Illuminating Moral Distress in Social Work
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Illuminating moral distress in social work: A grounded theory study informed by critical realism by Richard Lavoie A Thesis submitted to the Faculty of Graduate Studies of The University of Manitoba in partial fulfilment of the requirements of the degree of MASTER OF SOCIAL WORK University of Manitoba Winnipeg Copyright © 2021 by Richard Lavoie Abstract What is it about social work that makes it so ethically challenging? Why do social workers seem to feel moral distress so accurately captures their experiences? And why has there been so much conceptual confusion regarding moral distress? Although well documented in other helping professions, moral distress has not been well represented in the SW literature. Yet, social workers are accustomed to working in ethical challenging conditions. Building from the seminal work of previous scholars and backed with practical experiences from current practitioners this study applies critical realist methodology to grounded theory methods to reconstruct a conceptual model of moral distress. A mix of qualitative and quantitative studies have established the groundwork for further analysis. Empirical evidence was gathered through interviews with experienced social workers. Data analysis was conducted through an abductive lens intended to integrate all potential theoretical explanations. Participants described situations that gave rise to significant moral consequences that impacted their mental health and professional career. They described feelings of frustration, anger, resentment, and self-defeat related to an inability to act on their perceived ethical duty. Ethical challenges were categorized into 5 commonly described themes. 1) Powerlessness 2) Advocacy for Social Justice and its influence on social workers 3) Moral impact of undemocratic work environments 4) Self-determination and barriers preventing participant’s efforts to empower clients 5) Moral consequences for social workers working within the medical model. The 5 major themes have been recognized as the leading factors giving rise to moral distress. This study exposes the interrelated features and underlying mechanisms leading to moral distress in social work and demonstrates that moral distress is more complex and dynamic than scholars have previously specified. i Acknowledgements I would like to thank all the participants who graciously agreed to share their experiences. Only through their genuine willingness to recount challenging moral situations that this study is able to make a contribution to the literature on moral distress. I also would like to thank my advisor Sid Frankel for his knowledge, dedication and invaluable support throughout this project. A special acknowledgement goes to the advisory team, Dr. Laura Taylor, Dr. Merril Pauls and Dr. Bonnycastle for their insight and support. ii Dedication This paper is dedicated to my wife Kathy who was ever so patient and supportive, and all our children Ray, Renee, Matt and beloved son Luke who has left his realm of earthly presence, may you rest in peace. Thank you all for your kind support and sacrifices along the way. I am truly inspired by your love, patience and support. I finally made it! This paper is dedicated in a special way to my cherished friend, Laura Taylor, who was an inspirational teacher, valued friend, and member of the advisory committee. iii Table of Contents List of tables…………………………………………………………………………………… Vii List of figures………………………………………………………………………………….. Viii Chapter 1: Introduction……………………..…………………………………………………. 1 Theoretical foundation……………………………………………………………………..4 Chapter 2: Literature review…………………………………………………………………….18 History and definition..…………………………………………………………………….21 Varying definitions………………………………………………………………………...30 Related theoretical concepts……………………………………………………………….34 Empirical Nursing Research…...…………………………………………………………..46 Empirical Social Work Research…………………………………………………………..54 Conceptual Social Work Research………………………………………………………...87 Summary Literature Review……………………………………………………………...115 Chapter 3: Methods………………………………..…………………………………………..120 In search of a paradigm…………………………………………………………………..125 Informed by Critical realism…...………………………………………………………...127 Grounded theory…………………………………………………………………………132 Other theoretical contributions…………………………………………………………...134 The researcher…………………………………………………………………………....142 The participants…………………………………………………………………………..146 Recruitment process…………………..………………………………………………….147 iv Data collection……………………………………………………………………………149 Data analysis……………………………………………………………………………...153 Chapter 4: Findings………………….………………………………………………………...156 Applying critical realist lens……………………………………………………………...157 Findings ………………………………………….............................................................158 Chapter 5: Discussion..………………………………………………………………………..181 Implications for theory…………………………………………………………………...184 Implications for practice and education………………………………………………….188 Recommendations for future research……………………………………………………189 Limitations………………………………………………………………………………..190 Appendices Appendix A - Interview questions……………………………………………………………...205 Appendix B - Summary of definitions………………………………………………………….205 Appendix C – Summary of research...…….……………………………………………………213 - Summary of empirical research in nursing………………………………………213 - Summary of empirical research in social work….……………………….……...219 - Summary of theoretical methodological literature in social work……………... 224 Appendix D - Informed Consent Form…………………………………………………………229 Appendix E – Instructions…………...…………………………………………………………232 Appendix F – Related theoretical concepts……..……………………………………………….233 Appendix G – Invitation to participate..…………………………………………………………239 v References……………………………………………………………………………………..243 vi List of Tables Table Page 1. Intensity and frequency of MD among Health Care Profession………………………….7 2. In search of a paradigm…………………………………………………………………122 3. Common themes………………………………………………………………………..159 4. Critical Realist Conceptualization……………………………………………………...165 5. Summary of definitions…………………………………………………………………205 6. Empirical nursing research cited in this study…………...…………………………….213 7. Empirical Research in Social Work…………………………………………………….219 8. Summary of theoretical methodological literature in social work……………………...224 vii List of Figures Figure Page 1. Model for theory of moral distress…………………………………………………………28 2. Moral suffering, conceptual model……………………………………………………….108 3. Grounded theory model of moral distress………………………………………………...185 viii Chapter 1 Chapter one introduces the research topic and provides a basis for the relevance of the topic and contributions this thesis will make to theory, practice, policy, and social work education. Introduction Moral distress (MD) has been described as a psychological state that manifests itself through experiences of compromised moral integrity. It can have physiological, emotional, behavioral and spiritual effects on those experiencing it. Given its power to elicit such negative emotional responses, moral distress has been suggested to be a major contributing factor in decreased job satisfaction for nurses and other healthcare professionals; resulting in many withdrawing from their duties, changing positions, or leaving the profession entirely (Hamric, 2012). Although well documented in nursing and other helping professions social work (SW) scholars are surprised that it is not sufficiently characterized in the social work literature (Weinberg, 2009; Oliver, 2013; Lynch and Ford, 2016; Openshaw, 2011). Social workers share similar ethical responsibilities with nursing and frequently confront similar ethical challenges. Both professions are social agents working to improve the quality of lives, both uphold codes of ethics depicting their profession as moral endeavors, and both are gendered professions with strictures on autonomy and status that contribute to the stress of pursuing their moral and ethical practice (Weinberg, 2009). However, not all SW scholars agree that the contributing factors of moral distress are indistinguishable among social workers, nurses and other health care providers. Some authors suggest there are significant differences and recommend that unique forms of measurement are required to classify MD factors with the SW profession (Oliver, 2011, 2013; Mänttäri-van der Kuip, 2016; Lev & Ayalon, 2016; Lynch & Forde, 2016), while other scholars highlight parallel experiences and denote analogous causal factors of moral distress 1 within different contexts (Houston, S., Casanova, M., Leveille, M., Schmidt, K., Barnes, S., Trungale, K., and Fine, R., 2013; Kalvemark et al., 2004; Wienberg, 2010; Fantus et al. 2017). This study seeks to illuminate the multifaceted interaction of causal factors related to moral distress in social work by integrating practical social work experiences, values, concepts, definitions and theories with the existing literature and analyzing their relationship with other influential constructs. The data from this study will accentuate moral challenges in everyday SW practice. Social work practitioners commonly encounter ethically challenging circumstances, and it is highly probable that they will experience MD at some point in their career. The need to establish a nuanced understanding of MD in SW has never been greater. Indeed, recommendations from the Honorable Ted Hughes in the Phoenix Sinclair inquiry reveal the ‘real-world’ challenges of social work. In reference to ethical challenges of front-line social workers, Justice Hughes stated, “I believe that the social