Norma Jean Profitt, MSW, PhD, RSW
Several years ago I left my employment due to perpetual moral anguish. Since then I have tried to understand how my moral fibre came to be eroded by institutional policies and practices. A friend recently inquired whether I had burned out; in her feminist framework, burnout has political, economic, social, and cultural roots. Although I don’t believe that I burned out in the traditional sense of the term, the violation of my deeply held values and ethics did culminate in a kind of moral crisis. Here I suggest that a critical rethinking of what we typically call “burnout” may help some social workers name what they are experiencing in hierarchical settings and elsewhere.
Christina Maslach and Susan Jackson (1981) defined burnout as a syndrome of emotional exhaustion/depletion, depersonalization and cynicism, and decreased professional efficacy. In depersonalization, helpers lose their compassion for the people they serve and treat people in demeaning ways. Although researchers and practitioners have increasingly underlined the role of organizational factors in burnout (Edú-Valsania et al., 2022), burnout has commonly been understood as an individual psychological phenomenon in which individuals fail to cope, lack resilience, or neglect self-care in dealing with ongoing work stress. Consequently, strategies to combat burnout are individualistic in nature such as mindfulness, yoga, and the ubiquitous bubble bath.
The notion of moral distress has formed part of our social work vocabulary for some time (Weinberg, 2009) and I have written about it on two occasions in Connection Magazine (Profitt, 2022, 2021). Moral distress can be succinctly understood “as anguish or anxiety tied to a sense of imperiled integrity” (Carse & Rushton, 2017, p. 16). The literature on moral anguish across disciplines has now expanded to encompass the concept of moral injury (Weisleder, 2023). Originally developed by psychiatrist Jonathan Shay to capture the narratives of war veterans (Cahill et al., 2022), moral injury has been applied to the helping professions to refer to the angst helpers feel when they perpetrate, fail to prevent, bear witness to, or learn about acts that transgress deeply held moral beliefs and expectations (Litz et al., 2009, p. 700). Betrayal by people in leadership and positions of power or peers may form part of the dynamic of moral injury.
In the process of disillusionment that ended in my departure from my employment, there were many factors at play that generated my moral suffering. For example, new frameworks and policies imposed from the top down without any input from service users or frontline staff and the steady ascendancy of the medical model led to the feeling of being trapped in an ever tightening vice. The act of carrying out policies and practices to which I was opposed was spiritually corrosive. Even though I tried to evade or work around them, I felt morally implicated in the violation of service users, in other words, complicit.
In contrast to Maslach and Jackson’s component of depersonalization, integral to the definition of burnout, I felt a heightened sense of ethical commitment to service users and sensitivity to how they were affected by program changes. I did not experience a reduced sense of professional efficacy in relation to service users; however, such a response would have been perfectly comprehensible in the circumstances. Add to this scenario the wearying emotional labour involved in navigating management expectations to be “positive” and a “team player”, meaning to refrain from voicing thoughtful critique. In effect, I was expected to erase myself as a moral agent.
Research on moral anguish in the helping professions reveals complex and nuanced relationships among moral distress, moral injury, moral sensitivity, moral courage, moral resilience, and burnout. Studies have found moral distress to be a significant contributing factor in burnout (Epstein & Hamric, 2009; Fumis et al., 2017; Maunder et al., 2023; Oh & Gastmans, 2015; Shoorideh, 2015). Both theorists and practitioners strenuously argue the same (Dzeng & Wachter, 2020; Epstein et al., 2020; Weisleder, 2023). Others claim that what we have been calling burnout is more likely to be moral injury (Dean et al., 2019), which is distinct from burnout (Dean, 2023), the feeling of having fizzled out (Weisleder, 2023). Indeed, research shows that moral distress and burnout are close phenomena (Fumis et al., 2017). Given our social work values and ethics, some degree of moral distress is likely inherent in practice, suggesting that moral sensitivity to issues of justice and unethical actions is a prerequisite to moral distress (Mänttäri-van der Kuip, 2020).
Recent literature suggests that betrayal by leadership and those in power in institutions and organizations is the root of moral injury (Cahill et al., 2022; Dean, 2023). The assumption here is that we, as social workers, believe that our moral understandings and expectations are shared by institutions, administrators, managers, and even by society at large and thus feel betrayed when we realize they are not. As advocates of social justice cognizant of structural and systemic oppression, this assumption may be misplaced. Even so, we can still feel betrayed by people in leadership positions with whom we may have moral relationships, and at the same time, by institutions for failing service users in need.
Alongside possible betrayal, the act of facing into how institutions and systems hobble our ability to satisfactorily carry out our moral responsibilities according to our ethical principles is really taxing. In the process of being hobbled we can harm others and enact moral wrong, which then, in turn, can fracture our moral identities. Moral identities encompass “what a person takes responsibility for, responds to, is concerned about, cares for, and values” (Walker, cited in Peter & Liaschenko, 2013, p. 339). And so it is no wonder that we can come to feel “compromised moral agency” (Mänttäri-van der Kuip, 2020, p. 742) as well as reservoirs of grief.
The creation of counter-stories is critical in helping us repair fractured moral identities (Peter & Liaschenko, 2013; Molinaro et al., 2023). One counter-story is immediately available to us through exploring the political critique inherent in our experiences of moral distress and injury. We can plumb these experiences to reveal their embeddedness in broader socio-political structures of power and the complex social relations at play in institutions and organizations. It is vital that we draw attention to the social, institutional, political, and cultural forces that create the actual conditions for moral suffering, including feelings of powerlessness, frustration, and anger. As I have previously noted (Profitt, 2021), this is imperative because where institutions erase context and individualize moral distress, the individual professional can be perceived as both the source of failure and the site of remediation.
The development of moral communities of practice may fruitfully support efforts to make visible the conditions that generate moral anguish. Such a community can foster ethical reflection on “the troubled call of conscience” (Carse & Rushton, 2017, p.16) and the ways in which workplaces challenge our moral integrity through the “forced betrayal of our deepest values” (Wible, 2019). We can seek to clarify and understand the conditions and actors impinging on our moral agency and how we are affected ethically and spiritually.
Furthermore, we can thoughtfully consider “the limits of our own power, control, and understanding (Carse & Rushton, 2017, p. 22) and how internal constraints interact with external ones (Mänttäri-van der Kuip, 2020). We can also take stock of the harm caused by complicity and bystander negligence (Braxton et al., 2021). Importantly, we can explore ways to sustain and bolster our moral integrity and resilience in difficult work arenas. This can be tough to do when we are distressed and may find ourselves in heightened emotional states.
Circling back to my friend’s question about whether I had burned out, I would say now that institutional conditions made it impossible for me to live my moral commitments. In her blog “Burnout is bullshit”, physician and advocate Pamela Wible (2015) urges that we stop using the term burnout because it obscures important moral and ethical issues. I concur. Working under neoliberalism and managerialism, we have been obligated over and over again to serve the interests of other forces to the detriment of service users. Although we have always operated within practice constraints given the social structural inequalities present in society, challenges to ethical practice have deepened over time in the current context of austerity. And yet, we do find ways to resist and repair our bodies, minds, and spirits.
As advocates for social justice, we will always be amidst power dynamics and differences in ideologies, values, and allegiances. Therefore, ongoing progressive moral engagement is essential if we want to pursue social justice, individually and collectively. Understanding all aspects of moral anguish will enable us to engage more capably in such efforts. Cognizant of the potential pathologization of our existential and moral struggles, we can find ways, hopefully in community, to move through moral distress, moral injury, and “burnout”. We can, yet again, clarify and reaffirm our values and ethics, and, yet again, renew ourselves in an expanded sense of morality, for ourselves, service users, and the public good.
DR. NORMA JEAN PROFITT, RSW, is a social activist who holds her PhD in social work from Wilfrid Laurier University, and is a former associate professor in the School of Social Work at St. Thomas University. She was the recipient of the Governor General’s Award in 2016. Her prior articles in NSCSW’s Connection magazine include “The political language of moral distress” and “Moral distress & collective advocacy.”
References
Braxton, J. M., Busse, E. M., & Rushton, C. H. (2021). Mapping the terrain of moral suffering. Perspectives in Biology and Medicine, 64(2), 235-245.
Cahill, J. M., Kinghorn, W., & Dugdale, L. (2023). Repairing moral injury takes a team: What clinicians can learn from combat veterans. Journal of Medical Ethics, 49(5), 361-366.
Carse, A., & Rushton, C. H. (2017). Harnessing the promise of moral distress: A call for re-orientation. Journal of Clinical Ethics, 28(1), 15-29.
Dean, W. (2023). Moral injury – Healthcare systems in need of relational repair. American Association for Physician Leadership, 10(3), 46-48.
Dean, W., Talbot, S., & Dean, A. (2019). Reframing clinician distress: Moral injury not burnout. Federal Practitioner, 36(9), 400-402.
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Epstein, E., & Hamric, A. (2009). Moral distress, moral residue, and the crescendo effect. Journal of Clinical Ethics, 20(4), 330-342.
Epstein, E. G., Haizlip, J., Liaschenko, J., Zhao, D., Bennett, R., & Marshall, M. F. (2020). Moral distress, mattering, and secondary traumatic stress in provider burnout: A call for moral community. AACN Advanced Critical Care, 31(2), 146-157.
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Maslach, C., & Jackson, S.E. (1981). Maslach Burnout Inventory Manual. Palo Alto, CA: Consulting Psychologists Press.
Mänttäri-van der Kuip, M. (2020). Conceptualizing work-related moral suffering-Exploring and refining the concept of moral distress in the context of social work. British Journal of Social Work, 50(3), 741-757.
Maunder, R. G., Heeney, N. D., Greenberg, R. A., Jeffs, L. P., Wiesenfeld, L. A., Johnstone, J., & Hunter, J. J. (2023). The relationship between moral distress, burnout, and considering leaving a hospital job during the COVID-19 pandemic: A longitudinal survey. BMC Nursing, 22(1), 243.
Molinaro, M. L., Polzer, J., Rudman, D. L., & Savundranayagam, M. (2023). “I can’t be the nurse I want to be”: Counter-stories of moral distress in nurses’ narratives of pediatric oncology caregiving. Social Sciences & Medicine, 320, 1-8.
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Profitt, N. J. (2022). Moral distress and collective advocacy. Connection Magazine, 5(2), 16-17.
Profitt, N. J. (2021). The political language of moral distress. Connection Magazine, 4(20), 17-18.
Shoorideh, F. A., Ashktorab, T., Yaghmaei, F., & Alavi Majd, H. (2015). Relationship between ICU nurses’ moral distress with burnout and anticipated turnover. Nursing Ethics, 22(1), 64–76.
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Weisleder, P. (2023). Moral distress, moral injury, and burnout: Clinicians’ resilience and adaptability are not the solution. Annals of the Child Neurology Society, 1(4), 262–266.
Wible, P. Not “burnout”, not moral injury-human rights violations. March 18, 2019. Ideal Medical Care. Not “burnout,” not moral injury—human rights violations – Pamela Wible MD (idealmedicalcare.org)
Wible, P. Burnout is bullshit. December 16, 2015. Ideal Medical Care. Burnout Is Bullshit – Pamela Wible MD (idealmedicalcare.org)
I think one component that needs to be included in the discussion is “shame”. Shame is a complicated painful feeling and can include feelings of personal unworthiness and failure to live up to personal standards. We can feel shame when we have to enforce policies on our clients that we know are not helpful or even just. The questions for all of us are: How long and under what circumstances can we continue in a job when we feel so personally/professionally compromised? Dr. Profitt speaks about community where I presume she means others on the team may share and acknowledge the suffering under certain regimes. Obviously this would be important and can help ameliorate feelings of isolation or the sense one is “a voice in the wilderness” but what if others on your team or in your agency/institution do not acknowledge the same issues?