Value-Based Mavericking

Maureen P. Molinari, Saybrook University, USA

Kara Vander Linden, Saybrook University, USA

Abstract

This classic ground theory (CGT) study presents a theory to explain a four-stage process for resolving moral distress encountered in professional environments. Value-based mavericking explains that misalignment between personal and professional values may lead to moral distress and burnout and, that while coping strategies may ease symptoms, the underlying problem still exists. Value-based mavericking presents a process that includes evaluating professional alignment and values and then choosing if and how to continue working in the current professional environment. Following the CGT method, data from primarily healthcare professions were collected. Data were analyzed using coding and constant comparative analysis to develop the theory. Value-based mavericking presents a different way of approaching moral distress and burnout that has not been previously addressed in the literature.

Keywords: classic grounded theory, moral distress, burnout, values

Introduction

Burnout has been recognized as an occupational hazard and widely researched since the mid-1970s, when psychoanalyst Herbert J. Freudenberger first coined the term (Freudenberger, 1977). Freudenberger (1977) observed a concerning trend in some of his patients.  People who were once enthusiastic and dedicated employees began reporting fatigue, boredom, or feelings of being overworked despite the fact that no other factors in their lives seemed to have changed.  Since burnout was recognized and the term coined, numerous researchers have been trying to determine ways to lessen the burden of burnout in the professional environment.  Consequences of burnout are pervasive, including affecting physical and emotional health and organizational loss (Awa, Plaumann, & Walter, 2010; Marine et al., 2006).  The economic impact of burnout is challenging to quantify and is often measured in terms of absenteeism and turnover (Jacobson et al., 1996; Raiger, 2005).  Some of the suggested causes of burnout at the organizational level include “insufficient time, skills, and or lack of social support at work” (Marine et al., 2006, p. 1).  Due to significant consequences for individuals and organizations, numerous researchers are searching for ways to ease the effect of burnout. Throughout the literature, moral distress and burnout are recognized as potential threats to wellbeing.  People experiencing moral distress and burnout may not experience optimal wellbeing or experience job satisfaction.

This study began by looking at the relationship between healthcare practitioners and their clients. However, the main concern of participants that emerged from the data of this classic grounded theory study was the impact of moral distress and burnout on their professional and personal lives.  This occurred as the first practitioner interviewed discussed the role that one client had in becoming her champion as she modified her career path.  The main concern that emerged from this interview and the ones that followed was related to moral distress and burnout experienced by healthcare professionals when various aspects of the healthcare system prevented them from being able to best serve the needs of their clients.  Thus, moral distress frequently leads to burnout.  Value-based mavericking presents a process that includes evaluating professional alignment and values to then choosing if and how to continue working in the current professional environment.

Methodology

This classic grounded theory study was performed by a doctoral student studying Mind Body Medicine at Saybrook University. To arrive at a theory based on “an integrated set of conceptual hypotheses” (Glaser, 1998, p. 3), the authors were guided by six stages, many which occurred simultaneously throughout the research process. The stages of a CGT study are preparation, data collection, constant comparative analysis, memoing, sorting and theoretical outline, and writing.

In preparation for this study, a general area of interest was identified as the client-practitioner relationship.  A preliminary literature review was not conducted to follow the dictates of the method and to limit preconception on the topic area (Glaser, 1998).

Data collection and analysis began with the collection of the first interview with a health care provider, which was coded using open coding as described by Glaser (1978).  Initially, every concept in the data that the researcher could identify was coded. The question “what is this data a study of?” (Glaser & Holton, 2007, p. 48) drove open coding.  Coding continued throughout the dissertation process, yet switched to selective coding when the core variable, the variable that accounts for the most variation in the data, emerged.  During coding, the researcher enacted strategies to increase awareness of and set aside preconceptions.  Theoretical sampling, as guided by the theoretical ideas developing from data analysis, was used throughout to identify subsequent data sources, primarily interviews with other healthcare providers, to reach theoretical saturation when no new variation was found in the data (Glaser, 1998).

Constant comparative analysis was used throughout the research process. As each piece of data was collected and coded, the concepts that were identified in the data were compared to each other to discover theoretical patterns and relationships within the data.  These patterns and relationships were captured in the form of memos.  According to Glaser (2013), “memos are where the emergent concepts and theoretical ideas are generated and stored when doing GT analysis” (para. 3).

As explained by Glaser (1998), theoretical coding was then used to tie the concepts of the emerging theory back together by conceptualizing the relationship between the concepts.  Theoretical coding helped identify the underlying structure of the theory as memos were sorted and a theoretical outline was developed.  At this point, relevant literature was integrated and the theory was written up.

Value-based Mavericking

A grounded theory seeks to explain a pattern of behavior used by the participants in the substantive area to resolve a main concern.   Within the theory of value-based mavericking, the main concern is transcending moral distress that is discovered, or uncovered, while building a career.  Some people enter professions with preconceived ideas about how their professional role will unfold.  Those entering helping professions may be following a calling to serve others and are often guided by ethical and professional standards intended guide the scope of practice.  However, in trying to adhere to the ethical and professional standards, organizations sometimes create structures and guidelines that prevent professionals from being able to fully help others creating a scenario where moral distress occurs.  Moral distress, within the theory of value-based mavericking, is a feeling of despair, occurring when witnessing situations in professional settings where one’s personal and professional values conflict with the values and operational guidelines of organizations.  Moral distress may intensify as situations challenging one’s moral values continue to present; yet, one feels limited in their autonomy to offer solutions.  Feeling unable to offer and implement a different manner of easing situational challenges may cause moral distress.

Value-based mavericking explains that misalignment between personal and professional values may lead to moral distress and burnout and, that while coping strategies may ease symptoms, the underlying problem still exists. Value-based mavericking presents a process that includes evaluating professional alignment and values to then choosing if and how to continue working in the current professional environment or to create a new career path.

Value-based mavericking is a process for creating an integrated value-based personal and professional identity by examining and uniting values in a manner resulting in a unified identity.  Stage 1, discovering a profession, presents influences such as family values and environment that affect profession choice.  Stage 2 is defined by a growing awareness that is triggered by encountering conflict within the professional environment.  Using mind body skills such as meditation and journaling, may aid in increasing self-awareness.  Self-awareness continues to grow, increasing sensitivity to value conflict and identifying areas of moral distress.  Stage 3, superseding moral distress, is choosing how to resolve moral distress in the professional environment and includes developing a vision and identifying champions who assist in the process.  Understanding that the original professional choice may not accurately represent current values marks stage 4, resolving moral distress: uniting values, and involves choosing how to integrate and align personal and professional values. Some continue working within the current organizational system; others straddle two worlds–the conventional and unconventional, some change careers, and yet others choose to do nothing.

Stage 1 Discovering a Profession

Stage 1, Discovering a Profession, begins with recognizing how values were formed and then understanding if and how values influenced initial career selection.  Values play an integral role in professional choice, yet some values may have been reflexively adopted from family, community, and or the environment where one lives.  Over time, adopted values, and those not consciously chosen, may not accurately reflect one’s present-day values. Values are important because they provide a foundation for interpreting various situations, especially situations in the professional environment that challenge moral values. Fitzpatrick et al. (2016) investigated the processes of articulating or changing values and increasing value- congruent behavior.  In the study by Fitzpatrick et al. (2016), the authors explained how challenges made values more salient to participants. With awareness of values, individuals needed to focus attention on the processes of clarifying and living congruently with values. Value-based mavericking uncovered a similar pattern of behavior.  Discovering the connection between one’s values and choice of profession is a key concept in uncovering moral distress in later stages of this process.  When values are incongruent, moral distress emerges or deepens.  Several factors influence values including personal beliefs, family values, external environment, social norms, pursuing financial security, responding to a calling, and discovering proclivity.

Personal beliefs and values. Personal beliefs are values guiding decision-making and are formed by various influences, such as family, cultural, personal experiences, and for some, social norms of their physical environment.  Personal beliefs form a foundation to interpret cultural norms and influence how situations are understood. Some personal beliefs are unwavering.  Others are shaped by the influence of other people, families, and events occurring in the personal and professional environment. Schwartz (1994) suggested that values are acquired through socialization to dominant group values and “through unique learning experiences of individuals” (p. 21), suggesting that values are fluid and influenced by various factors.  In value-based mavericking, personal beliefs may shift over time particularly with additional professional and life experiences, such as an unexpected death of a loved one.  A participant shared how financial independence grew into one of her core values following the death of her father, which in turn led to her mother being financially vulnerable.  Financial vulnerability led the participant to choose a profession to compliment her desire to be a healer and also to achieve financial independence.

Family values and career choice are also intertwined. Families often share patterns of beliefs and values, such as valuing education, or not, expectations of marriage and family, and financial beliefs, all of which were seen in the data.  For example, if families experienced financial scarcity and decreased quality of life, family members may champion professions perceived as providing financial security.   Family influence may be supportive, such as the formal or informal introduction of role models.  Role models may introduce professional opportunities not previously explored and may lead to uncovering interests that one had not considered.  On the other hand, those not feeling aligned with family values, may not feel compelled to please family members.  If family values influenced individual career choice, yet it is later discovered that those values do not represent one’s true aspirations, career misalignment may emerge.  Some follow family expectations, conforming to family values as opposed to pursuing individual personal interests that may not reflect one’s true ambitions.

A calling, in this theory, is an internal feeling, a pull toward a profession that may override other factors, such as family values.  Honoring a calling may feel virtuous, a feeling some are driven to fulfill and will do whatever it takes to realize the calling.  Some approach professions to which they feel called with a sense of honor or a desire to be of service to others; yet, not all callings are associated with serving others.  Participants described feeling a professional calling; one participant stated it this way, “It’s totally my calling,” when discussing current professional choice to work in the medical field.

Experiencing a calling can also present a challenge, particularly when a calling is drawing someone toward an unconventional professional choice. Whereas conventional careers paths often have clearly defined educational and on the job training requirements, unconventional professional choices often lack direct educational requirements, training, or career path.  This lack of perceived certainty may oppose family and or professional values of conformity.  Following the calling may then be experienced as oppositional to norms.   Since unconventional career paths may not be as well defined, the person may need to develop resolve or have a champion to overcome barriers.  A participant noted how a previous patient became a champion of her skills encouraging her to start a private practice.  Yet making the change took time and resolve.  Making career choices based on influencing factors such as family values, rather than following an internal desire or calling, may be unsettling.  If one feels a calling, yet is unable to honor the call, then a spiritual void may arise.

Experiencing a spiritual void may be precipitated by disconcerting professional and or personal experiences.  Researchers investigating the benefits and consequences of pursuing a calling have suggested that a calling may change over time, be influenced by external experiences (Dobrow, 2007), and lead to greater self-congruence and positive life satisfaction (Hagmaier & Abele, 2015). Kaminsky and Behrend (2015) suggested that one may be drawn to a particular profession, yet not experience a calling. Regardless if one is following an internal calling or not, once a profession choice is made, there is usually a period of education and on-the-job training that follows.  During a time of education and training, external experiences may uncover a calling or proclivity for something else.

Stage one concludes with developing professional expectations and shaping professional identity. Developing professional expectations is a process that often begins during stage one and while choosing a career.  Professional expectations are influenced by various factors and may contribute to expectations of how professional life will be.  A participant shared that he chose to pursue a career in medicine yet after working in the field became disillusioned by the expectation of organizations to more time completing documentation of patient encounters than spending time talking with clients.  The experience of prioritizing electronic charting over interaction with clients eventually led to symptoms of burnout.

Factors influencing professional expectations include family values around professional expectations, peers in similar professions, time spent during education, and various factors experienced during the continual process of mastering skills associated with professional expectations.  Significant resources, such as time, money to pay for education and training, may have been dedicated to achieving the vision of a professional role.

Shaping professional identity is the culmination of developing a professional persona influenced by individual values, education, and training.  Career roles are often associated with a specific professional identity, such as developing a sense of authority or being an expert, which may lead to developing confidence.  Gaining the confidence of a professional identity may allow one to interpret professional interactions through a lens of experience, rather than relying on professional scope of practice or predominant culture to ascribe meaning to events and circumstances.  This is an integral piece of stage one because it is the culmination of developing self-awareness and understanding how various influences shaped professional identity while also becoming an expert.  Expertise gained may allow a person to think independently, outside of professional norms or other influences.

Discovering a profession suggests a variety of influencing factors lead one toward a specific profession.  Some factors support individual interests, including family values, while others, such as the external environment, may not be supportive, such as having limited access to educational opportunities.  Those with strong family values may consciously or unconsciously make career choices in order to appease family members.  Sometimes initial career choices reflect a combination of personal and familial values, resulting in career choices providing a fulfilling professional career.  That may not be the case for everyone.  Many are unable to identify an interest early in their life and instead choose a career for other reasons, such as seeking financial stability, which is still often linked to values.  During stage 1, some are learning and mastering the skills of a profession, while simultaneously identifying and clarifying individual values.

Stage 2 Growing Awareness

Stage 2 of Value-Based Mavericking is Growing Awareness. Growing Awareness involves recognizing a gap between values when continually experiencing events in the professional environment that challenge values.  Feeling challenged by this misalignment is distressing and for some, affects family life.  In the beginning of becoming aware of misalignment, some people use mind body skills to help increase awareness of the source of discontent or to help identify the cause of distress.  Using mind body skills, such as meditation, or mindful movement may aid in the process of determining how to respond to moral distress. Growing Awareness is composed of two phases: encountering conflict and recognizing and identifying areas of moral distress.

Encountering conflict. Encountering conflict in the professional environment is likely, yet the source of conflict differs for each person.  Encountering conflict is experiencing events that conflict with one’s values, such as perceived marginalization of others as seen in the data.  It may also involve ineffectively and repeatedly managing problematic situations without changing the outcome.  Experiencing repeated events that are in contrast to one’s values may be stressful and result in internal conflict.  Some people accept challenging situations as an inevitable part of the professional environment while others are bothered by situations challenging values and may experience an awakening of self-awareness.  Stressors occurring in the professional environment, especially repeated ones, may prompt some to begin to question if the professional environment is a good fit.  This is the first phase in growing awareness.

When encountering significant events, some choose to reckon the events while others may isolate themselves, cocooning, while reflecting on values and choosing what to do.  In a longitudinal study, Fitzpatrick et al. (2016) suggested that the more aspects of a life situation change the more values adapt over time, a process called “values socialization” (p. 8).  A period of cocooning or retreating to examine values may assist in determining how to proceed.  If life-based and career-based stressors occur simultaneously, then the personal effect may be greater, provoking additional self-awareness.

As a result of feeling challenged by stressors, some seek and learn supportive coping strategies, such as meditation or balanced physical activity in which some participants engaged.  For example, one participant, working in a stressful environment, recognized that other people’s emotions were causing stress to themselves and to him.  Through additional training, he learned techniques to mitigate other people’s stress, which in turn help him better care for his own emotional health.  Others turn to unsupportive behaviors to deal with stress, such as substance abuse or emotional eating as described by other participants.  When choosing supportive, health-enhancing coping mechanisms, individuals may be introduced to different peer groups and perhaps different ways of thinking or evaluating experiences.  The introduction to different peers may also result in deepening self-awareness, especially when accompanied by the introduction of new and different perspectives and ways of coping.  Although helpful to immediately ease symptoms of stress, learning and using coping skills may have limited effectiveness for mitigating underlying causes of stress.  However, the awareness developed by using these coping strategies may aid in recognizing and identifying areas of moral distress, the next step in growing awareness.

Recognizing and identifying areas of moral distress. The emergence of moral distress, caused by value conflict, is different for each person. Identifying a value conflict and not being able to change the culture, leads to moral distress.  Experiencing value conflict in the professional environment, particularly when the source of the conflict opposes the original calling for pursuing a specific profession, may result in moral distress.  People working in helping professions may be particularly vulnerable to moral distress when identifying value conflict. For example, a participant, also working in healthcare, shared how external issues outside of her control, such as the lack of insurance reimbursement for preventive healthcare services and changing healthcare culture, awakened feelings of moral distress as her job was more focused on billable services than patient health. Organizational culture and values of prioritizing financial profit over client health opposed the participants value of being a healer who provide care to prevent illness without regard to profit. Recognizing moral distress in the professional environment begins the process of choosing how to reckon such experiences.

Experiencing personal stress while simultaneously experiencing value conflict in the professional environment may also affect how moral distress is perceived, magnifying aspects of personal and professional situations that are incongruent with one’s values.  Separating personal and professional values may be challenging, professional productivity may decline and/or personal relationships suffer.  Consequently, some may not respond to personal or professional stress in the same manner.  Those experiencing moral distress and feeling that their profession is a calling may feel compelled to identify solutions, reckoning moral distress to continue working in the chosen profession.  One aspect of reckoning personal and professional values is to re-assess professional expectations.

Sometimes, professional life does not mirror professional expectations that were developed in stage one.  If a professional environment fails to meet professional expectations, then some experience value conflict and may feel ineffective in his or her professional role and this experience may lead to moral distress. For example, a participant reflected on his dedication to his career, yet expressed frustration and personal conflict with the medical profession when patient care was affected by the need to do excessive paperwork, which made him begin to consider other career options.

The culmination of stages one through three lead some to a threshold, a time to choose what to do.  Choice becomes an important personal tool, choosing to remain in one’s current situation or taking a leap and making a change.  Change is inherently challenging and often a slow progression if the choice is to make a change.  However, making a choice to change is often needed to proceed to the next stage, Superseding Moral Distress.

Stage 3 Superseding Moral Distress

Stage 3, Superseding Moral Distress, is about assessing the current situation and determining what may be required to reckon moral distress.  Often, the initial reaction is to seek out new skills or ways to ease conflict in the professional environment, yet that may not provide a solution.

Value conflict is the essence of moral distress and understanding values may provide clarity about how situations opposing foundational values may lead to moral distress. Clarity about values assists in the process of noticing solutions.  Superseding moral distress is fluid, different for each person and situation and therefore a range of actions exists.  A common solution is assessing if additional skills or a different approach to challenging situations might be required to improve the current situation.  Seeking an external solution is important because it exposes people to different people and ideas.

In many instances, when encountering moral distress, the current professional situation becomes unbearable and fraught with internal conflict that affects quality of life.  Some look for ways to assuage feelings by considering if and how new skills may help, placing value on an external solution to an internal conflict.  Actively seeking answers often leads to the introduction of new people and developing a support system.  Meeting new people may introduce new ideas or a different way of approaching the problem.  Meeting new people and seeking social support, often outside of one’s usual support system, may be part of the process of superseding moral distress by fostering connection.  Connection may ease feelings of being different from peers and the conundrum of how to navigate encountering moral distress in the professional environment.  Social support may include identifying champions, supportive people who help identify ways to build or enhance professional networks.  Identifying champions is a key piece to this stage as a relationship with a champion may feel validating, rather than feeling alone, stuck, and lacking a solution.

Reaching out to different people is taking a step toward being open to change.  With openness and curiosity, champions, who are people supporting another person’s skills and ideas, may be found. Champions may provide support and encouragement and may also provoke different ways of thinking about how to address barriers.  One participant shared about the supportive role a champion played in her journey to open a private practice.  The champion was a supporter of her skills and was sure to introduce her to potential clients, championing her therapeutic skills and recommending her services to friends and colleagues.  Champions may also introduce individuals to different professional networks, expanding professional boundaries. Relationships with champions may also help a person become more  self-assured, a useful skill if leaving a conventional professional environment to pursue unconventional, undefined profession.  Champions may provide a bridge for people who may be conflicted between wanting to do something else yet lacking self-assuredness to move forward.

Identifying champions may also lead toward creating a tribe.  A tribe is a group of individuals that share common ideals, not necessarily professions.  A participant shared an experience of awakening when identifying a tribe, “You’re with a group of similarly minded people and almost always some amazing things happen.”

In the process of assessing if additional skills are necessary or determining how to supersede moral distress, some may choose inaction as a choice. Inaction may be based on current life circumstances, such needing to provide financial security for others, or a variety of other reasons unique to individuals.  Developing clarity by examining values and assessing skills and professional options may also lead toward developing a vision for resolving moral distress.

Stage 4 Resolving Moral Distress: Uniting Values

Resolving Moral Distress: Uniting Values, the fourth and culminating stage of Value-based Mavericking, is characterized by mavericking, an individualized pursuit to unite personal and professional values guided by clarity of individual values gained during previous stages.  Armed with self-awareness of the intersection between professional and personal values gained during previous stages, and how uniting both may lead to professional fulfillment, people make choices about to proceed forward.  Some choose to continue working within the current organizational system; others straddle two worlds–the conventional and unconventional, some change careers, and yet others choose to do nothing.  With awareness of one’s values, professional choices may be assessed with the intention of understanding and then perhaps, uniting personal and professional values.  How people choose to align values varies based on a variety of factors.  Some change professional roles, others remain in a current role despite value misalignment.  However, when choosing to remain in one’s current role, there is an increased personal self-awareness regarding the cause of the misalignment and also an understanding about reasons to remain.

Choosing how to align personal and professional values is the uniting piece of this process theory, even choosing to do nothing is a complex decision influenced by various factors.  Choices are unique and based on a reckoning of adopted and current values with a clear understanding of how one’s current life situation and responsibilities may influence choices.   For some, the lack of a clearly outlined professional path and not knowing how to navigate a new path may be unsettling, especially for those who have followed a linear professional life path and have been influenced by conventional values.  This stage highlights the importance of developing or enhancing self-awareness around values to then be able to choose how to create a professional life that complements one’s values.  Understanding various factors that led one to identify and choose a career are pivotal pieces in understanding oneself more clearly.  Factors such as family, geographic location, exposure to a variety of career options, or not, influence career choice.  Understanding such factors during previous stages of the theory may be important for understanding how and why moral distress and professional misalignment emerged and then this knowledge and self-awareness may be part of the solution for resolving moral distress.

Elements of previous stages inform how one navigates stage four.  Options for resolving identified in Value-based Mavericking include doing nothing, remaining in a current role, leaving a current profession in pursuit of one that better reflects one’s values, straddling two professional environments to meet different personal needs, or remaining in the current environment and seeking solutions to problems.  Resolving moral distress varies depending on various influencing factors, yet choices are made with a higher degree of self-awareness.  There is a complexity of balancing life’s demands, such as meeting financial needs for family, while holding one’s values in high regard.

The non-linear process results in choosing a pathway that best serves a person in his or her current life and is not a dogmatic linear, one-size fits all process.   The process one chooses begins by examining and uniting values.  Examining and understand the root of some values, is essential in beginning the process for unifying one’s identity. Additionally, value-based mavericking includes making intentional career choices and decisions, uniting personal and professional values into an integral representation of oneself.  This representation of oneself may occur in a conventional professional environment, or by creating a different, or sometimes unconventional professional environment.  The unique aspect and driving force of value-based mavericking is the intention of uniting values.

Conclusion

The main concern of participants of this classic grounded theory study was the impact of moral distress and burnout on their professional and personal lives.  The pattern of behavior used to address this concern is value-based mavericking. Value-based mavericking explains that misalignment between personal and professional values may lead to moral distress and burnout and, that while coping strategies may ease symptoms, the underlying problem still exists.  Value-based mavericking presents a process of evaluating professional alignment to choose if and how to continue working in the professional environment. Value-based mavericking is a process for creating an integrated value-based personal and professional identity by examining and uniting values in a manner resulting in a unified identity. Individuals experience and resolve moral distress and burnout differently, yet the connecting thread of how each person resolves his or her moral distress is using individual values to guide the process. Values, based on the family and cultural environment that people are born into, begin to be examined to determine if current values aligned with current worldview. This theory proposes that examining and understanding how a variety of influences, such as family and environment, unconsciously leads to the development of individual values that then proceed to guide behaviors, such as choosing a career.  Each person chooses a unique career path based on individual values and various life circumstances. If misalignment between personal and professional values within the career leads moral distress individual values may guide resolving moral distress encountered in the professional environment. With an awareness of how various influences may have guided original career choices, some begin the process of resolving moral distress encountered in the professional environment. The process begins with a reckoning of the values one is born into and with the acknowledgement of influences that shaped those values, moving forward, aligning, and then choosing an action that is most suitable.  Some make changes, some do not.  Not everyone has the ability or willingness to acknowledge how the past has shaped choices and to do something about it, such as make career changes.  Value-based mavericking is about the process of making a choice.

Discussion

Value-based mavericking has obvious connections to literature in the area of moral distress and burnout but also to self-determination theory.  A brief discussion of the related literature and its relation to value-based mavericking is presented next.

Moral distress

Jameton (1984) originally coined the term moral distress in the mid-1980s and defined it as, “when one knows the right thing to do but institutional constraints make it nearly impossible to pursue the right course of action” (p. 6). Varcoe, Pauly, Storch, Newton, and Makaroff (2012) expanded the definition to say that moral distress is “the experience of being seriously compromised as a moral agent in practicing in accordance with accepted professional values and standards.  It is a relational experience shaped by multiple contexts, including the socio-political and cultural context of the workplace environment” (p. 59).  Using open-ended questions to study nurses’ perceptions of moral distress, Varcoe et al. (2012) demonstrated that differing opinions about handling situations in the healthcare environment led to moral distress.  Responses to the open-ended questions of the study revealed that nurses felt they were compromising care when following orders of superiors, yet when raising concerns nurses’ opinions were overshadowed by organization culture (Varcoe et al., 2012).  Further, the experience of moral distress was due to a perceived and also actual sense of powerlessness to provide decisions within healthcare organizations (Varcoe et al., 2012).  Value-based mavericking suggests that when experiencing situations compromising values, moral distress emerges triggering some to examine personal and professional values and professional affiliation.

Nathaniel (2007) created a classic grounded theory three-stage process called, Moral Reckoning.  The stages include: Stage of Ease, Stage of Resolution, and Stage of Reflection.  In the Stage of Ease, “each person evolves a set of core beliefs and values through the process of becoming” (p. 2). In value-based mavericking, values are explored as they relate to choosing a profession in stage 1 and then play an integral role in uncovering moral distress in the professional environment in stage 2.  While Moral Reckoning focused only on nurses, the theory supports aspects elucidated in value-based mavericking, such as the importance of value clarification. Additionally, Moral Reckoning suggests “Professional or institutional norms may challenge core beliefs” (p. 3).  In value-based mavericking, some were confronted with the dissonance between individual and institutional values that later became a pertinent piece when choosing where and how to unite values.  Value-based mavericking suggests that when experiencing situations compromising values, moral distress emerges triggering some to examine personal and professional values and professional affiliation.

In value-based mavericking, experiencing moral distress was a catalyst for increasing self-awareness, examining one’s values, and making small steps toward uniting values.  Value-based mavericking suggests that moral distress emerges as a consequence of value conflict, which may then lead to burnout.

Burnout

Authors in the area of burnout has focused on defining what it is, its characteristics, and its consequences and there continues to be an ongoing debate and lack of consensus about the application of the term.  Freudenberger (1977) was one of the first to describe burnout, which he defined as “becoming exhausted by making excessive demands on energy, strength, or resources” (p. 159) in the workplace.  Despite the popularity of the term burnout, there continues to be a lack of consensus among researchers and mental health professionals regarding the significance of the term and if burnout syndrome is a distinct medical disorder and worthy of being included in the DSM IV (Heinemann & Heinemann, 2017).  Burnout has in many instances become a catch all term to describe a common experience.

Key characteristics of burnout include “overwhelming exhaustion; feelings of frustration, anger, and cynicism; and a sense of ineffectiveness and failure” (Maslach & Goldberg, 1998, p. 63), impairing personal and social functioning.  Three core dimensions of burnout are described as: emotional exhaustion, referring to feeling depleted of emotional resources; depersonalization, describing a detached response to other people; and reduced personal accomplishment, a decreased sense of self-efficacy leading to possible depression and inability to cope with job demands (Maslach & Goldberg, 1998).  Value-based mavericking suggests a progression from moral distress to burnout.

Consequences of burnout are pervasive, including physical and emotional health and organizational loss (Awa, Plaumann, & Walter, 2010; Marine et al., 2006).  The economic impact of burnout is challenging to quantify and is often measured in terms of absenteeism and turnover (Jacobson et al., 1996; Raiger, 2005). Some of the suggested causes of burnout at the organizational level include “insufficient time, skills, and or lack of social support at work” (Marine et al., 2006, p. 1).  Due to significant consequences for individuals and organizations, numerous researchers are searching for ways to ease the effect of burnout.

Yet, despite numerous efforts to resolve burnout, value-based mavericking suggests examining foundational values to identify if one’s current professional environment is in alignment with values.  Value-based mavericking suggests that when the gap between personal and professional values widens, symptom management may not appropriately address moral distress and or burnout.  In value-based mavericking, there are several options for resolving moral distress, such as creating a different professional environment, doing nothing, or pursuing a different career. Moral distress and burnout may act as catalysts, sparking the process of value-based mavericking.  Self-determination theory is a complementary framework for understanding conditions supporting progression through the theory of value-based maericking.

Self-determination theory
Deci and Ryan’s (1985) self-determination theory (SDT) proposes that conditions supporting autonomy, relatedness, and competence facilitate high quality forms of motivation and optimal functioning.  There are concepts in value-based mavericking, including developing mastery, creating community, and self-awareness that share similarities with SDT.

Autonomy. According to Deci and Ryan (2008), “autonomy means to act volitionally, with a sense of choice, whereas independence means to function alone and not rely on others” (p. 16).  In value-based mavericking, experiencing value conflict may be a catalyst for uniting personal and professional values, an autonomous choice.  The theory of value-based mavericking also suggests that identifying a tribe and creating community are key aspects supporting value-based mavericking, also supported by SDT, specifically, autonomy. However, as discussed previously, autonomy does not imply independence.  In fact, one of the key concepts facilitating value-based mavericking is creating community.  Furthermore, in SDT, relatedness “refers to feeling connected to and cared for by others” (Ryan et al., 2008, p. 153) and strengthens value-based mavericking which will be discussed next.

  Relatedness. In SDT, relatedness “refers to feeling connected to and cared for by others” (Ryan et al., 2008, p. 153) which satisfies a basic human physiological need fostering well-being. In value-based mavericking, creating a community of like-minded individuals who provide support and positive feedback is part of the process of identifying how to resolve moral distress.  Additionally, feeling connected and sharing similar visions may increase commitment to determining individual solutions, fostering a sense of connection.  Identifying a community may also support envisioning different ways of being in the professional environment or creating a different environment, as opposed to remaining in one’s comfort zone. In value-based mavericking, fear of stepping out of one’s comfort zone seemed to be assuaged by creating community.

Competence. Using an evolutionary framework, Deci and Ryan (2008) proposed that an intrinsic need for developing competence might be an inherited skill used to develop “new potentialities for adaptive employment” (p. 252).  The authors suggested that “striving for competence may be seen as a route for flexible functioning of human group in the context of changing environmental demands” (p. 253). In value-based mavericking, the need and desire to achieve mastery has multiple adaptive outcomes, including incorporating unconventional skills into a current professional role and achieving mastery to increase credibility and validity to others as they may be viewed as experts.  The credibility gained when developing mastery may also increase self-assuredness in one’s skills, further enhancing autonomy in a variety of environments.

Self-determination Theory shares similarities to value-based mavericking, particularly the core tenets of achieving basic psychological needs for optimal human functioning through autonomy, competence, and relatedness.  Vansteenkiste and Ryan (2013) suggested that those in environments lacking conditions for optimal functioning might be at risk for defensive functioning, particularly when exposed to controlling, critical, or environments rejecting psychological needs.  Value-based mavericking suggests that when encountering moral distress in a professional environment, rather than reverting to defensive functioning, some progress through stages creating supportive environments that may assist in determining how to resolve moral distress.

Implications for Practice

The consequences of burnout have been well-established in the healthcare literature.  Addressing burnout predominantly focuses on relieving symptoms.  Yet relieving symptoms may not address underlying issues of career misalignment.  Implications for practice based on research from this study suggest that career misalignment may increase the experience burnout.  Addressing career misalignment begins with a person developing self-awareness of values and then determining if values are aligned with current professional choice.  The implications of developing additional self-awareness may be uncomfortable.  Some may recognize misalignment and be faced with a choice for how to resolve, a complex decision with numerous confounding factors.  Resolving misalignment is a dynamic process and the result may lead to making change, or not.  The implications of this research are offering a different way to resolve burnout.

Limitations and Future Research

One limitation of this research was that most participants interviewed were working in various roles within healthcare, reducing the types of professions represented.  Yet, the process of value-based mavericking may share similarities to other professions, particularly the process of identifying, clarifying, and uniting values in a congruent manner to resolve moral distress.   Another limitation of the research was that many of the participants were highly educated and financially stable which provided them with the opportunity to explore other options.  Poverty or a lack of extra financial resources often affects people’s access to options, including accessing additional education if needed or having time to dedicate to develop self-awareness and understanding of values.

Future researchers may consider how value-based mavericking might apply to other professions outside of healthcare to determine if the variables hold true.  Initially, it looks like it might apply to other social service professions like teaching.  Future researchers may see if it also relates to non-service oriented professions. Additionally researchers may look at how education and poverty affect the process and how organization change, such as increased use of technology that limits human interaction and value-based mavericking maybe related.  The authors are also interested in researching more about values, specifically how the process of identifying and clarifying values affect decision-making and perhaps job satisfaction.

Future researchers might also try to determine if awareness of individual and professional values alone impacts moral distress and burnout.  Without awareness, an uncomfortable and also unexplainable discontent may be expressed in the professional environment.  Yet with awareness of what led to moral distress and burnout, people may be better able to navigate and figure out solutions to ease moral distress and burnout.

Conclusion

Moral distress may progress to burnout, prompting a deeper inspection and understanding of individual values.  A deeper understanding may lead toward a desire to unite professional and personal values.  The process of value-based mavericking is often met with challenges, such as making decisions that oppose cultural norms, particularly for those who choose to create an unconventional path.

The process of choosing to unite values includes examining the current professional environment and then deciding if one wishes to remain in that environment or do something else. Career decisions are often fraught with complexity, yet if the internal desire to make a change is strong, some reach a threshold and change directions. Mind body practices such as meditation, journaling, and mindful movement lead toward clarity and may assist in uncovering one’s individual professional choices, rather than remaining in a profession that does not fulfill one’s needs. As Joseph Campbell (n.d.) wrote,

Work begins when you don’t like what you’re doing. Tension, a lack of honesty, and a sense of unreality come from following the wrong force in your life. As an adult, you must rediscover the moving power of your life. (para. 1)

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