“Their needs are higher than what I can do”: Moral distress in providers working with Latino immigrant families

Abstract

Social service providers tasked with alleviating the problems of the most marginalized and vulnerable populations are at particular risk for work-related stress and subsequent burnout. This article aims to move beyond individualized understandings of provider burnout and render visible the structural barriers that limit providers’ capacity to authentically help their clients. Guided by the concept of moral distress, we examined the experiences of 17 service providers who deliver behavioral and mental health services to Latino immigrants in a metropolitan area in Texas. An applied thematic analysis of individual interviews collected in 2015 revealed providers’ frustration with the countless systemic issues and helplessness in their inability to make substantial changes in their clients’ lives. This emotional toll, in turn, created a cycle where providers’ capacity to envision authentic, systemic change became limited. Our findings suggest that social work needs to go beyond the recommendations for self-care to prevent provider burnout and to address the inherent paradoxes in service provision to oppressed and vulnerable groups. We urge a shift toward a social action model to show an authentic commitment to social justice and to empower both providers and the marginalized populations they serve.

Keywords

Service providers burnout moral distress Latino/Hispanic immigrants mental health

Introduction

The National Association of Social Workers (NASW) recognizes the wellness of social workers as a key component of “competent, compassionate, and ethical social work practice” and calls for professional self-care (NASW, 2008: 269). A burgeoning literature has documented the myriad demands placed on social workers and the consequences such demands hold for their physical and mental health. The concept of burnout has gained the most attention in pointing to the emotional exhaustion that stems from overwhelming work demands (Maslach et al., 2017) and its detrimental impact on the well-being of social workers, their clients, and the organizations within which they work (Lizano, 2015; Lloyd et al., 2002). The individualized understandings of provider burnout and self-care, however, may not be sufficient in capturing the experience of providers tasked with alleviating the problems of the most marginalized and vulnerable populations.

A growing body of research suggests that providers working within mental and behavioral health settings are at a greater risk for burnout in comparison to other health or social service providers (Eliacin et al., 2018; Green et al., 2014). Efforts to understand why often highlight individual-level factors (e.g. low self-esteem, poor coping mechanisms) and work characteristics, such as caseload (Green et al., 2014). Yet, some scholars have begun to question micro-level perspectives of burnout. Social workers operate within a cultural, political, and economic context that shapes the provision of social services (Fook, 2016), which in turn, likely affects experiences of burnout. As Weinberg (2009: 149) points out:

the neo-liberal environment in which social workers function creates huge stressors due to erosion of the social safety net, reductions in resources, and increasing restrictions on the autonomy of professionals, making it very difficult for them to fulfil that desire for goodness.

In an effort to capture the structural dimensions that potentially shape burnout, this article draws on the concept of moral distress to explore the experiences of social service providers working with Latino immigrant families. In doing so, we document how macro-level barriers forced upon clients simultaneously shape the capacity of service providers who are trying to help them.

Provider burnout and moral distress

Maslach et al. (2017) identified three dimensions of the burnout experience: exhaustion, cynicism, and decline in professional efficacy. Characteristics of burnout thus extend beyond notions of fatigue to include the development of negative attitudes toward clients, increased work dissatisfaction, and perceived decrease in personal accomplishments (Maslach et al., 2017; Salyers et al., 2015). Social workers who experience burnout are more likely to suffer from poor health, including physical and emotional exhaustion, anxiety, and depression (Lizano, 2015; Lloyd et al., 2002). Additionally, burnout diminishes provider’s capacity to engage with clients in an empathetic and compassionate manner, thereby hindering the quality of services and client satisfaction (Green et al., 2014; Morse et al., 2012). Burnout also holds financial implications for agencies: it decreases work productivity and increases rates of employee turnover (Paris and Hoge, 2010).

There is growing recognition that the greater structural demands placed on social workers likely increase risk for burnout (Engstrom et al., 2009). Yet, many of the recommendations to prevent burnout focus on the importance of self-care, coping strategies, and stress management interventions (Baranowski, 2015; Coyle et al., 2005). Such a focus obscures the fact that burnout often stems from factors that are beyond the control of social workers. As Maslach (2017: 143) pointed out “there is a bias toward fixing people, rather than fixing the job situation.” The amelioration of provider burnout necessitates attention to broader structural processes (Wall et al., 2016). As such, an increasing number of social work scholars have called for deeper attention to the concept of “moral distress” (Fantus et al., 2017; Mänttäri‐van der Kuip, 2016; Oliver, 2013; Weinberg, 2009). Moral distress extends an understanding of burnout by considering providers’ requisite responsibility to uphold professional values and ethics and the organizational, institutional, and political barriers that preclude them from doing so (Jameton, 1984; Weinberg, 2009). Specifically, providers might develop burnout because of large caseloads, but become morally distressed when they think that the large caseload is negatively affecting the quality of the services they can deliver (Wall et al., 2016). Thus, moral distress recognizes the political dimension of social work practice by shifting attention away from the capacity of individual providers to the structures which fail both, them and their clients (Lynch and Forde, 2016; Weinberg, 2009).

To date, most research on moral distress has taken place within the field of nursing (e.g. Austin et al., 2003; Cummings, 2010; Jameton, 1984) and has only recently been extended to hospital social work (Fantus et al., 2017; Fronek et al., 2017). Arguably, the experiences of providers who work with the most marginalized groups, such as Latino immigrants, also require special examination given the many constraints and pressures they experience on the job. Indeed, the Trump administration (Byers and Shapiro, 2019) and the climate of economic austerity (Baines and Cunningham, 2015; Banks, 2011) have had a particularly negative impact on the most marginalized and oppressed groups.

Working with Latino immigrant families

The current oppressive immigration climate in the United States and exclusionary immigration policies further add to the complexity of ensuring adequate service provision to immigrant clients (Byers and Shapiro, 2019; Van Natta, 2019). For example, due to escalations in punitive measures that target undocumented individuals in the U.S., a growing number of Latino families experience forced family separations or live in the constant fear of deportation (Candel and Fayazpour, 2019; Križ et al., 2012). Studies have highlighted the various ways in which the anti-immigrant policies put Latino immigrant families at risk for mental health problems, financial hardship, and housing insecurity (Casteñeda and Melo, 2014; Lovato, 2019). In addition, even when Latino immigrant families may be eligible to apply to public services, few parents enroll their children when a member of the family is undocumented due to fear of deportation (Casteñeda and Melo, 2014).

Studies have begun to document the experiences of providers working with Latino immigrants and potential factors that may put them at a risk for burnout (Baranowski, 2015; Engstrom et al., 2009; Jones, 2012; Lanesskog et al., 2015, 2019). Jones (2012) found that social workers providing services to Latino immigrants in New York often felt frustrated and powerless. They reported working “against the grain” and in a “hostile working environment” (Jones, 2012: 47) including restrictive social welfare and institutional policies that limited services for undocumented immigrants. Similarly, mental health practitioners working with undocumented immigrants along the U.S./Mexico border reported feeling limited in their capacity to address the distinctive needs and circumstances of their clients, who faced significant financial barriers, had no health insurance, and were in a constant fear of immigration enforcement (Baranowski, 2015). In addition, there are unique stressors related to the provision of language-appropriate services and resources. For example, bilingual providers are often tasked with additional work responsibilities related to translation and being called in to serve as an interpreter (Engstrom and Min, 2014). As Lanesskog et al. (2015: 314) concluded, Latino-serving workers seem to be “stretched beyond capacity.”

Given the greater structural demands placed on social service providers working with Latino immigrant clients, there is a critical need to understand the experiences of provider burnout more deeply. In this article, we use a qualitative instrumental case study design to explore the experiences, challenges, and recommendations of mental and behavioral health providers working with Latino immigrant families.

Methods

Data presented below draw from a larger qualitative study that explored the experiences, perspectives, and needs of community leaders, stakeholders, and social service providers who worked predominantly with Latino immigrant families in a metropolitan area in Texas. The goals of the larger project were to identify: (1) community mental health concerns and service barriers and (2) avenues to promote mental health among Latino immigrant families. Using a site-based sampling approach (Arcury and Quandt, 1999), the research team identified sites in which potential participants were likely to work. Identified sites included non-profit agencies, school-based services, primary care and behavior health clinics, churches, and after-school programs.

After receiving permission from each site, the team recruited potential participants by posting flyers at organizations and through agency list-serves. In the case of the latter, the research team sent recruitment emails to list-serve owners, who distributed the email following approval. Respondent-driven methods, a modified version of chain referral (Trotter, 2012), supplemented these recruitment efforts. Specifically, interviewers asked enrolled participants if they knew other programs or agencies that provided services to Latino immigrant families, and if so, to distribute study recruitment flyers to at least one person in that agency.

The research team enrolled potential participants in the study if they met the following criteria: (1) age 18 or older and (2) actively provided services to a predominantly Latino immigrant population. Based on these criteria, the research team enrolled 24 participants—representing 21 different organizations—in the larger study. All participants provided written consent for participation, and the university’s review board granted IRB approval.

Instrumental case study design

During preliminary analysis of data collected in the larger study, a common practice in qualitative research (Miles and Huberman, 1994), we observed that behavioral health providers, including social workers, mental health counselors, and healthcare outreach coordinators, described feeling helpless in their capacity to assist their clients. In other words, it seemed as if this sub-group of providers experienced a unique form of burnout in comparison to other participants in our study. To uncover deeper insights about this preliminary observation, we implemented an instrumental case study design and selected for analysis only those interviews with participants providing mental and behavioral health services. In doing so, we hoped to examine the dimensions and complexities of provider burnout more deeply and produce new insights (Stake, 2000). To this end, we endeavored to answer the following research question: how do the constraints social service providers experience in the context of working with Latino immigrant families shape burnout?

Instrumental case sample

Below, we focus on data collected with a sub-sample of 17 participants from the larger study who provided mental and behavioral health services. The majority of participants held a master’s of social work or related degree. Providers worked in a variety of settings, including schools, child guidance centers, behavioral health and primary care clinics, juvenile justice system, organizations specializing in domestic violence and sexual abuse, legal assistance for unaccompanied minors, or substance abuse rehabilitation. In the sub-sample, most providers were women (76%) and self-identified as White (53%). Six participants (35%) identified as Latino/a and two were first-generation immigrants. To protect the confidentiality of participants, we report their professional roles in broad terms, and all names used are pseudonyms.

Data collection

Data collection took place from March to December 2015. All participants completed a qualitative interview that explored providers’ experiences working with Latino immigrant families, including perceptions of how immigration contributes to experiences of psychosocial adversity, barriers, and potential solutions for supporting this community. Interviewers used probes to elicit detailed and specific examples of providers’ experiences. Interviews ranged from 27 to 60 minutes with an average length of 41 minutes. One interview was conducted in Spanish, and the remaining interviews were conducted in English.

Data analysis

The research team utilized applied thematic analysis (Guest et al., 2012) to consider the thoughts, perceptions, and feelings of participants regarding their experiences working with Latino immigrant families. We generated an audit trail to facilitate team-based analysis and record coding and interpretive decisions (Rodgers and Cowles, 1993). Analysis proceeded in three stages. First, both authors generated preliminary themes through a comprehensive reading of half of the instrumental cases. Then, we defined and arranged preliminary themes into a codebook, which we revised through an iterative process of reading and re-reading interviews with the remaining cases. We reached saturation after the analysis of 15 interviews, at which point the codebook stabilized (Guest et al., 2012).

During the second phase of analysis, we focused on developing the properties of emergent themes by comparing and contrasting dimensions of themes in the data with existing conceptual frameworks in the literature (Timmermans and Tavory, 2012). Our efforts to capture the empirical realities of burnout among behavioral health providers led us to of the concept of “moral distress,” as elaborated by Weinberg (2009). Drawing on this framework, we operationalized moral distress as encompassing two dimensions: (1) the structural barriers that limit providers from delivering services in ways they deem as ethical and (2) the emotional ramifications of experiencing those barriers.

In the third phase of analysis, each author coded the interviews independently to compare, revise, and contextualize the theme and dimensions of moral distress within participant interviews. We held regular meetings over a six-month period to compare the coding, reconcile any disagreements, and to illustrate visually the process through which moral distress emerges. We worked across both coded text and individual interview transcripts to describe the experiences of providers in the sub-sample (Sobo, 2009).

We used the principle of intensity sampling, in which an information-rich case is chosen (Patton, 1990), to draw on the case of Linda because it provided the deepest and the most pertinent information about emergent themes. Even though Linda’s narrative does evoke the themes seen throughout the interviews, our intention is not to suggest that Linda’s case is representative. Rather, we utilize her case to illustrate important links among themes, especially as it relates to how moral distress emerges and becomes amplified in the existing social services’ structures. We then compare and contrast Linda’s experiences with other participants in our study to explore variation in the experiences of moral distress across different social service settings (see Simons, 2014).

Findings

The findings are organized into four themes that describe experiences of burnout among behavioral health providers working with Latino immigrant families: (1) “the system has failed them;” (2) compromised service quality; (3) “who really can help?;” and (4) individual solutions to structural problems. Figure 1 provides a visual illustration of the providers’ social reality in working with Latino immigrant families.

Figure 1.

Factors producing and perpetuating moral distress in providers working with Latino immigrant families.

“The system has failed them”

Providers who worked with Latino immigrant families described the many ways in which systems and institutions failed their clients, including poverty, lack of affordable housing, overcrowding, separation of families through deportation, lack of quality education, and inaccessible healthcare services. This created a work environment in which providers attempted to address clients’ needs and issues, but often in ways that were beyond their immediate reach and capacity. Communicated with skepticism in some cases and in a matter-of-fact tone in others, providers’ descriptions of their work with immigrant families seemed to convey a daily work reality that was highly problematic in terms of service provision.

For example, when asked about the broader issues affecting Latino immigrant families, Linda responded in the following way:

There’s a lot. I would say poverty is a big one. Just not being able to access the social safety net that other people in poverty can access like food banks, food stamps, housing benefits, and things like that. Not that there’s a lot out there for anybody.

Linda appeared skeptical about the tangible options of help for low-income families. She explained that rising housing costs and unemployment further exacerbated experiences of poverty, especially among families wherein one or more members might have undocumented immigration status. Linda added that many families did not reach out for help because “there’s also like the distrust of the system, not that I blame them, not that it’s an immigrant thing at all. A lot of people distrust the system, and I don’t blame them at all.” Just like her clients, Linda did not seem to expect the current system of service delivery to be able to address effectively the disparities facing the immigrant families she was trying to help.

Other participants also emphasized the systemic barriers that immigrant families faced in their daily lives. For example, many providers talked about how Latino immigrant parents had to work two or three jobs to be able to make a living in the U.S. due to the low minimum wage. This in turn, limited the time they could dedicate to their children and families and often required youth to start working at an early age to help their families financially. Some providers reported that in addition to the poverty and overcrowding that many Latino immigrant families experienced at home, residential segregation shaped additional stressors. According to Susan, who worked as a social worker within a school setting, families were often “trapped and isolated” in “immigrant enclaves” ridden by poverty, lack of access to healthcare and social services, and a high mobility of residents. Susan added that many families did not have access to health insurance, which further added to their stressful living situations. These issues were often tied to immigration status. Aimee, a counselor in a hospital setting, explained that many of her clients struggled with some kind of immigration-related problem:

A large portion of the parents are new immigrants or have some type of immigration related concerns. So, maybe the child is here. They’re not an immigrant, but dad has been deported recently. So, there’s been stress in the family. The child is living in the United States, but mom and dad are back in another country for a little bit. So, trying to figure out custody issues.

Compromised service quality

Providers’ narratives shed light on the dual nature of the system of service provision: the system fostered inequality by creating structural barriers for clients, while simultaneously limiting individual capacity to deliver services. Providers frequently expressed dissatisfaction and frustration as they reflected on their own position within a system that provided limited social services, long waitlists for care, shortage of bilingual services and providers, and a general lack of resources for their clients. As a result, providers felt personally affected by systemic failures that engendered a shortage of providers; experiences of being overworked; and the need to perform tasks outside providers’ job descriptions.

Having worked in the juvenile justice system for only two years, Linda has already become very dissatisfied and critical of how the system worked. Linda explained that while the youth she worked with were still in the juvenile justice system, they had access to mental health and other social services. Once they were released on probation, however, they lost access to all of their services. She experienced the dilemma of wanting to ensure her clients received the treatment they needed, but also facilitating their release from the justice system quickly: “And it’s like, ‘Ok, but when I get out, I have no services.’ And so, that’s a really big struggle. I don’t want anybody to want to stay on probation due to services.” Linda reported that she always tried to link her clients with community services but emphasized that the wait lists were “tremendous.” In a similar manner, Jane, a school counselor, reported that the main thing they need is more providers: “I feel like we could have five times as many of us and that would probably begin to address really the level of what we could actually do for the students.”

The shortage of bilingual services and providers was another reason for compromised quality of care that many participants discussed. David, a bilingual mental health counselor, explained that the majority of his co-workers struggled with communicating with immigrant clients. He described how language barriers sacrificed the quality of services: “If there’s a language barrier, that’s huge in terms of trying to assess somebody appropriately and fully.” Language barriers were observed by providers working across settings. For example, Ana, who provided mental health services in a large elementary school, reported: “I’m one of the only people that provide mental health services on campus that is Spanish-speaking.” She explained that she frequently learned that students who needed assistance were underserved because of the language barrier. Similarly, Linda was shocked by the lack of bilingual providers in institutions such as psychiatric hospitals: “Even at a psych hospital - they don’t have bilingual staff. They use the cleaning staff to interpret at a psych hospital. And I’m just like, you got to be kidding me.” Linda was additionally frustrated by the comments she frequently heard that there were no Spanish-speaking applicants for clinical positions:

My daily rant “Why is it so hard to find bilingual clinicians?” What is it in our policies, or in our education system, or in our structure? Like institutionalized racism, like what is going on that we cannot find them? Because that’s what I’m told over and over again “Well they’re just not there.” And I’m like “Why?” What are we missing?

Linda lamented the fact that her basic proficiency in Spanish limited her capacity to provide counseling to her Spanish-speaking clients, and she wished her graduate school had prepared her better for the practice setting.

Participants also described experiences of being overworked and having to perform tasks outside their job descriptions, which compromised the quality of services. For example, Camila, who worked with youth involved with the legal system, described how difficult it was to find services for kids in schools where social workers and counselors were drastically overworked: “a lot of the services that are available at the schools or in places where the kids might be, I mean, they’re spread very thin. The need is so great, and there might be one counselor for 300 kids.” Being asked to perform tasks beyond providers’ job descriptions and expertise was also common. For example, Gloria, who worked with Latino immigrant survivors of domestic violence or sexual abuse, reported how she had to respond to the case management needs in the agency even though it was beyond her assigned tasks as a counselor: “a lot of my time will end up going to case management things. And I would be able to focus more on counseling if there was more help with that.” Compromised service quality, as described in provider narratives, was perceived as negatively affecting work experiences and causing increasing dissatisfaction.

“Who really can help?”

Given the countless structural barriers facing both clients and providers, providers’ perceived inability to make substantial changes in their clients’ lives set the stage for the emergence of helplessness. Being significantly constrained by the system took an emotional toll on the providers in form of frustration, disempowerment, and doubts in the effectiveness of their work. Providers described being tired and overwhelmed by the expectations to do more than they were capable of doing given a variety of systemic barriers, the limitations of their training, and time constraints. Additionally, providers were guided by internal, moral, and professional standards and expectations to address the needs of their clients. Facing countless constraints in their efforts to address those needs often led to losing hope in the value of their work.

Most often, providers’ narratives manifested helplessness, which culminated in feelings that there was nothing providers could do to really help their clients or improve their situation. In Linda’s case, feelings of helplessness emerged as she reflected on the fact that her clients were frequently unable to meet their basic needs, such as food and healthcare. For example, she explained that some youth entering the juvenile justice system “haven’t eaten anything in days.” When asked how to address these needs, she replied: “We can help as much as we can help, but just systematically - it’s broken, it’s not a good scene.” Linda seemed to be overwhelmed and disempowered by the tremendous injustice the immigrant adolescents were facing in their lives. Throughout her narrative, Linda used expressions, such as “there’s nothing I can do,” “it’s out of our hands,” and “that’s a really big struggle” to describe her inability to provide the help her clients really needed.

Similar to Linda, other providers described working in a context where they were constantly reminded of their inability to make changes they perceived as essential to supporting their clients authentically. When asked what challenges she faced in her work, Gloria described the “overwhelming” amount of needs within the families she was serving. Faced with the enormous gap between the needs of her Latino immigrant clients and what she was able to provide in her counseling role, Gloria questioned the ethical implications of this imbalance:

I’ve worked with clients for a little bit, and realized that their needs are higher than what I can do. So ethically, I really shouldn’t keep working with them, but it is really hard to find the next step. Who really can help?

The overall feeling of helplessness permeated providers’ interactions with families. Providers came to understand that the myriad needs and problems families experienced were often beyond their capacity to provide assistance. Yet, the expectations that a provider’s role was to help alleviate social problems remained.

Individual solutions to structural problems

Although providers were keenly aware of the structural limitations placed upon them and their clients, attention to structure often faded when asked what interventions were needed to solve the many problems described above. The majority of providers suggested solutions which aimed at client behavioral change, coping skills, and education. Few providers called for advocacy and community development efforts to improve the quality of life and mental health outcomes of Latino families.

For example, in spite of her heavy focus on structural barriers in analyzing the needs of Latino immigrant families, Linda rarely described structural change in her narrative. She did emphasize the importance of community resources, especially in terms of creating a sense of connection for the youth in the juvenile justice system: “A place to belong, a society that cares about them,” and “connection to school and just connection to the community in general.” Yet, she also emphasized a larger need for access to mental health services. While equitable access to quality mental health services is certainly important, such a change would do little to solve the problems Linda mentioned as being most salient in the lives of her clients: poverty, housing shortages, and undocumented legal status.

In a similar manner, Nancy, a school counselor, recognized that many of the issues affecting her clients’ mental health were situated in structural causes, such as low family income and instability in the communities. Yet, when asked what a potential solution would be, she responded, “Counseling [laughing] - for everyone.” She expanded her vision for service provision by incorporating both youth and the family, noting, “There’s only so much you can do with just the kid.” Yet, she prioritized interventions aimed solely at micro-level change:

(…) a big part of it is counseling and support but not only with the teens. It is support for the families also, like education for the families, and facilitation of accessing resources and then, yeah, I mean counseling, even a support type group.

The words of Amelia, a school counselor, further summarize the focus on changing individuals rather than systems that was visible throughout the interviews: “For help we need counseling - lots of counseling!”

Importantly, there were few exceptions to this general pattern. Some providers called for initiatives such as advocacy, community development, and preventive efforts to improve the quality of life and mental health outcomes of Latino families. Susan emphasized that to make a difference in the lives of the families, the focus needed to be on their living conditions and community environment. Susan talked at length about how affordable housing and “strong, targeted, community development programs” were some of the highest necessities that should be addressed. She placed the experiences of the youth she worked with in the context of their neighborhood and suggested that “beefing up the community neighborhood supports is really important.” She also talked about the need to mobilize communities and work with community leaders on important issues that affect the neighborhoods. Susan tried addressing structural issues, such as unstable neighborhoods, with structural changes, specifically strengthening the neighborhoods where her clients lived.

Discussion

The current study is the first to examine the experiences of providers working with Latino immigrant families from the angle of moral distress. Our findings illustrate how working with this marginalized group produces and perpetuates providers’ moral distress: they are expected to help clients address needs to improve their lives, yet they are severely limited in their capacity to enact authentic change due to institutional and structural barriers. The interaction of the systemic failures and compromised service quality creates an environment within which feelings of helplessness, dissatisfaction, and disempowerment emerge. This emotional toll in turn creates a cycle where providers’ capacity to envision authentic, systemic change becomes limited.

Most notable was the tension between structural problems and individual solutions. Despite frustration with the current context of social service provision, the majority of providers did not envision structural change, but rather highlighted individually focused interventions. Although providers usually situated their clients’ problems within broader social and institutional systems, their vision for what was needed seemed somewhat decontextualized. Consequently, responsibility for improving clients’ lives was placed solely on individuals—providers and clients alike. This may indicate that service providers ascribe to the ideology which seems to have dominated the social service sector and which views health and well-being as a matter of individual responsibility, even in the most difficult circumstances such as poverty and social isolations. Structural problems thus continue to be addressed with predominantly individual-level solutions.

In this study, some of the unique challenges faced by providers were related to the undocumented status of some of their clients. Nevertheless, legal status does not insulate the majority of Latino immigrants from experiencing other forms of injustice such as structural racism (Viruell-Fuentes et al., 2012). In addition to struggling to address clients’ immediate needs, such as healthcare and housing, providers are challenged with facing and responding to the negative public discourse that portrays Latino immigrants as criminals, lazy, and unworthy of help. The autonomy of service providers and ability to do what they believe is needed is thus severely limited by many forces beyond their control. These collisions and inherent paradoxes in service provision to oppressed groups seem to inevitably lead to the providers’ experience of moral distress. Our findings resonate with previous research which pointed to the stressful work environment of providers working with Latino immigrant clients (e.g. Jones, 2012; Lanesskog et al., 2015, Lanesskog et al., 2019). Nevertheless, this study expands our understanding of the implications of working with highly marginalized populations. Working in a context of countless systemic barriers facing clients is not just stressful for the worker, potentially leading to burnout; it also causes an incongruence between social work professional values/ethics and the providers’ everyday reality.

Beyond self-care

The study findings imply that addressing providers’ burnout through individualized and psychological interventions, such as coping, self-care, stress management, or mindfulness training (Coyle et al., 2005; Wendt et al., 2011; Wilson, 2016), is insufficient. Although potentially beneficial in alleviating some of the burnout symptoms, self-care strategies do not address structural constraints of service provision, such as insufficient resources and other root causes of providers’ burnout. Until the systemic constraints that providers face in their work environment are adequately addressed, the vicious cycle of providers’ moral distress and likely burnout and turnover will continue. Thus, moral distress needs to be viewed as problem for the social work profession, not just for the individual providers or even for their work settings. Social work education needs to include a discussion on moral distress to prepare social work students for the ethical and moral challenges they will face in the contemporary field settings (Lynch and Forde, 2016; Oliver, 2013). Future service providers need to understand the tensions they are likely to experience as a result of the limitations of the social service delivery model in addressing the structural barriers Latino immigrant families and other marginalized groups face. More importantly, social work education needs to incorporate more content on macro-level interventions, especially advocacy and social action. In face of the tremendous social injustice affecting thousands of immigrants, the profession needs to be actively involved in advocacy against the anti-immigrant policies and public sentiments.

Given the exploratory nature of the study, the purposive sampling methods, and focus on service providers from one city, we should avoid generalizing from these findings. It is also likely that the perspectives of other professionals working with immigrant families or even within the same professions may vary. Moreover, this study was not intended to be comparative between the responses from White practitioners and bicultural and/or bilingual practitioners. Given these limitations and the nascent state of research on moral distress in behavioral and mental health services, there is an ample room for future studies including an exploration of the providers’ contradictions between their analysis of the problems facing clients and proposed solutions. It would also be important to examine the experiences of providers who work with different marginalized groups, including refugees and asylum seekers, clients living in poverty, or those with a criminal background, as the systemic barriers these clients may face are apt to go beyond the providers’ mental health and behavioral training and lead to moral distress.

Conclusion

The findings of this study suggest that there needs to be more attention and acknowledgment of the various systemic constraints placed upon clients and the service providers who are trying to help them. Understanding organizational and structural barriers from the perspectives of providers—and the ways in which such barriers shape moral distress—can yield important contextual information on the quality of provider–client interactions and ways to improve social service delivery. Nevertheless, long-term solutions to the systemic failures that the most vulnerable clients face and the resulting experience of moral distress in service providers require a radical shift in social work and related professions. A shift toward a social action model would show an authentic commitment to equity and social justice and to empowering both providers and the marginalized populations they serve.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Katarzyna Olcoń

Lauren E Gulbas

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