“It's soul destroying to be honest”: A qualitative study of morally uninhabitable working environments and the responsibilization of healthcare professionals working in concurrent disorders

Healthcare professionals' wellbeing is crucial for healthcare system functioning and population health. Prolonged moral distress may result in burnout, undermining healthcare professionals' wellbeing, negatively impacting quality of patient care, and resulting in considerable healthcare system costs. We conducted 36 interviews with healthcare professionals working with patients with concurrent mental and substance use disorders in British Columbia, Canada, exploring their perceptions of the institutional constraints which shaped their experiences and caring practices. We conducted a reflexive thematic analysis of the interviews guided by the theoretical concept of responsibilization. While most participants found their work rewarding, many encountered institutional constraints which limited their ability to provide the standard of care to which they felt morally and ethically obligated. Prolonged exposure to such morally uninhabitable working environments resulted in participants' moral distress and burnout. Central to participants' narratives was the role of responsibilization in both contributing to and exacerbating moral distress and burnout. On top of their caring duties, participants perceived a need to over-function to offset institutional constraints within healthcare, and address their and their colleagues' moral distress and burnout without adequate institutional support. Findings demonstrate how individual-centered interventions are inadequate without proper institutional support, and have the potential to re-enact rather than rectify moral distress and burnout. Structural interventions are paramount to redress these occupational harms and protect healthcare professionals’ wellbeing.