I’m Still Standing: Impacts and Consequences of Ethical Dilemmas for Social Workers in Direct Practice
by Donna McAuliffe, Ph.D., GSocRes, BSocWk (Hons)
The University of Queensland, Australia
Abstract
Social workers will inevitably encounter ethical dilemmas in their work. Ethical dilemmas can impact on social workers positively or negatively, at a number of levels, and in a range of ways. This paper outlines findings from a study in which Australian social workers detailed their experiences of ethical dilemmas, and discussed the short and long-term impacts and consequences resulting from these experiences. Recommendations are made for improved education and training for social workers in ethical decision-making, and the importance of professional support and supervision.
Key Terms
Social work practice; ethical dilemmas; job-related stress; organisational-professional conflict; moral autonomy
Introduction
Definitions of ‘ethical dilemmas’ in social work practice have been comprehensively addressed in the literature, with the essential agreement that for a ‘dilemma’ to exist, there must be a weighing up of competing principles within a context of mutually exclusive courses of action (Reamer 1983; Rothman 1998; Congress 1999; Banks 2001). Further clarification has been offered about the distinction between technical, legal and ethical issues, with the latter referring to those problematic situations that in some way relate to rights, responsibilities and obligations that have a moral and value-based foundation (Banks 2001). As the debate about ethics and practice standards inhabits a contextual and often contested landscape within social work, it is acknowledged that what constitutes an ethical dilemma for one social worker, may not necessarily constitute an ethical dilemma for another social worker – even within the same workplace or in relation to the same practice situation. It is important then, to recognise that when a social worker becomes involved in what they consider to be a moral quandary, this can be an intensely personal experience that can cut deep to the heart of entrenched personal values. While organisational directives and policies, legislative requirements and statutes, and professional ethical codes may lay down expectations in terms of agency mandate, law and practice standards, social workers will respond to these guidelines from a position of moral autonomy. The resultant impacts and consequences, both negative and positive, for social workers following involvement in a situation defined by them as an ‘ethical dilemma’ is the focus of this paper.
Literature and empirical research
There is little in the social work literature that has explored the impacts of ethical dilemmas on social workers. Holland and Kilpatrick (1991, p. 140) in their qualitative research have perhaps come the closest to touching on this subjective experience in noting that most of their participants (who were direct practice social workers) ‘expressed a poignant sense of loneliness or isolation in their struggle with moral questions’. It is a reasonable step to explore ethical dilemmas within the context of work-related stress, given that the very nature of a dilemma will engender some sense of struggle, and accounts from social workers through literature certainly suggest that ethical dilemmas are commonly complex and fraught with difficulty.
There has been an interesting progression in the literature and empirical research over the past two decades that has explored the links between occupational stress and workplace burnout, and the difficulties that social workers and other human service workers have experienced within organisational environments and in their relationships with clients, colleagues, and supervisors. A historical review of the literature shows that worker stress and burnout was framed in the early 1980s by the work of writers such as Cherniss (1980), Freudenburger (1980), Maslach (1982), and Pines (et al 1980) who found that human service workers subjected to stressful work environments could experience anxiety, depression, and stress-related disorders, as well as relationship problems or physical or mental illness. Later work conducted by Courneyer (1988) added to the picture, claiming that professional impacts of work stress could include lack of confidence in making decisions, changes in work performance, uncertainty about professional responsibilities, prejudice against certain clients, demotion or loss of employment. A study conducted by Weissman (et al 1983) found that for social workers involved in direct practice in child protection, anxiety about effects of decisions, difficulty in separating personal and professional responsibilities, lack of professional support and the need to be in control were contributing factors to ineffective management of cases. Hawkins and Shotet (1989) drew explicit links between work-related stress and moral indecision, claiming that stress caused by moral indecision may manifest on the emotional, cognitive, behavioural and physical levels, and could affect front-line workers either personally and/or professionally. Literature suggested that these personal and professional impacts may be increased or minimised depending on a worker’s supervisory and social support networks within the organisation (Pines et al. 1980). It was also suggested that professional autonomy could play a large part in moderating job stress (Cherniss 1980). While links between burnout and values were tentatively suggested (Walsh 1987), links with ethical issues were not explicitly drawn. Joseph (1983, p. 51) writing in relation to deinstitutionalisation of the mentally ill, noted that although ethical issues were prolific, and the potential for burnout was high, the ‘ethical strands have not been sorted out or articulated sufficiently’.
Against this backdrop, the social work literature began to explore the impact of job stress, role conflict and worker burnout in more detail (Donovan 1987; Jones 1993; Soderfeldt et al. 1995; Balloch, Pahl and McLean 1998; Um & Harrison 1998), including exploration of the impacts of burnout on personal (marital) relationships (Jayaratne, Chess & Kunkel 1986). A study conducted in the UK by Collings and Murray (1996, p. 382) exploring predictors of stress among social workers found work stress to be strongly related to ‘having no answer to clients’ problems (not being sure what to recommend)’. While research in the early 1990s largely continued to explore individual factors that predisposed workers to stress, organisational and structural factors became much more prominent in later research. Framing the issue in a more positive light, organisational climate factors that contributed to job satisfaction included collaborative collegial and supervisory relationships, an encouraging and trusting work environment, and involvement in decision-making (Bednar 2003). Factors that contributed to psychological and physical ill-health included the effects of work overload on personal lives, lack of control over work and decision-making, lack of social support, poor management, and unclear work roles (Michie & Williams 2003). It is now commonly recognised that organisational-professional conflict is a major source of work stress, and according to Lait and Wallace (2002, p. 464) ‘human service providers may be particularly vulnerable to organisational-professional conflict because social work is a particularly value-driven occupation whose members may share an especially strong internalisation of professional values and moral principles’. This is an important point given that a high percentage of ethical dilemmas in direct practice, as will be illustrated in this paper, result from a conflict between organisational demands and professional values. While many of the issues that have been documented in previous research are reflected in the experiences of Australian social workers in the stories to follow, there is also a contribution from this research about the positive and beneficial outcomes for social workers who have successfully managed to negotiate difficult ethical situations.
The study
A qualitative study was conducted with 30 Australian social workers who explicitly stated that they had experienced what they defined as an ethical dilemma in their front-line practice. Participants were drawn from a range of practice fields including child protection, mental health, youth work, aged care, disability services, school social work, health and relationship counselling and family violence. The agency contexts in which social workers were employed at the time of the ethical dilemma were state and non-government organisations, public hospitals and education systems. Of the thirty participants, nineteen were female and eleven were male. Twenty worked in urban/metropolitan locations, 8 in regional areas, and 2 in rural communities. The mean age of participants was 37.4 years, and all had more than five years experience since graduating with a social work degree. Half of the participants were members of the Australian Association of Social Workers. Eighteen of the thirty social workers identified themselves as working within multidisciplinary teams, and twelve described themselves as the only social worker within the agency.
In order to access social workers in rural and regional locations, as well as interstate, an online method of data collection was developed for the purposes of this study. The method, termed ‘Email-Facilitated Reflective Dialogue’ enabled the researcher to conduct in-depth interviews over a six month time period with social workers from a range of locations (McAuliffe 2003). While 20 of the participants were interviewed in this way, a further 10 were engaged in face-to-face in-depth interviews. The focus of the research was to explore ethical dilemmas in front-line practice, including understandings of ethics, personal and professional supports, familiarity with ethical codes and standards of practice, and the impacts and consequences resulting from the incident (McAuliffe 1999, 2000). This paper reports findings in relation to those impacts and consequences.
Profiles of Ethical Dilemmas
Identification of ethical dilemmas in practice situations is not always an easy task. While the social work literature provides many examples of definitions of the term ‘ethical dilemma’, a useful construct has been provided by Rothman (1998) to assist in determining the ethical components of a case, in order to decide whether an ethical dilemma actually exists. Rothman suggests applying a ‘dilemma formulation’ to a practice situation that will reduce the conflicting principles to _____v. _____. Dilemma formulations were applied to the 30 scenarios in this study, using principles from the Australian Association of Social Workers Code of Ethics (1999). Two examples of ethical dilemmas are provided here to illustrate the nature of the issues that were experienced:
Case 1: A client dying of AIDS made a confidential request that the social worker, Gordon, supply him with information about euthanasia. Gordon decided to uphold the ethical responsibility of providing information to the client so that he could make an informed decision, but had to decide whether to document the patient’s request in the medical chart. Gordon decided not to document the request and the patient later informed Gordon that he had decided not to pursue euthanasia on the basis of the information he had been given. Dilemma formulation: Respect for Human Dignity and Worth (client right to information) V Organisational Compliance.
Case 2: A client of a disability service requested that Nell, the social worker, arrange respite care for her child, as she was no longer able to cope. No respite care was available due to lack of resources. Nell decided to covertly assist the mother to ‘abandon’ the child so that she could receive emergency respite. The ethical dilemma, as framed by Nell, was that she assisted the mother to deceive the government, placing the client in a potentially difficult situation, and putting her own job at risk in the process. The mother did receive the necessary respite as a result.
Dilemma formulation: Priority of Client Interests V Organisational Compliance.
These stories are illustrative of the many and varied ethical dilemmas that social workers experience in their workplaces. A common response is for social workers to view these situations as stressful, although it is acknowledged that the degree of stress varies considerably depending on the complexity of the situation and availability of support. For some, the stress is manageable and work or home life is not affected. For others, however, the stress reaches a critical point where there may be a need for medical or psychiatric assistance. The immediate and short-medium term (defined as up to 12 months) stress responses of the social workers in this study have been explored using a categorisation developed by Weiten (2001):
* Emotional responses (eg. annoyance, anger, anxiety, fear, dejection, grief)
* Physiological responses (e.g. autonomic arousal, changes in health status)
* Behavioural responses (eg. coping efforts).
Participant responses that fell under each of these categories are illustrated in Table 1:
Table 1: Short-medium term responses to the experience of an ethical dilemma
Emotional Responses
Physiological Responses
Behavioral Responses
Depression
Agitation and irritation
Isolation/social withdrawal
Overwhelmed feelings
Paranoia
Anger and frustration
Decreased tolerance
Physical Exhaustion
High Blood Pressure
Immune system problems
Insomnia
Humor
Physical fitness
Self care
Focus on tasks
Devising action plans
Denial
Emotional responses
Social workers typically experienced a range of emotional responses that they directly associated with their involvement in an ethical dilemma. Descriptions included periods of distress characterized by tearfulness, crying, and breaking down in ‘inappropriate’ situations.
Some social workers felt ‘out of control’ of their emotions and said that this led them to isolate themselves from family and colleagues who could have offered support. Some of the comments that illustrated the depth of emotion, both at home and work were:
Emotionally, at home I began to be unable to separate my work depression. I became depressed about everything. At night I couldn’t sit up with my husband. I’d be down on the bed staring at the ceiling, crying. Lost. Just totally lost. So it impacted a lot at home [Nell].
I had really classic stress-related symptoms. I was edgy, nervy…I was often tearful. I know that I cried a lot, just through tiredness too. It was a stress thing for me. And I’d lock my office door and have a cry. Didn’t want to take phone calls…[Annie]
Depression was talked about as a specific experience, and in at least three cases participants discussed anti-depressant medication with their doctors. Depression was manifested in a range of symptoms, including mood instability, inability to sleep, and feelings of detachment and hopelessness. Some participants also expressed feeling agitated and irritable, as illustrated in the following comments:
I had insomnia for six months and was very depressed and very teary a lot of the time…just felt that there was nothing anyone could do for me…I went to the doctor and said give me something to sleep, and give me something to not make me feel so terrible, and he said I can give you antidepressants, but I said I don’t know if I want to go down that road, so I didn’t [Julie].
I became quite irritable and agitated and stressed…I ended up making some crazy decisions but that’s just what happened at the time. I probably wasn’t thinking very clearly and I probably continued to not think that clearly until not that long ago [Lucy].
Stress responses also caused some social workers, particularly those who had been vocal in their opposition to unethical practices carried out by others, to fear that they were constantly under scrutiny by management. In some cases, this ‘paranoia’ was understandable given the risk to employment. Some comments were:
I was a bit hypervigilant, a bit paranoid…I knew I was paranoid but I also knew I had a right to be paranoid, but I was still paranoid…I was tense, my blood pressure shot through the roof, I was on medication already…I felt really betrayed, really vulnerable and fragile…you start to lose your trust…[Daniel]
I discovered that I was afraid to work as a social worker. I was afraid to write my reports in case they were used against me. I was afraid to speak at team meetings in case this was used against me [Emma].
Anger and frustration were words commonly used to describe the emotions experienced in relation to organizations that were perceived as being unsupportive or the cause of the problem. Where frustration was unable to be directed at the appropriate target because of fear of repercussions, responses were internalized, resulting in further withdrawal. The intensity of anger was illustrated in one situation that was directly related to the ethical dilemma:
With this ethical dilemma I was extremely angry and that was by far the domineering feeling. I’m not a terribly verbal angry person I guess…how it manifested really was that I really resented coming to work…I went a bit passive-aggressive, didn’t want to do a report so I didn’t. I didn’t feel like I had a safe way of venting my anger because the job situation was so precarious, so it really forced me to be passive-aggressive…I really felt those extremes, that I was angry, frustrated, disgusted, and then I’d have a quiet moment where I’d go ‘but I must be doing something right’ [Annie].
Isolation and feeling alone in the struggle were common themes in a number of stories, particularly where there were few internal supports or the worker was left dealing with the brunt of the conflict. Withdrawal and detachment is often a self-protective coping mechanism used when those under stress are trying to keep this hidden from others. There is often a concern among those in helping professions that they need to be seen to be coping, and withdrawal is often a consequence. Isolation in some of these situations was also a result of some workers not having access to supports, or choosing not to use supports that could have been available. Prolonged withdrawal can lead to emotional distancing and disconnection from others. The following short quotes demonstrate these feelings of isolation.
I felt I was isolated…I was very much alone at the time…I have a real sense of being disconnected from what was happening around me… [Rob]
With respect to the event, I certainly felt very alone [Nell]
Some social workers reported decreased tolerance for both clients and colleagues during the time of the ethical dilemma. Decreased tolerance is associated with ongoing stress and can manifest in negative reactions to others in the work environment. The following comments demonstrate lack of tolerance in relation to clients and managers:
My tolerance levels really went downhill more than anything…I mean I can’t imagine ever being extremely abrupt but I think I became more strict with clients, less flexible in terms of negotiating to reschedule appointments [Wendy]
I also became aggressive at work, particularly in meetings where some manager was speaking the government speak…I’d let them know I thought it was crap. Looking back it was almost like I got myself into this spiral spinning faster and faster into this aggressive social work machine which finally just blew a fuse [Nell]
The examples given above suggest that ethical dilemmas can contribute to emotional responses that for many social workers are debilitating and distressing. Emotional impacts of ethical dilemmas in the workplace cannot always be contained within the confines of the work environment. It is simply not possible to switch such intense emotional responses off at the end of the day so that they do not impact on families and home lives.
Physiological Responses
In addition to emotional responses, seven participants described quite serious physical symptoms that they believed were manifestations of stress triggered by the ethical dilemma. Research evidence supports the links between stress and some forms of physical illness and physiological responses. Health indicators include fatigue, headaches, sleep disturbances, frequent colds, gastrointestinal disorders and flare-ups of pre-existing medical conditions such as high blood pressure and asthma (Paine 1982; Weiten 2001). While it is not possible to make causal links between the reported health problems and the ethical issue, it is important to acknowledge participants’ subjective experiences of the impact of stressful situations on their physical well-being. The most common physiological response reported was physical exhaustion, the feeling of being drained of energy with an associated mental weariness that made going to work a struggle. Some of the participant’s comments in relation to physical and mental exhaustion were:
When the issue was at its most intense I personally was quite stressed out by the situation. I was quite withdrawn socially and I felt very drained physically… [Kimberley]
Personally it was very draining because I had to live in the community. I had to see families outside work…it really was draining when I think back to these times because it cost me a number of things… [Max]
It was probably tiring, a tiring thing…it was draining because you didn’t feel positive about it [Ruth]
Another stress-related symptom experienced by some participants was insomnia, the inability to sleep well. Most commonly, insomnia is a direct result of anxiety. In these cases, insomnia was associated with the anxiety about decision-making and the worry about consequences of actions. Sierra described her experience of short-term insomnia:
I remember that night when I was thinking about it, I wasn’t sleeping properly and churning and feeling butterflies in the stomach and things like that [Sierra]
For some, the insomnia became chronic requiring medical attention and counselling. In one case, the insomnia lasted well over six months as the complexity of ethical issues in relation to one case continued to plague the worker. The experience was described in this quote:
Its interesting because you don’t think you can function if you don’t have sleep but I talked to this counsellor and she said that just resting is just as restorative as having a sleep. So I’d get up every morning not thinking about the fact that I didn’t sleep and I’d go to work, do my work, wouldn’t concentrate on it at all, and I really tried to not concentrate on the fact that I wasn’t sleeping, and I’d go to bed normally, do everything normally as if it would go away, well it didn’t. I tried to put it to the back of my mind. Maybe that was wrong. Maybe I should have dealt with it, and maybe if I had dealt with it, it would have gone away [Julie].
Hypertension or high blood pressure were other physical symptoms described by some participants. These physiological responses are also exacerbated by stress, and were discussed by participants who were engaged in ethical conflict over a longer period of time. The descriptions illustrate the extent of distress experienced by the workers and their poor states of physical health:
I would sit on the beach near where I was living and feel that my head was going to explode. I used to think I am going to die, I can’t sustain this pressure, but I felt I had to support the client and see her safely transferred out of this obviously toxic environment before I left…I went to another doctor and was told that I had seriously high blood pressure and a small hole in the heart valve due to poorly managed asthma… [Belinda]
I eventually collapsed on my bed and didn’t move for three days…The other part is that by now my stress levels were so high that I had been experiencing chest pains and palpitations for quite a while. I was receiving medical attention for this [Emma]
It has long been suspected that prolonged stress can have negative impacts on the immune system, leaving people susceptible to viral infections and recurring bouts of influenza (Weiten 2001). A number of participants mentioned becoming sick or coming down with the flu, giving them a short-term relief from the stress by legitimately staying home from work. In more extreme cases, physical illness was more serious, as illustrated in the following examples:
In the end it was my physical health that broke down…I was on antibiotics every month in 1998 before I went off…I was falling to monthly viruses that always developed into chest and sinus infections. I had regular laryngitis, not to mention skin rashes, ulcers. I guess the prolonged stress took itself out on my immune system [Nell]
Within a week of the successful conclusion of the three-week struggle, I fell ill with pneumonia. In the end I was off on sick leave for five weeks. The struggle depleted me in several dimensions of my self, physical, emotional and mental. In my weakened state I had been easy prey for the virus [Clarence]
The comments from participants indicated that some suffered extreme physical responses to the amount of stress under which they were placed by their involvement in the ethical dilemma. In some cases, ill health resulted in extended periods of sick leave, but participants eventually returned to work and carried on. In at least three cases, however, workers resigned from their positions as a direct result of the accumulation of emotional stress and physical illness. A common factor in these cases was that internal supervisory support was lacking, colleague relationships were poor, and family support was limited. One worker who experienced severe emotional and physical problems was able to remain in the workplace due to high levels of colleague and personal support. These findings support the statement made by Pines (in Paine 1982, p. 199) that: “When the social environment is noxious, burnout will occur, even if other things are acceptable; if the social environment is very supportive, burnout will not occur even if the work itself is extremely stressful”.
How participants ultimately coped was also due in large part to the behavioral responses and coping strategies they adopted to alleviate stress.
Behavioral Responses
Participants described a range of coping mechanisms to assist them in dealing with stressful ethical dilemmas. Coping refers to active efforts made to control, reduce or tolerate the demands of stress (Weiten 2001). The strategies adopted were both adaptive and maladaptive (Donovan 1987). Some tried to make light of the incident with humour and others were attentive to physical fitness and self care. Some examples of these more adaptive strategies were:
I have always used humor as self-protection from the pain of life, and on one level this has worked well for me… We entered a fitness routine which I found really helpful…we went to the gym, joined a badminton club, we rode horses, we cycled, I went swimming, we walked…I channeled my anger into this and found it great for my stress release [Emma]
I was trying to exercise more and trying to eat really well…just trying to do things for myself and focusing on saving up money and planning my trip away… [Lucy]
Another strategy employed in the workplace was to focus on tasks that needed to be achieved on a daily basis so that the bigger picture would not become overwhelming. Some participants worked on devising strategic action plans and this enabled them to continually balance the pros and cons of decisions and maintain control of the process of decision-making. While the task-focused approach may not have been professionally rewarding for some, it did serve its purpose, as seen in the second of the following examples:
When working on cases I try to pace myself and ensure that I have a plan of action, with review points along the way as to where I am at…and how I can justify my decisions and recommendations [Pam]
The other way that I have managed to survive…is that I have become task-focused. I never wanted to work on a task-focused model and I never used to. I think that if you are going to be a task-focused social worker you might as well be a welfare worker [Ivy]
Another strategy that was used by some participants was to deny the reality of the situation by either ‘brushing it off’ and moving on to another case, or employing more extreme forms of denial. When situations are brushed-off, the opportunity for reflection is lost and it is difficult to learn from mistakes or focus on newly acquired knowledge. In the first example, the ethical dilemma was resolved within a short time frame, while the second situation continued on over a number of months. The examples represent the two extremes of denial.
I was straight into the paperwork fairly quickly and didn’t have much of an opportunity to think about how I was feeling about things. I think it is probably unfortunate that my way of dealing with many situations is by brushing it off and continuing with work [Sarah]
I certainly developed a pattern over time where I progressively lost respect for the management of the division…my coping was therefore about subsequently disregarding most of what they said and doing my own thing. Another way to cope I introduced was by telling myself that I had resigned and therefore I could treat each day like I was really only there for another couple of weeks [Nell]
The coping behaviors outlined above were reflective of the ways in which participants constructed their sense of power or powerlessness. Where these social workers felt powerless in the face of organisational conflict, they tended to adopt passive-aggressive or strategic styles of behavior, or became task-focused so that individual rewards would obscure the perceived failure of systems to meet client needs. These behavioral responses served an important purpose in assisting workers to remain in their workplaces until some sense of resolution had been reached, or until they elected to resign.
A summary of these emotional, physiological and behavioral responses indicates that most participants experienced the impact of ethical issues in a predominantly negative way during the time when the dilemma was at its most critical. It is of particular interest that participants who experienced chronic emotional and physiological stress responses were unable to access good social supports and experienced considerable isolation within their places of work. This finding supports the conclusions drawn by Donovan (1987) that social supports can be an important moderator of work stress. It is also of note that those participants who reported moderate to severe stress responses were intensely involved in the ethical issue over a fairly protracted period of time, the majority between six to twelve months. This finding is supported by research suggesting that ‘duration’ is a variable in causing stronger stress responses (Beehr in Cooper 1998). Participants who experienced neutral to medium stress were more likely to have worked through the ethical dilemma relatively quickly, had good social supports, and moved on with few lasting negative effects. This is not to say that they did not continue to think about the issue and experience some discomfort in relation to it, but the extreme emotional and physical responses were not as apparent.
Long-term impacts of the Ethical Dilemma
The majority of participants offered descriptions of how the ethical dilemma impacted on them both personally and professionally in the ‘longer-term’, defined as over 12 months. While social workers focused primarily on what they learned from the experience, they also discussed the negative outcomes. The common themes were the impact on attitudes and awareness, impact on practice, and impact on personal relationships. These long-term impacts are summarized in Table 2. Positive impacts are denoted as (+), and negative impacts as (-):
Table 2: Long-term Impacts resulting from Ethical Dilemma
Impacts on Attitude
Impacts on Awareness
Impacts on Practice
Personal Impacts
Cynicism about role of human service organisations (-)
Acknowledgement of value of social work as a profession (+)
Political realities and power dynamics (+)
Clarity of roles and responsibilities (+)
Exploitation and work abuse (+)
Need for Self-care (+)
Importance of Supervision (+)
Policy and Procedures (+)
Social Justice advocacy (+)
Career promotion (-)
Professional development opportunities (-)
Professional reputation (-)
Student assistance (+)
Influence on Policy (+)
Relationships (-)
Career change (-)
Impacts on Attitudes and Awareness
Involvement in difficult practice situations can have lasting impacts on the ways that social workers view their workplaces, and the attitudes that they have towards organizational structures, management systems, colleague relationships, and their own value and worth. For some, there was a strong sense of cynicism, reflected in the following comment:
In the end, however, it took its toll. You can’t work like that, fighting against the management and the system, always trying to be smarter and stay one step ahead and not burn out. I’ve changed in that I am now so cynical about the management of the department. I’ve also changed in that I am fairly cynical about how much real social work is happening in those government social work jobs [Nell].
While the above comment illustrates one extreme of cynical awareness, there were other cases where it was acknowledged that an understanding of political realities and power dimensions could result in a much deeper level of personal commitment to social work. This concept was well illustrated in the following statement that also captures the essence of resilience and survival:
I have found new strengths from within, and new levels of reality to measure the world by. It has also brought the reality of the lack of direction and lack of power to react of our total political and justice system. No one is in control, there are only masses of people trying to control each other. This knowledge brings a strange sense of freedom and an understanding that each of us walks daily through our own minefield – some are luckier than others. I’ve had a leg and an arm blown off – but I’m warm and still standing [Emma].
This awareness of structural and power issues at both the practice and systemic levels can have a significant impact on behaviour in the workplace. The need for clarity in relation to roles and responsibilities was mentioned by some participants and included being more ‘up-front’ with clients, and having a greater awareness of boundaries in relation to clients, colleagues and managers. Social workers recounted stories of how their heightened awareness of political realities had resulted in a reconstruction of their understanding of the operation of human services, and the lack of value that is often placed on service delivery. In one case, the ethical dilemma was described as:
A mechanism that slowly taught me that the real world is about politics, it is about power, it is about perceptions, and therefore it is not about people [Don].
Another participant described her experience as a ‘big reality check’ saying:
The message it sent to me was to know my place in the system. Counselling services are not valued as terribly important. [Annie].
An awareness of political realities highlighted concerns about exploitation, evident particularly in the community sector that often operates in a climate of inadequate resources, low pay, long hours of work and lack of supervision. For those social workers who experienced feelings of exploitation, there was a questioning of the value of social work, and resulting reflection on the personal reasons for continuing to work in human services. Four social workers made the decision to leave direct client work as a result of the long-term impacts of the ethical dilemma, while another four left their respective places of work with feelings of ‘unfinished business’. One social worker said of his decision to resign from a position in a hospital:
I decided that I could no longer work under a system that so clearly could on very rare occasions put good people’s lives at risk. For my own sanity, and need for life after hospital social work, I moved on [James].
It is significant to note that the social workers who resigned from either their job, or from the profession, had little support either from colleagues or supervisors at the time of experiencing the ethical dilemma. There was little positive encouragement or valuing of their contributions, and this impacted negatively on self-esteem and professional confidence, and made the transition into new positions difficult. The importance of self-care strategies such as managing workloads more efficiently, taking time out when needed, and making productive use of supervision was discussed by most of the social workers interviewed. The recognition of the importance of supervision was a common theme, illustrated in the following comment:
Now I’m in a position where I’m a supervisor and I do it really well. I’ve learnt by negative example. I’m supportive, I’m available, I’m regular, I do what I say I’m going to do…and the social workers that I’ve got are much younger than me and I don’t dismiss anything that they raise as insignificant. If they take the trouble to raise something I think it has to have some importance for them [Ruth].
Impact on Practice
The highest number of ethical dilemmas related in some way to organizational policies and procedures, with social workers being caught between adhering to their personal or professional values or complying with organizational mandates. Many of the smaller community-based agencies did not have clear policies in place, and this left social workers unsure of what direction to take. As a direct result of unclear policies, some workers made deliberate changes to their work practices after being caught up in these types of situations. The following comments illustrate how policies, procedures and attention to administrative detail have been incorporated into practice:
I guess I would not trust another worker as much as I would have in the past and I would always insist that policies and procedures would be put in place to help prevent abuses of trust in the future. I would not mind insisting on this even if it looks as if you have no trust in a person by implementing it [Kimberley].
I’m still feeling I’m in siege mentality. In my practice now I work longer hours, I make sure that all the paperwork is done, I make sure case notes are written up. I make sure everything is documented. I just make sure all departmental policies and procedures are adhered to. I’m a real Attila the Hun to my workers. I just really make sure that there is no room whatsoever for any personal criticism of me, any professional criticism of me, and that I’m seen to be my job really, really well [Julie].
The concern with clarity about responsibilities also extended to increased commitment to principles of social justice, and two participants described how the ethical crisis had impacted in a positive way on their advocacy skills:
Professionally I am a lot stronger and an excellent advocate for people these days. I take it as a source of pride to battle bureaucracies and unjust, or unfair or unethical practices. I believe dealing with this crisis made me assess my professional role and clarify what I am really on about [James].
I have become singularly, absolutely singularly minded about standing up to corrupt practice. I think I will never ever shirk the responsibility of taking matters to the highest level when it is appropriate…I have become a lot more clear about responsibilities…a lot wiser in understanding systems [Max].
While the sense of increased mastery over the practice environment was a positive experience for some, there were also situations in which some social workers considered that stances that they had taken based on professional values had resulted in loss of promotional opportunities. Taking a stand on controversial issues can lead to organizational retribution, a concept that is clearly evident in literature about the risks of ‘whistle-blowing’ (DeMaria 1997). Organisations often punish staff perceived to be ‘trouble-makers’, and this punishment can take overt or more insidious forms. Loss of opportunities to progress in a career, withdrawal of support for professional education or continued learning, and downgrading of physical resources were some of the ways in which organizational retribution was evidenced in social workers stories. Organisational support for professional development is an important component of a supportive work setting and withdrawal of this support can seriously affect commitment to the job (Cherniss 1995). In addition, damage to professional reputation is also a serious risk when a worker decides to take a stance against an organisation that may wield power in the employment market. Fear of loss of reputation encourages workers to conform to agency values and not speak out against perceived injustices. The following comments illustrate the occupational impacts experienced by way of loss of promotional opportunities, organisational retribution and damage to reputation:
It cost me a formal promotion, an opportunity to take on a much more senior role…basically I never got past the post because of my persistence in this matter …The ultimate punishment was that I fought incredibly hard to do my Family Therapy Course…I had to use my holidays, my sick leave, anything possible to be able to complete it [Max].
Retribution is swift…I remember one time I disagreed about something and one day I was in an office twice this size because I was seeing families…the next day I was in an office half this size…‘I was threatened with legal stuff…I was threatened with my job security…I had my name blackened…my reputation… [Daniel]
I suspect that my name has been charred to a cinder and I ask my union rep to check this out. He replies that I am on an ‘under the table’ black list… [Emma]
While these experiences were highly distressing for the social workers involved, there was also a general consensus that being involved in a complex ethical dilemma provided an opportunity for a valuable learning experience. Most of the social workers commented on how they had been ‘challenged’ by the experience, and there was a strong sense that, with the passage of time, the ethical dilemma could be reflected on for its ‘experience’ value rather than for it’s ‘stress’ value. One participant in the following comment described this positive impact:
In the longer term, this experience, from a personal viewpoint, has strengthened my belief that the kind of work that I do on a daily basis is quite unique and something that should be given the full credit that it deserves for its complexity and degree of difficulty…Rather than this scenario being intimidating or frightening, I believe that they are actually professionally affirming and contribute to a social worker’s professional development [Gordon].
As the social workers interviewed were relatively experienced practitioners, many had supervised social work students, and commented on what they were able to provide by way of practical advice in the context of professional education. Examples were given about discussions with students regarding the need to maintain clear boundaries in their work, limitations of confidentiality, knowledge of the code of ethics, and the influence of organizational structures on decision-making. As well as the positives impacts for student supervision, social workers discussed implications for teaching, research, professional discussion forums, and the development of policy initiatives. Some examples are provided in the following comments:
The Department has since formed a small working party looking into the broad issue of parents with psychiatric illnesses and the difficulties this poses for social workers in working with these families in relation to child protection issues. So I have added this issue to the agenda for them to consider [Sophie].
I now strongly counsel staff about not being alone in a car with a child or in fact with a client, and that male staff need to be very circumspect about whether they in fact interview female clients in home visits without another staff member present…in a way having been to hell and back myself, I did know how I could make the journey less traumatic for those who were traveling on their own journeys to their respective hells [Rob].
Participants who were able to find productive ways to use the ethical issue in their practice appeared more likely to be able to remain in their workplaces and could locate the conflict within broader structural systems and policies. While they may have had little control over the outcomes of the ethical dilemma at the time, they were able to use what they had learned from the experience to influence outcomes at higher levels.
Impact on Personal Relationships
When involvement in an ethical dilemma is personally confronting and sustained over time, and there are insufficient supports in the workplace, the potential for impact on personal relationships is increased. There has been little empirical research into the impacts of human service work on intimate relationships, although one study of female child welfare workers and their husbands concluded that job stress did exacerbate marital disharmony (Jayaratne et al 1986). The social workers in this study talked about the stress that the ethical dilemma caused at home, and this stress was primarily in relation to two issues. The first issue was the concern about career changes and possible loss of employment, and the financial impact that this would have on the household. One comment in relation to finances was:
My husband was mostly concerned for me, but having a joint house mortgage, was rather concerned about the possible interruptions to my income. During such conversations about risking our income, I guess I realized just how committed I was to getting this lady a quality service for her daughter…it did cause some stress for me at home [Nell].
The second issue was the impact on the relationship itself. The impact on personal relationships was exacerbated by the degree of stress response that was manifested in depression, anxiety, and physical exhaustion previously described. Social workers who experienced serious stress responses described communication and intimacy difficulties in personal relationships, as illustrated in the following comment:
It must have been a dreadful time for my husband. I don’t think I was particularly communicative, I don’t think I was a joy to be around, I think I was pretty dismal, I don’t think we had lots of sex around that time…it was just a really dark period for me [Julie].
Many of the social workers interviewed expressed frustration that partners and close friends could not understand why the ethical dilemma was so consuming in terms of time and mental energy. For people who do not work in human services, a common response seems to be a lack of understanding about the nature of the work, and a detachment from the emotional content that is so much a part of practice. This detachment can cause social workers to feel even more isolated if they feel that they cannot share their distress with significant others.
Resolutions for the Future
Reflective practice, according to Fook (1999) is about the identification of strategies that can be used in the future should a similar incident or case arise. Social workers who reflect on their practice, rather than ‘brushing it off’ or moving into a state of denial, are more likely to be able to locate the learning experiences from within even a very disturbing situation. The ethical dilemma discussed for the purposes of this research was not, in most cases, the only ethical dilemma ever experienced, and social workers were realistic about the fact that ethics are a part of the social work domain and dilemmas in relation to ethics and values are inevitable. Having said this, there was also a recognition that some ethical dilemmas are much more soul-destroying than others. Interestingly, the majority of social workers did not feel that they would do anything differently in terms of their practice should the same ethical dilemma confront them again. They did, however, recognize (after the fact) the critical need for supervision and collegial support to assist in decision-making and later reflection. Some comments along these lines are illustrated below:
In the event of there being a clash between my professional values, my personal values, and my responsibilities to my client and employer, I would endeavor to work through the supervisory process (which did not exist at the time of the incident)…[Rob]
Next time I would surround myself with a lot more professional support…next time if I got managers who refused me access to these things I would fight long and loud [Nell].
I think I will do more discussion of ethics in my supervision [Ivy]
There was an acute awareness of the dangers of attempting to manage ethical issues in isolation, and a general acknowledgement from those who succumbed to acute and chronic stress that this could have been avoided had support been available, or utilized if it was available at the time.
Discussion
The findings from this research indicate that social workers need to be mindful of the risks inherent in dealing with ethical dilemmas in direct practice settings. As ethical dilemmas, by their very nature, involve a conflict of principles, social workers need to be clear about what principles are underpinning quality practice, and the professional responses that are expected by colleagues, managers, employers, and clients. The interesting picture that is presented from the stories of these social workers is that while there were significant levels of distress associated with many of the dilemmas, impacts on awareness and some parts of practice were predominantly positive, while the negative impacts related more to tangible effects on relationships and careers. As time passed, social workers were better able to reflect on the positive aspects of the challenges presented to them. Those who elected to leave the profession were less likely to have opportunity for positive reframe as they were left with the lingering bitterness of the experience, and feelings of professional failure. Findings from this study clearly suggest that a number of social workers experienced a range of emotional and physical symptoms found in the literature on work stress and burnout. The stories of depression, exhaustion, detachment, agitation, insomnia, intolerance and paranoia related by participants could easily have been detailed in any of the case studies contained in books on the subject. It is interesting to note, however, that very few of the esteemed writers in the work stress area mention ethical issues as a potential contributing factor to professional burnout. Maslach (in Cooper 1998) has perhaps come the closest in her identification of value conflict as one of six ‘mismatches’ between workers and their organisations that can contribute to burnout.
It is also important to acknowledge not only that a number of participants experienced immediate and longer-term impacts that were detrimental to their physical and emotional well-being, relationships and career prospects, but a number failed to report significant negative impacts or levels of distress at all. Those who did not report negative impacts did, however, discuss the positive impacts such as an a re-defining of the personal value of social work, and the ability to use the experience to bring about change in other parts of their work. Duration of the ethical issue appears to be a factor associated with levels of stress. The majority of workers who indicated that the ethical dilemma was managed within a shorter timeframe (24 hours to one month) were less likely to have experienced ongoing trauma. The workers who identified as ‘team players’ rather than ‘sole workers’ and who had lower levels of conflict with the organisation were also less likely to have been prominent in the examples of stressful impacts. Participants who used their social supports constructively fared better than those who isolated themselves within the workplace. Workers who had good support at home from partners who were also professionals managed the fallout from ethical dilemmas in a more constructive way. Workers who acted in accordance with strongly held convictions and ethical responsibilities were better able to deal with unexpected outcomes. These findings have implications in two areas.
Firstly, social work educators have a responsibility to ensure that emerging professionals know that ethics underpins practice, and as such, ethical issues and dilemmas and the knowledge of how to deal with these effectively is an integral part of the social work task. Social work students need to be taught about ethical decision-making models and frameworks, as inherent within these frameworks is the expectation that social workers not manage complex ethical issues in isolation. Social workers are strongly urged to consult others, to evaluate personal and professional value positions, to establish the legal, organizational and policy context, and have a sound working knowledge of ethical codes and standards of conduct (Congress 1999, Loewenberg, Dolgoff and Harrington 2001). In situations where social workers do become stressed by the work, or feel paralysed to make a decision, then support is critical. Good preparation for practice can mitigate against negative impacts later. There is a good case to be made for social work educators ensuring that professional ethics receives its own place within a curriculum so that students have opportunity to discuss ethical issues in depth using relevant case material and paying close attention to the potential complexities of practice.
Secondly, social workers need to take the issue of professional supervision much more seriously than they do at present. It is still commonplace to hear stories of social workers engaged in difficult child protection, juvenile justice, mental health, domestic violence, and disability work with little or no supervisory or collegial support. There is often a misguided sense that once graduated with a professional degree, one should know what to do with complex cases, and should be able to manage ethical decisions single-handedly. Supervision is an ethical responsibility under the Australian Association of Social Workers Code of Ethics (1999) and the reasons for this are clear in literature and have been borne out in empirical research (Munson 2002; O’Donaghue 2003). Social workers who are isolated professionally have limited resources to be able to engage in reflective practice, which is the mechanism for turning difficult and distressing situations that can impact negatively on health and emotional well being, into constructive learning opportunities that provide insight and become a source of future ‘practice wisdom’. Where the workplace does not provide appropriate supervision, then social workers have other options including locating an external professional supervisor or engaging in peer supervision. It is recognized that difficulties exist for supervision in rural and remote communities, and it is the responsibility of employers in these areas to ensure that staff are supported to find ways and means to obtain this important level of support.
Conclusions
Ethical dilemmas need to be recognized for their potential to seriously undermine a practitioner’s confidence, sense of value, and ability to continue working in a constructive way with both clients and management. The potential personal and professional impacts and consequences that have negative implications cannot be ignored. It is incumbent on the profession to take more seriously social workers cries for help when ethical dilemmas throw them into professional crisis, and offer support when organizations fail to acknowledge when a social worker has upheld professional values in preference to agency compliance. It is also to be acknowledged that although literature focuses predominantly on worker stress and burnout in the management of complex situations, there are also positive impacts and consequences for social workers who do manage to use their experiences to enhance their practice. The reflective process, assisted by supervision and support, is critical in ensuring that social workers can learn and develop in their practice from ethically complex situations. Finally, it is only by listening to the stories that are rarely told that social work can best develop educational and support strategies to assist those walking through daily minefields on the front lines of practice.
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