints. Research participants spoke of distress that
erupts when care is afforded to clients not provided to other equally deserving clients. Some
social worker participants have been inclined to withhold or buffer information about the
distribution of resources in order to protect the client. It is understood clients may not utilize
resources appropriately but the consequence if a social work intervenes by altering or
discontinuing services may cause clients to decompensate. Clients may develop an inability to
maintain their previous level of function, which could result in a hospital admission. Agency
expectations and policies can create significant consequences to clients who may be banned from
services due to minor infractions and was a noted source of distress for participants.

Stigma. Clients who have been stigmatized based on socioeconomic positioning or
specific afflictions were a noted source of distress for social work participants. Marginalized
individuals are frequently treated unfairly but may be unaware of their rights or may be without
the support to navigate complex systems. Interviews revealed that those individuals perceived as
making bad choices are inadvertently blamed for their situation and further marginalized by a
system that rations services. Examples that were identified in the study included people
struggling with obesity, mental health or addictions. Service availability for these groups is often

28
meager and difficult to access. One participant referred to the distress experienced when
residential addiction programs do not permit clients to receive prescribed medications. An
individual’s social location may also affect team perceptions. During interviews, participants
suggested that patients with similar medical issues would be treated differently based on
stigmatized issues. One participant referred to a situation where the patient struggled with drug
addiction. “If you remove the stigma of the lifestyle and gave the medical issues to another
patient, then I don’t think they (the healthcare team) would have looked at her the same way”
(Participant H).

Systemic issues. The health system must impose its mandate regarding the delivery of
services onto its clients and staff. Interviews revealed that philosophies can differ between
various levels management and the frontline worker. Workload impacted by bed utilization, large
caseloads, lack of resources, case complexities and task-oriented work are examples of external
conflicts that five of the social workers identified with. Due to persistent patient turnover,
compassionate care may be overshadowed by task-centered duties. “I’m being pulled away from
doing the things I need to do because I’m too busy doing the things I’m told to do” (Participant
D). One participant felt that workload demands led to rushed interventions with clients. Another
social worker felt enmeshed with agency priorities at a sacrifice to other important tasks. “It’s a
brainwash, its oppression and I have it” (Participant G). Distress can arise when workers are
required to interpret policies that will impose stress to clients. “You just want to quit, you want
to say forget it, you can’t work like this, with people that think like this” (Participant A). System
flow is a reality in healthcare. Facilitating transitions perceived to be unhelpful to clients or when
there is potential for harm can foster a sense of helplessness for workers. “Its an us/them

29
mentality. So you won’t have success there” (Participant B). Patient risk and suffering were
significant triggers of moral distress identified by some participants in this study.

Internal conflicts. Three participants acknowledged a lack of confidence and skills as an
influence on the experiences of moral distress. An internal conflict may surface when clients
experience a poor outcome and lead the worker to question their ability to have done more to
improve the situation. One participant spoke of a sense of responsibility towards good or bad
discharges (Participant F). Improving skills through education opportunities is at times hindered
by workload and financial matters and was a noted concern for two participants. Social workers
may not be allotted time off if coverage is not available and costs can be at the expense of the
individual.

Role ambiguity. Five participants identified role ambiguity as a source of moral distress.
The role of social work is often misunderstood and devalued by team members and leadership.
This compels staff to impose their own perceptions and expectations of the role onto the social
worker. “….you’re always being pulled in different directions and you have to prioritize the
organization’s values versus yours and sometimes that manager’s calling the shots and you might
bend to what they want” (Participant D). An advocacy role is often required to mediate patient
needs and organizational priorities, placing social work at the center of controversy. One
participant referred to “bullying tactics” that were frequently used to influence the social work
intervention (Participant C). A lack of appreciation or understanding of the role was an identified
barrier for clients to access social work services. Referrals may be missed if other team members
do not recognize or appreciate the social worker’s role. Furthermore, interviewees identified

30
value conflicts that arise when other team members disregard or oversimplify resolutions to the
social worker’s identified concerns.

Communication issues. Their expertise with communication creates a natural fit for
social workers to diffuse the tensions and conflicts that arise for clients. Communicating agency
policy, especially in relation to discharge planning can place social work in a position that
compromises rapport with clients and was a notable issue among five participants. “You’re made
to be the bad guy” (Participant F). Social workers become the perceived gatekeepers of resources
and often deliver difficult news to clients. Educating clients about services and resources can be
a positive interaction, but workers can become disillusioned if client expectations are unmet.
Participants reflected on examples when clients were misled about services and resources they
thought would be available after transitioning into a new area of care. The social worker is the
person who responds to misunderstandings and is asked to diffuse the conflict “I’m the deliverer
of bad news” (Participant D). Social work is based on caring relations and not until there is a
foundation of rapport and trust can social workers uncover client needs. Relying on social work
to convey difficult news directly impacts the professional relationship central to social work
practice. “So it stops us from being able to do the rest of our work” (Participant A). Respecting
the client’s rights to information and clearly articulating messages is highly valued for social
work but the lack of transparency about treatment plans and goals of care has encouraged
distress for some participants. Unwarranted stress for the client may arise “….we need to be
transparent with these families. I think it (information) is vague and I think it’s intentional in the
means that if they are vague, then they don’t have to be held accountable” (Participant G).

31
Autonomy. Preserving client autonomy was the second major theme identified as a
source of moral distress. Supporting client self-determination, avoiding dependency and
mitigating risks were notable sub-themes among respondents. Study participants reflected on
experiences when they were called upon to preserve individual interests while interfaced with the
broader system.

Self-determination. Social workers are frequently in the position where they are diffusing
tensions between family members and members of a care team, who may allow their own values
to infringe on the client’s right to make decisions or live at risk. Advance care planning and the
rights of family members to override a client’s previously held wishes for treatment can also
create conflict if family do not agree with the medical providers’ recommendations surrounding
goals of care. Family members who make decisions to consent to futile or invasive treatments
were a noted source of unease for a couple participants. In reference to an end of life situation,
one participant noted, “It was torture. Why would we do that to this poor woman” (Participant
D).
The system’s need to prioritize bed utilization may also influence the client experience.
Two participants reflected on concern when clients are placed in a care facility before their
baseline is established, leading to greater chance of unnecessary moves and disruption to the
client. Social workers may experience distress when alternate care programs must be considered
that could disrupt the client’s routine and stability. Moral distress can result when agency
caregivers do not endorse a philosophy and invest the time to preserve client autonomy. One
participant spoke of the propensity for residential care facilities to erode independence and selfdetermination through the use of scheduled services. Dependency can arise when caregivers

32
disregard program mandates and consistently do for the client rather than encourage
independence. Supporting clients often requires an active response but caregivers may be doing
“the bare minimum with clients” (Participant J).

Mitigating risks. For five participants, moral distress manifested from feeling powerless
to alleviate potential harm. Client safety is paramount to healthcare workers, but there are times
when all elements of risk cannot be mitigated for various reasons. Some interviews revealed that
a lack of support services create risks while organizational priorities seem to overshadow risks.
Clients who are assumed capable have the right to live at risk, but a distinction between tolerable
and intolerable risk can be difficult to conclude. Preserving independence is a deeply held value
for social work and moral distress can erupt when practitioners are required to make decisions
regarding client capability. It is a weighted burden. “I take power out of people’s lives and I
experience moral distress when I need to do that” (Participant C). Clients may have impairments
that impose upon their judgment but still be deemed capable to make decisions for themselves.
Two participants reflected on the careful consideration required surrounding the level of
intervention to impose on clients who are participating in behavior that may provoke risk to
themselves or others.

Outcomes of Moral Distress

Respondents identified an interplay between moral distress and physical and
psychological symptoms. Anger and frustration in response to unresolved moral distress were
noted during five interviews. The manifestation of these feelings differed among participants. In
response to value conflicts, one participant reported feeling “indignant, very indignant”
(Participant B). Another person acknowledged that anger has prompted candid discussions with

33
clients about feelings they have associated with systemic conflicts, but question the utility of the
information provided (Participant A). Issues of moral distress resonate beyond hours of work and
have interfered with personal time for some participants. Episodic and chronic depression,
anxiety and fatigue were issues for five participants that were associated with moral distress and
low job satisfaction. One participant commented: “I feel sad, really sad sometimes” (Participant
A). Three participants acknowledge a timid response to conflicts, or doubt in their ability to
stand against injustices, which led to heightened stress. For five of the participants, a lack of
confidence and knowledge of systems was an identified factor in the source of moral distress at
the beginning of their careers but then eased over time.

Five of the participants linked sleep issues or insomnia with moral distress. Feeling
conflicted about case decisions or ruminating about client outcomes has triggered symptoms and
interfered with job productivity. Some participants also mentioned headaches, fatigue and sick
time when struggling with moral distress. Feeling depleted can inhibit the energy that is required
to resolve issues that erupt from distress. Poor job satisfaction secondary to large caseloads,
stress, and exhaustion were notable issues for four participants. As the literature suggests,
questioning your suitability for a job can also arise from value conflicts. Three participants
attribute moral distress as a factor in their decision to leave their jobs. Feeling helpless to enact
positive change, and feeling devalued within their role were aspects in these decisions. One
participant had loved her job but left due to persistent value conflicts.

The outcomes of moral distress can extend beyond the social worker and implicate
interactions with clients. During four interviews, it was noted that avoiding clients or specific
elements of a client situation were tactics used to evade moral distress. One participant spoke of

34
detaching emotionally from clients. Workers have also avoided specific people within the
organization in order to prevent potential value conflicts. A sense of hopelessness and frustration
may deter investment in a situation and disengagement may be used when the worker is aware
the client will not qualify for services. “It feels like you’re flogging a dead horse. You can’t do
anything about it. So you just don’t bother” (Participant D). A reduced commitment to resolve
situations may enhance feelings of distress and helplessness to enact positive change. One
participant noted they had become complacent to task oriented work and felt remorse at the lack
of meaningful contact with clients (Participant D). Three people acknowledged a timid response
to value conflicts due to fear of retribution or fear of speaking up to leadership. Participants
spoke of the need to consider the benefits of an advocacy role in response to value conflicts on
their teams.

Support with the moral burden

According to participants, an important component for reducing moral distress involved
the support of others who could validate their concerns and who understood the social work role
and core competencies. Supervisors, peers, and ethics services were among those sources of
assistance noted by some as being useful to conceptualize problems, provide guidance, and offer
new perspectives relevant to the dilemma.

Clinical practice leaders. The Fraser Health Authority employs clinical practice leaders
to provide leadership and clinical support to social workers. Engagement with clinical practice
leaders was a common strategy employed for reducing moral distress among participants. It was
important that supervisors were authentic, approachable and understood the issues surrounding
moral distress. Practice leaders were identified as a source of support, especially when the value

35
conflict exists between social work values and organizational priorities. Participants may refer to
practice leaders to streamline identified concerns and ease the pressure on the situation, or
encourage the social worker to take further action to address the source of conflict. “What I
typically do is I go to the clinical practice leader and if I get the support of the practice leader,
then I will have more courage to advocate” (Participant H). However, the infrastructure does not
always allow for the availability of practice leaders and this was noted as a source of heightened
distress for one participant.

Peers. Drawing upon social work peers for suggestions, support and guidance was
another common theme. Shared experiences with peers can offer validation and opportunities to
draw from others’ skills, experience and expertise. “Hearing from others who understand what
I’m feeling really lowers my distress” (Participant B).

I also have social work friends that I can talk to who get it, and understand the depth of
the struggle or the weight of it for me. I second-guess myself so having someone help me
brainstorm, who understands the system and reminds me what my role is and understands
the complexity of the system helps. (Participant J).
A sense of camaraderie can evolve from shared experiences with moral distress. “It’s like
sharing battle scars” (Participant A). It was noted that not all participants have been able to
garner support from peers. Rapid turnover and separation from a team of social workers or peers
can hinder support. One participant noted that while peer consultation is valuable, moral distress
could actually increase if the support person did not share similar values. Useful for some was
the support from partners and friends willing to offer different perspectives but who are not
caught up in the emotion that can arise when navigating systemic challenges.

36
Ethics services. Social workers are often at the center of controversy when ethical
dilemmas arise and can contribute to moral distress. Among the research participants, all but one
participant had received ethics training during their healthcare employment. The amount of
training ranged from half a day, up to an eight-module training series. All participants were
aware of Fraser Health ethics services to resolve dilemmas, but there was a range of positions
regarding the interest towards ethics consultations. The two participants who participated in the
extensive training did not express shared positions related to the value of introducing ethics
services. Three participants spoke of resistance received when introducing an ethics consult to
their teams while one person noted that the team neither encouraged nor discouraged
consultation and thereby questioned its utility. Two participants noted they embrace ethical
discussions that involve wading through the different elements of the dilemma. There was credit
granted for the support ethic services can offer healthcare teams to identify salient points to a
situation and there was also recognition that the involvement of ethics services will not
necessarily change outcomes for the client or healthcare team. One participant reflected upon an
ethics consultation for end of life issues and concluded, “nothing came of it so what’s the point”
(Participant D). Consistent with the published material, there were no conclusive findings that
arose from this study relative to the interplay between moral distress, ethical dilemmas, ethics
training and ethics consultations.

Creating Meaning from Moral Distress

During interviews, research participants were not directly asked how they create meaning
from moral distress, but there was exploration surrounding outcomes, benefits and implications
to their practice. Interviewees revealed resistance to factors that created distress and indicators of

37
resilience that has formed in their practice. In response to experiences related to value conflicts
and leadership, one participant noted, “I went along with it but it didn’t feel very good. Over
time I just stopped” (Participant C). While some participants were able to link experiences of
moral distress with professional growth, others did not recognize their strength to overcome the
conflicts they endured. One person seemed uncomfortable to admit they left two jobs as a result
of moral distress. I saw this as a potential testament of commitment to the profession and
awareness that those jobs were not a good fit with their values. As the literature suggests, finding
the right fit for a job can decrease value conflicts and improve job satisfaction. Another
participant noted that a lack of fear was the incentive to maintain integrity and resist moral
distress. This person contends they would leave a job if there were a lack of freedom to act
ethically. A sense of autonomy without any fear of retribution or job loss allows this person to
stand up against injustices and perform ethically. “I anticipate moral distress would elevate if
ever I believed I couldn’t influence the situation” (Participant B). Not experiencing a fear of job
loss enhanced the courage to respond to injustices for two participants.

During interviews, participants revealed the need to experience moral distress in order to
recognize its influence on practice “You need experiential examples before you get it”
(Participant G). A trend erupted among seven participants who recognized an increased
commitment to resolve value conflicts following previous experiences with moral distress. “I’ve
learned how to deal with it more. I have my little anger attack and then I get on with it”
(Participant A). Previous occurrences can offer resolution strategies, knowledge of system
navigation and increased confidence. Decisions imposed by the agency, which created
significant consequences for clients inspired commitment to resolve future conflicts for some
participants.

38
There are some things I won’t compromise even if I’m disciplined and I have been
disciplined. I think once I’m able to take action, one way or another, then I’m usually
able to get resolve, or I get to a place where I’m so burnt out that I retreat and take care of
myself (Participant C).

Previous experiences can inspire the social worker to discern professional and personal
boundaries and reduce the propensity for distress. Choosing not to become enmeshed in
situations can reduce the prevalence of moral distress without compromising the relationship
with clients. One participant noted the importance of asserting boundaries and deciding not to
convey difficult information to clients on behalf of the organization. Acting against moral
distress by resisting some of the expected task oriented work can be liberating and help define
values and priorities. “It’s the outcome for the client, not how I get there. And that helps quite a
bit in dispelling the moral distress” (Participant C). Good communication skills are vital for
social work and three people noted that their experiences with moral distress led to increased
courage and skills to address value conflicts within their teams.

Previous situations can highlight the importance of the advocacy role and the need to
persevere. Anger can motivate social justice initiatives. “Its my privilege to work with people to
preserve their self determination” (Participant G). “I think those cases with moral distress has
helped me to advocate effectively for a patient and that gives me job satisfaction, even if the
team is annoyed with me” (Participant H). The presence of moral distress may be useful. “It
indicates I care, that I’m invested and it predisposes me to take action on behalf of someone, for
something, which are all good things, although they are not always fun at the time” (Participant

39
C). “I’m more mobilized when people have no ability to fight back. There are things that are
unjust and I’m not prepared to walk away from those kinds of situations” (Participant B).

Seeking solutions and validation from other social workers and colleagues can offer
valuable information. “I don’t ever stop seeking solutions. I’m hopeful” (Participant A). Social
workers may create alliances with others in the quest for resolution. “It feels manipulative
sometimes because you’re taking these back routes trying to meander around the case and trying
to plant information to enough people that maybe the ideas will shift” (Participant H).
Professional guidelines strengthen practice and may also be used as a tool for reference in
educating team members about the social work perspective and reduce incidence of conflict.
Three people noted that their professional code of ethics and professional practice standards
offered validation and prompted their commitment to preserve client rights. “….The code of
ethics provides a great deal of comfort to fall back on when something falls out of my
experience” (Participant C).

An intersect between low confidence and moral distress inspired four respondents to seek
education. Two participants had actively sought education specific to moral distress, compassion
fatigue and burnout. Counselling services were an identified source of support for some social
workers struggling to resolve moral distress. Some participants had relied on union
representatives for support with conflicts within the organization and two participants actively
sought work within the union as a means of enacting change within the larger system. One
person noted that work with the union led to a sense of productivity as an agent of change. One
person felt that union work can “…mobilize other people to advocate for change” (Participant F).

40
One person identified a positive change in interactions with leadership after committing to their
union role.

According to five participants, an awareness of limitations to the social work role is
important for setting boundaries and reducing moral distress. Experiential knowledge can
encourage flexibility within practice and promote insight relevant to the constraints of the role. “I
have to preserve myself and that benefits my health and my family and clients” (Participant H).
The ability to discriminate on the costs and benefits towards taking action against a conflict is an
important strategy some participants have adopted. Decreasing expectations of external agencies
can also decrease the propensity for moral distress. Two people acknowledged that external
agencies and other disciplines are also coping with significant caseloads and doing their best
within a chaotic system. That awareness is useful to reduce ruminating thoughts and distress.
One person noted that after years of practice, “…I calm down faster” (Participant A).
Understanding organizational pressures and the interface with bed utilization is an important
objective. When there is a breakdown in the system, such as a failed discharge, some respondents
consider their contributions to strengthen plans for clients, offsetting distress that might
otherwise appear without an investment of time. “There have been cases where I have had
problems where I’ve struggled with someone else’s work or a policy, but I did solid work, I
maintained integrity and authenticity, and I provided the resources” (Participant G). For one
participant, she and her team were making a concerted effort to concentrate on the positive
exchanges with clients. According to participants, moral distress can be interrupted by
acknowledging the responsibility clients have towards outcomes and reminding yourself that you
have done all you can towards resolving a situation.

41
Limitations of the study
The small sample size was a limit to the study. With only eight participants from Fraser
Health, the results cannot be generalized to the organization’s social work department or
profession overall. Exploratory research is intended to gather new details about a subject and
while the findings have offered interesting insight, using a small sample group and qualitative
design does not offer conclusive findings. Individual participants were assured that their area of
work would not be identified within the analysis, but regardless, participants may have been
reluctant to fully engage in the discussion about moral distress at work. Because the principal
researcher and participants all work for Fraser Health, there is a likelihood of future encounters
and this may have limited a participant’s comfort with full disclosure during interviews. This
may also have deterred some people from responding to the invitation to participate. Also, there
is potential that as a social worker in health, I may have over-identified with some aspects of
information while overlooking other areas.
Noteworthy was that six participants had more than nine years of experience and only
one person had less than five years of experience. None of the participants were under thirty-one,
while six were over forty-one. Those new to the profession may not recognize the features of
moral distress or may have felt apprehensive to identify with their experiences and these factors
may have influenced participation in the study. This research does not uncover potential linkages
or associations between age, experience, and moral distress.
The topic of moral distress is often confused with burnout, compassion fatigue and
ethical dilemmas. Although interview questions were designed to reflect the established
definitions and constructs relating to moral distress in the literature, it is possible that participants
could not always distinguish these variances in response to every question. Interview questions

42
were framed with intent to explore the distress that arises when there is a conflict or compromise
with the social worker’s own values and beliefs and while professional values may be an
extension of one’s personal belief system, exploration of the distinct influence personal beliefs
may have had with moral distress was not identified.

Discussion and Implications for Practice

Although research participants may not deliberately consider the strategies and strengths
they use to make meaning from moral distress, they were able to draw upon experiences that
motivate or inhibit actions for resolve. Several participants have strengthened their strategies to
cope with dilemmas or become selective with the conflicts they shoulder, and some have made
job changes that better fit with their own values. Research participants reflected on past and
present experiences of moral distress and generally felt more adept to address value conflicts
compared to earlier years in their careers. Previous experiences had become useful to define the
course of action during future encounters with moral distress. Symptoms of moral distress are
uncomfortable in nature but may also create the impetus for change and resolve. While some of
the participants may have previously adhered to agency objectives, the subsequent moral residue
that arose from inaction influenced future actions. As noted in the findings, one participant
reflected on changes to professional practice as a result of past experiences with moral distress.
“I went along with it but it didn’t feel very good. Over time I just stopped” (Participant C). “Not
feeling qualified or responding to an ethical conflict by feeling concerned but taking no further
action makes one susceptible to moral distress – distress resulting from a discrepancy between
what one thinks ought to be done and what is actually done” (Grady et al., 2008, p. 7).

43
Social workers and the ethics of care theory have a mutual interest in justice, compassion,
empowerment and the emancipation of power. Understandably that within the current healthcare
climate, controversy can appear between the social worker’s goals and that of the organization.
Value conflicts that develop while preserving client rights to fairness and justice were obvious in
this study. Moral distress often surfaces from unfair treatments bestowed upon clients who are
stigmatized or devalued within the healthcare system. “Justice says everyone is entitled to the
same treatment but an ethics of care may lead to differential treatment as it may dictate that some
people are needier of care than others based on situational and subjective judgments” (Gray,
2006, p. 1806). Efforts for justice and care can be thwarted by organizational priorities and some
participants noted that at times, they felt their role was questioned, devalued and ignored. Power
imbalances are frequently present within hierarchal systems and may inhibit or inspire the
worker’s ability to enact change but dedication towards fairness and justice can motivate action,
especially when advocating for vulnerable populations. A willingness to stand up against
injustices benefits the client and thus reduces the risk of moral residue and burnout. However,
social workers do not always feel empowered to stand against injustices. Research related to
moral distress and social workers suggests staff “choose not to address injustices in their places
of work” (Musil, Kubalı ḱ ova, Hubı ́kova ́, and Neasova ́, 2004, Papadaki & Papadaki, 2008; as
cited in Fine & Teram, 2013, p. 1314). Interviews revealed fear and intimidation are factors
sometimes inhibiting work with clients and creating stress for the employee. Fear of speaking up,
fear of conflict, socialization of compliance, lack of courage, fear of job loss and self-doubt are
correlated with moral distress (Oliver, 2013, p. 206). ). It is illogical to suggest social workers
stand up to every injustice that may be produced out of policy and process, but a solid framework
for the resolve of moral distress may offer greater job satisfaction and less job turnover.

44
Additionally, enhanced awareness and support could alleviate the propensity for agency staff to
misinterpret or condemn the social work role.

Within this study, little attention was afforded issues related to end of life, advanced care
planning or sudden death. Value conflicts that surface in these situations between the healthcare
team and clients have been a source of moral distress during my years in practice. However,
during this study, participants primarily reflected on value conflicts that emerged between
themselves and the agency. This does not negate the incidence of moral distress that does occur
during work with patients and families; however, this could suggest that the overriding factor in
moral distress currently, stems from the challenge to navigate the organizational system. Future
research could be concentrated on experiences that arise from value conflicts between worker
and client during end of life situations.
Economic factors and resource allocation frequently undermine the social worker’s
ability to perform their role as change agents. Social work has become less about client-centered
engagement and is more closely aligned with gate-keeping resources, managing behaviour and
mitigating risk (Oliver, 2013, p. 210). Connecting clients with services intended to improve
quality of life and mitigate risk is a common practice, but frequently interrupted by various
factors. During this study, the struggles associated with resource linkages were significant
triggers to moral distress. The current social-political climate does not favor social work clients
and has created a growing emphasis on the marketplace and personal autonomy, thus reducing its
responsibility for establishing and maintaining equity for those who need it most. Neo-liberal
ideals’ emphasis on self-sufficiency combined with a residual government state has resulted in
shifts to resource allocation (Raphael, 2011). The social worker’s sense of fairness and justice

45
can be motivating but a sense of hopelessness to enact change could perpetuate moral distress
and impact client care.

Moral distress is a reality of practice and all study participants had benefitted from
support from peers and practice leaders to clarify roles, offer validation, alternative perspectives,
and direction. Benefits from these supports are consistent within the literature. Creating
structures that prioritize and promote support specific to moral distress could be beneficial to
social workers, especially early on in their healthcare career. Focusing attention on the features,
consequences and coping strategies associated with distress could foster better outcomes for
worker and client. Encouraging practitioners to identify and process moral issues may decrease
the prevalence of employee turnover and promote collective solutions (Schluter, Winch,
Holzhauser, & Henderson, 2008). At times, low confidence contributed to the formation of moral
distress suggesting educational opportunities to increase skills could decrease the prevalence of
incidents.

I was intrigued that no social workers with less than two years experience chose to
participate in this study and only one person had worked as a social worker in health for less than
six years. This may suggest there is a lack of awareness related to the features of moral distress
or discomfort to acknowledge one’s struggle with these experiences. Future research could be
focused on the new social worker’s knowledge and response surrounding the features and
outcomes of moral distress and moral sensitivity. We may also consider the possibility that some
social workers are able to follow structure and procedure and detach from issues of moral
sensitivity. This tendency, however, may come at a cost to authentic, caring relationships with
clients (Oliver, 2013, p. 208). Published research frequently suggests social workers in health

46
will experience moral distress during the course of their careers, however, studies remain sparse.
A comparison study with social workers that do not identify with moral distress at work could
offer valuable insight relevant to the dilemma.

As the published literature suggests, there is potential to accept a neo-liberal ideology and
abandon social justice initiatives whereby many social workers have “adopted a more defensive
and morally timid position in response to the pervasive and insidious political and moral
conservatism of neo-liberal risk sociality” (Stanford, 2010, p. 1067). Those who contributed to
this study presented with a strong commitment to care and social justice and acknowledge that
recognition and management of moral distress has developed over time. This suggests the
resolve of moral distress requires experience and contemplation of an individual’s threshold of
tolerance. Furthermore, this study reinforces social work’s commitment to justice and care,
which may be challenged or hindered by resource shortages, value discrepancies and agency
priorities.

Conclusion

Social work in healthcare has become increasingly challenging due to constraints on the
system and therefore it is possible that without an ability to enact change, moral distress, moral
residue and burnout could increase. It is not known how many people left the profession as a
result of unresolved moral distress, but the literature suggests that the dilemma is inevitable in
practice and thus, stands to reason that social workers should be encouraged to critically reflect
on their values, beliefs, and practice within the organization. Moral distress would not exist in
absence of professionals who are invested in their clients and hence, it would seem valuable for
organizations to preserve their commitment. Findings from this study could inform educational

47
opportunities for social workers and the organization at large. This study focused on the ability
for social workers to create meaning from moral distress. Participants revealed that education,
validation and support, experience, and authentic interest in the client experience supported a
commitment to social justice, care and professional integrity.

48
References

Allen, R., Judkins-Cohn, T., deVelasco, R., Forges, E., Lee, R., Clark, L., Procunier, M.
(2013). Moral distress among healthcare professionals at a health system. Jona’s
Healthcare, Law, Ethics and Regulation, 15(3), 111-118.

Bell, J., & Breslin, J. (2008). Healthcare provider moral distress as a leadership
challenge. JONA's Healthcare Law, Ethics & Regulation, 10(4), 94-99.

Bransford, C. L. (2011). Integrating critical consciousness into direct social work
practice: A pedagogical view. Social Work Education, 30(8), 932-947.
doi:10.1080/02615479.2010.534449

Dalmolin, G., Lunardi, V.L., Lunardi, G.L., Barlem, EC.D., deSilverman, R.S. (2014).
Moral distress and burnout syndrome: Are there relationships between these
phenomena in nursing workers? 22(1), 35-42. Revista Latino-Amdericana
de Enfermagem. Doi: 10.1590/0104-1169.3102.2393

Davin, S., Schrader, V., & Belcheir, M.J. (2012). Influences of ethical beliefs and the
Impact on moral distress and conscientious objection. Nursing Ethics, 19(6),
738-749. doi: 10.1177/0969733011423409
Dudley, J.R. (2011). Research Methods for Social Work (2nd ed.). Allyn & Bacon.
Boston, MA.

49
Epp, K. (2012). Burnout in critical care nurses: a literature review. Dynamics, 23(4),
25-31.

Epstin, E., & Delgado, S. (2010). Understanding and addressing moral distress. Online Journal
of Issues in Nursing, 15(3), 1-1 1p. doi:10.3912/OJIN.Vol15No03Man01.

Ferguson, I. & Lavelette, M. (2006). ‘Globalization and global justice: towards a social work
of resistance’. International Social Work, 49(3), 309-318.

Fine, M.,& Teram, E. (2013). Overt and covert ways of responding to moral injustices in
social work practice: Heroes and mild-mannered social work bipeds. British
Journal Of Social Work, 43(7), 1312-1329.

Gabel, S. (2011). Ethics and values in clinical practice: whom do they help? Mayo Clinic
Proceedings, 86(5), 421-424. doi:10.4065/mcp.2010.0781

Grady, C., Danis, M., Soeken, K. L., O'Donnell, P., Taylor, C., Farrar, A., & Ulrich, C.
M. (2008). Does ethics education influence the moral action of practicing nurses
and social workers? American Journal Of Bioethics, 8(4), 4-11.
doi:10.1080/15265160802166017

Gray, M. (2010). Moral sources and emergent ethical theories in social work. British
Journal Of Social Work, 40(6), 1794-1811. doi:10.1093/bjsw/bcp104

50

Held, V. (2006). The Ethics of Care. Oxford University Press Inc. New York, NY.

Horne, M. (2014). What is happening with values in organization development? OD
Practitioner, 46(4), 52-55.

Jameton, A. (1984). Nursing Practice: The Ethical Issues. Prentice Hall, Englewood Cliffs.

Kalvemark, S. Hoglund, A, Hansson, M., Westerholm, P., & Arnetz, B. (2004). Living with
conflicts-ethical dilemmas and moral distress in the health care system. Social Science
and Medicine, 58(6), 1075-1084. doi: 10.1016.S0277-9536(03)00279-X.

Lützén, K., Blom, T., Ewalds-Kvist, B., & Winch, S. (2010). Moral stress, moral
climate and moral sensitivity among psychiatric professionals. Nursing
Ethics, 17(2), 213-224.

Lützén, K., Dahlqvist, V., Eriksson, S., & Norberg, A. (2006). Developing the
concept of moral sensitivity in health care practice. Nursing Ethics, 13(2),
187-196.

Maddi, S. R. (1996). Personality theories: A comparative analysis. (6th ed.). Brooks/Cole
Publishing. Pacific Grove, CA.

51
McAuliffe, D., & Sudbery, J. (2005). “Who do I tell?” Support and consultation in
cases of ethical conflict. Journal of Social Work, 5 (21), 20-43.
doi: 10.1177/1468017305051362

Meagher, G., & Parton, N. (2004). Modernizing social work and the ethics of
care. Social Work and Society, 2(1), 10-27.

Mill, J.S. (1863). Utilitarianism. ElecBook. London, ENG.

Oliver, C. (2013). Including moral distress in the new language of social work ethics.
Canadian Social Work Review, 30(2), 203-216. Retrieved from
http://search.proquest.com/docview/1528525253?accountid=10969

Openshaw, L. (2011). Moral distress and the need for moral courage in social work
practice. NACSW Convention Proceedings. Retrieved from
http://www.nacsw.org/Publications/Proceedings2011/OpenshawLMoralDistressE.pdf

Overview of theories of human behavior & the social environment. Applications to
social environment. Application to social work generalist practice. (n.d.).
Retrieved
from:http://home.apu.edu/~ksetterlund/20122013/theories%20handout%20with%
20terminology.pdf

52
Pauly, B.M.; Varcoe, C.; & Storch. J. (2012). Framing the issues: Moral distress in health
care. HEC Forum, 24, 1-11. DOI 10.1007/s10730-012-9176-y

Raphael, D. (2011). Poverty in Canada. Implications for health and quality of life.
(2nd ed.). Toronto, Ont: Canadian Scholars Press, Inc.

Rushton, C. H., Kaszniak, A. W., & Halifax, J. S. (2013). A framework for understanding
moral distress among palliative care clinicians. Journal of Palliative Medicine,
16(9), 1074-1079. doi:10.1089/jpm.2012.0490

Salas, L., Sen, S., & Segal, E. (2010). Critical theory: Pathway from dichotomous to
integrated social work practice. Families In Society: The Journal Of
Contemporary Social Services, 91(1), 91-96.

Schluter, J., Winch, S., Holzhauser, K., & Henderson, A. (2008). Nurses’ moral sensitivity
and hospital ethical climate: A literature review: Nursing Ethics, 15(3), 304-321.

Stanford, S. (2010). ‘“Speaking back” to fear: Responding to the moral dilemmas of risk in
social work practice’. British Journal of Social Work, 40, 1065-1080.

Storch, J., Rodney, P., Varcoe, C., Pauly, B., Starzomski, R., Stevenson, L., (2009b).
Leadership for ethical policy and practice (LEPP): A participatory action project.
Canadian Journal of Nursing Leadership, 22(3), 68–80.

53
Taylor M. F., & Bentley, K. J. (2005). Professional dissonance: Colliding values and job task in
mental health practice. Community Mental Health Journal. 4 (4) 469-480.
Doi: 10.1007/s10597-005-5084-9.

Taylor, M.F. (2007). Professional dissonance. Smith College Studies in Social Work,
77(1). 88-99. doi: 10.1300/J497v77n01_05

Teixeira, C., Ribeiro, O., Fonseca, A. M., & Carvalho, A. S. (2014). Ethical
decision making in intensive care units: a burnout risk factor? Results from
a multicentre study conducted with physicians and nurses. Journal of
Medical Ethics, 40(2), 97-103. doi:10.1136/medethics-2012-100619

Varcoe, C., Pauly, B., Webster, G., & Storch, J. (2012). Moral distress: Tensions as
springboards for action. HEC Forum, 24, 51-62.

55
Appendix B
Fraser Health Ethics Approval

Appendix C

56
Invitation to Participate

Social Work
Abbotsford Regional Hospital
32900 Marshall Road,
Abbotsford, BC V2S 0C2
604-851-4700 Fax: 604-851-4746

INVITATION TO PARTICIPATE IN A RESEARCH INTERVIEW
How Healthcare Social Workers Who Have Experienced Moral Distress Create Meaning from
their Experiences
Dear Potential Participant;
I am conducting a research study exploring the experiences of moral distress among social
workers in health. The purpose of the study is to uncover the ways in which social workers are
able to make meaning and heal from their experiences with moral distress. The study is intended
to identify contributing factors of moral distress and the means of coping with the internal and
external conflicts that participants identify with.
The research is being conducted as part of the Master of Social Work program at the University
of the Fraser Valley. The hope is that information from the study can be used for the purpose of
social work education and professional development and ultimately to improve job satisfaction
and the effectiveness of care to patients, residents and families.
If you choose to join the study, you will be asked to engage in one individual interview, which is
expected to last up to one hour. A series of open-ended questions will be asked related to your
experiences with moral distress. With your consent, the interview will be audio recorded. The
interview will be arranged at a time and place that is convenient for you outside of your working
hours.
The criteria for participation in the study are as follows:
1. You work as a social worker in Fraser Health
2. You self-identify as having experienced moral distress in your work with clients
- moral distress can be described as a state of conflict that may arise when moral
choices are hindered by opposing constraints
3. You are receptive to discussing your experiences with moral distress
Your participation in the study will remain confidential and will not be shared with anyone
within Fraser Health. Data that is collected in the study will not reveal any identifying

57
information about subjects involved. Prior to participating in the study, you will be provided with
a consent form outlining the study. You are encouraged to ask questions before consenting to
participate. If you choose to participate, you will have the option to withdraw at any time without
giving a reason.
The research study, including its purpose and methodology is approved by the Research Ethics
Boards at the University of the Fraser Valley and the Fraser Health Authority. If you have any
concerns about this research, you can contact Dr. Leah Douglas at the University of the Fraser
Valley at 604-504-7441, local 4292. If you have any ethical concerns about this research study,
please contact Adrienne Chan, UFV Associate Vice President of Research, Engagement, and
Graduate Studies, at 604-557-4074 or Adrienne.chan@ufv.ca. You may also contact the cochairs with the Fraser Health Research Ethics Board at 604-587-4681.
I invite you to contact me if you would like to learn more about this study:
Hali Miller, BSW, RSW
Renal Social Worker
Abbotsford Regional Hospital

58
Appendix D
Informed Consent

Hali Miller
Social Work
Abbotsford Regional Hospital
32900 Marshall Road, Abbotsford, BC V2S 0C2

How Healthcare Social Workers Who Have Experienced Moral Distress, Create Meaning
from their Experiences

CONSENT FORM
My name is Hali Miller and I am a student at the University of the Fraser Valley in the
Master of Social Work program. This study is intended to fulfill the requirements for the
Master of Social Work program at the University of the Fraser Valley. As part of my
educational requirements, I am conducting exploratory research to study the experiences
of moral distress among healthcare social workers. Upon completion, the study will be
published through the university library and presented to faculty and fellow students. The
findings may be submitted for publication in academic journals.
As a social worker employed with Fraser Health, and who has self-identified as having
experienced moral distress, you are invited to participate in this study. For the purpose of
the study, moral distress is associated with a state of conflict that arises when moral
choices are hindered by opposing constraints.
Background
Social workers in health are engaged with clients during periods of heightened stress and
emotion. In their role as advocates, social workers frequently interface with opposing
opinions and are called to diffuse the tensions that exist, at times, at a compromise to their
own values and beliefs. It is expected that practitioners will experience value conflicts
during the course of their careers. Moral distress can have implications on the delivery of
care to clients as well as job satisfaction. There is limited research available related to
moral distress for healthcare social workers. Insight that could be gathered about the
features, outcomes and resolve of the social worker’s experiences could be meaningful to
education and professional practice.

59

Purpose/Objectives of the Study
The purpose of the study is to uncover the ways in which social workers are able to make
meaning and heal from their experiences with moral distress. The study is intended to
identify contributing factors of moral distress and the means of coping with the internal
and external conflicts.
Moral distress has been linked to job dissatisfaction, employee turnover, burnout and
absenteeism. Information from the study can be used by the organization to inform
education and support services. Ultimately, we hope that findings may lead to improved job
satisfaction and the delivery of care for patients and residents.
Procedures involved in the Research
The study will involve one individual interview with each participant. It is anticipated that
there will be 6-8 participants and the interview is expected to last for one hour. The
interview will be scheduled at a time and place that is convenient for you and will not take
place during your work hours. You will be asked a series of open-ended questions
exploring your experiences with moral distress and whether you were able to identify any
resolve. With your consent, the interview will be audio recorded and notes will be taken. If
you do not want the interview recorded, then only notes will be taken. The purpose of the
recording and notes is so that I, the principal investigator, have the opportunity to review
the information and look for themes between your responses and those of other
participants.
Potential Harms, Risks or Discomforts to Participants
It is not anticipated that there will be significant harm or discomfort associated with this
study however, potential risks and the means of mitigating these risks are included below.
The interview will involve dialogue about your experiences with moral distress. It is
possible that this could elicit an unexpected emotional response from thinking and talking
about these experiences. The principal investigator is a social worker and is available to
discuss any emotional discomforts resulting from this experience. You are also advised of
the option to access counselling services through the Employee Assistance Program (at no
cost). You may request an appointment at: www.efap.ca. You may also access counselling
services through your Extended Health Services.
You may experience some concern or discomfort talking about your experiences. You may
feel regret surrounding your disclosures. Your confidentiality will be respected and there
will be no identifying information linking you to this study.
You may experience boredom or physical discomfort during the interview process. You will
be encouraged to request a break during the interview process and will be encouraged to
position or reposition yourself in a way that is comfortable for you during the interview.
Potential Benefits
You may benefit from the opportunity to reflect upon your experiences with moral distress.
The hope is that the information could be used to identify contributing factors of moral
distress, which could then be used to strengthen professional practice. Information from

60
the study could be used by the organization to inform education opportunities or gaps in
support services available to social workers.
There may be no direct benefits to you from your participation in this study.
There will be no compensation for your participation in this study.
Participation
Participation in the study is voluntary. You may withdraw your participation at any time
and will not be asked to provide a reason. You may contact the principal investigator by
phone or email if you choose to withdraw. If you withdraw, your data will be destroyed,
unless you indicate otherwise. You can decline to answer questions during the interview
but still remain in the study. You may stop the interview at any time.
Will My Taking Part in this Study be Kept Confidential?
Your confidentiality will be respected. The Co-Investigators, Dr. Leah Douglas and Dr.
Margaret Coombes will supervise the study. No information or records that disclose your
identity will be published without your consent, nor will any information or records that
disclose your identity be removed or released without1t your consent unless required by
law.
You will be assigned a unique study number as a participant in this study. Only this
number will be used on any research-related information collected about you during the
course of this study, so that your identity [i.e. your name or any other information that
could identify you] as a participant in this study will be kept confidential. Information that
contains your identity will remain only with the Principal Investigator. The list that
matches your name to the unique study number that is used on your research-related
information will not be removed or released without your consent unless required by law.
Your rights to privacy are legally protected by federal and provincial laws that require
safeguards to insure that your privacy is respected and also give you the right of access to
the information about you that has been collected and, if need be, an opportunity to correct
any errors in this information. Further details about these laws are available on request.
Study Results
You will be offered the option of receiving a copy of the final report. This will be sent via
email.
Information from this study will be kept for 5 years.
Questions
If you have questions or would like further information about this study, you can contact
the principal investigator at 604-897-3762. If you have questions or concerns that you
would like addressed by the University’s co-investigators, please contact Dr. Leah Douglas
at 604-504-7441 local 4292 or Dr. Margaret Coombes at 604-504-7441, local 4440.
The ethics of this project have been reviewed and approved by the University of the Fraser
Valley Human Research Ethics Board. If you have any ethical concerns about this research

61
study, please contact Adrienne Chan, UFV Associate Vice President of Research,
Engagement, and Graduate Studies, at 604-557-4074 or Adrienne.chan@ufv.ca
If you have any concerns of complaints about your rights as a research participant and/or
your experiences while participating in this study, you may contact the co-chairs at the
Fraser Health Research Ethics Board at 604-587-4681.
Consent Form
Principal Investigator:

Hali Miller, BSW, RSW

Co-Investigators:

Dr. Leah Douglas
(604) 504-7441 Local 4292
leah.douglas@ufv.ca

Dr. Margaret Coombes
(604) 504-7441 Local 4440
margaret.coombes@ufv.ca

I have read and understood the subject information and by signing below I freely consent to participate in the study
titled:
“How do healthcare social workers who have experienced moral distress create meaning from their
experiences?”
 I have had sufficient time to consider the information, ask questions and receive additional details and feel
satisfied to consent to participate.


I understand that my participation in this study is voluntary and I am completely free to withdraw from this
study at any time.



I understand there is no guarantee that this study will produce any benefits to me.



I understand that I have the right to withdraw from the study at any time and that confidentiality and/or
anonymity of all results will be preserved.



I agree to the use of audio recording to be used during the interview ( ) Please indicate with a checkmark.

If I have any questions about the study, I should contact the principal investigator. Alternatively, I may contact the
Co-Investigators, listed above. If I have any ethical concerns about this research study, I should contact Dr.
Adrienne Chan, UFV Associate Vice President of Research, Engagement, and Graduate Studies, at 604-557-4074 or
Adrienne.chan@ufv.ca.
If I have any concerns of complaints about my rights as a research participant and/or my experiences while
participating in this study, I may contact the co-chairs at the Fraser Health Research Ethics Board at 604-587-4681.
By signing this form, I do not give up any of my legal rights

Name (please print) ____________________________________________________________________________

Signature ____________________________________________________________________________________

Date ________________________________________________________________________________________

62
Principal Investigator Signature ___________________________________________________________________

Date _________________________________________________________________________________________

Once signed, you will receive a copy of this consent form.

63
Appendix E
Interview Questions
Research Question:
How healthcare social workers who have experienced moral distress, create meaning from
their experiences?
Research Objectives:
The purpose of the study is to uncover the ways in which social workers are able to make
meaning and heal from their experiences with moral distress. The study is intended to identify
contributing factors of moral distress and the means of coping with the internal and external
conflicts that may arise when working with clients. Information from the study may be used by
the organization to inform education and support services. Ultimately, the hope is that findings
may lead to improved job satisfaction and improved delivery of care for patients and residents.
Background Questions:
1. Level of education – BSW/MSW/PhD
2. Employment status – part time/full time/casual
3. Gender
4. Age (range 20-30, 31-40, 41-50, 51-60, 60+)
5. Other self identified features referring to social location (race, language, ability)
6. Years working as a healthcare social worker
Interview Questions:
1. What has been your experience with moral distress at work?
–Prompt: reference to continuity of care, end of life decisions (prolonging futile life
support, patient suffering), risks to patients
a) Has your moral distress been the result of external conflicts?
- Prompt: lack of time/workload restraints, case complexity, task oriented work
that is prioritized over counseling/advocacy services
b) or internal conflicts
-Prompt: do you resist taking a stand against perceived injustices that your client
presents with, lack confidence or courage to address the situation, lack of training,
feel a sense of helplessness to change the situation

64
3. How do you identify with your experience with moral distress?
-Prompt: do you experience specific feelings such as anger, frustration, powerlessness,
guilt, exhaustion, anger, depression, anxiety, nightmares, feeling undermined, avoidance,
detachment from the client/job
4. From your perspective, has agency policy or professional practice guidelines contributed
to your experiences with moral distress?
5. Reflecting on your experiences, how do you think your work with clients has been
impacted by moral distress?
–Prompt: avoidance to situations, choose not to stand up to injustices, greater
commitment to stand up against injustices, sought education; do you cushion or buffer the
consequences for clients – eg: tell them they’re better off at home (opposed to being in
hospital) because of all the disease
6. Did you take action to allow you to preserve your values? If yes, what allowed
you to do this within yourself or within the agency?
-Prompt -How do you respond to these situations that create moral distress?
7. Reflecting on your experiences with moral distress, can you identify with value
conflicts between yourself and the agency priorities? What are the value conflicts for
you? Eg: fairness and justice; safety issues; autonomy & self determination….
If so, how do you respond?
- Prompt: fear of speaking up, fear of looking imperfect/unqualified, fear of conflict, fear
of being perceived as non compliant, fear of job loss, self doubt
8. Do you feel responsible for client/patient outcomes?
9. Have you participated in ethics training?
-do you use Fraser Health’s ethics services when you are experiencing an ethical
dilemma and to resolve moral distress?
10. Can you identify any positive outcomes from your experience with moral distress? What
are they?
11. Do you feel supported in your moral burden – in other words, do you talk to others about
your experiences with moral distress? Who?
– do you speak with peers? Supervisors? Why or why not?

65

66