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Amid the ongoing pandemic, as overburdened and underfunded health systems are requiring health care social workers (HSWs) to assume responsibilities beyond their scope of practice, institutional constraints have undoubtedly heightened encounters of moral distress (MD). MD is the psychological disequilibrium that arises when institutional factors obligate an individual to carry out a task that violates their professional and/or personal ethics. Our qualitative study investigated HSWs' (n  = 43) MD in Texas during the 2019 COVID-19 pandemic. Findings from our study indicate that MD occurs across five levels: (i) patient care decisions; (ii) personal care decisions; (iii) team/unit decisions; (iv) organisational decisions; and (v) social justice decisions. MD is rooted in systems that disproportionately impact historically excluded populations, including social inequities such as financial instability, homelessness and substance use. Organisations need to explicitly consider social justice initiatives that seek to identify growing disparities in care that have been at the forefront of the pandemic; macro-level perspectives that expand MD must address social and health inequities that impede daily tasks of all health care workers. MD encounters that are rooted in social determinants of health can inform supervision, education and practice to ameliorate HSWs' value conflict. [ABSTRACT FROM AUTHOR]