(Almost) 50 shades of an ethical situation — international physiotherapists’ experiences of everyday ethics: a qualitative analysis

Figures & data

Table 1. Glossary of terms

Morality is an individual’s position to questions of right/wrong or good/bad action or omission (Gillen, 2003).

Moral agency is a person’s ability to make moral judgments based on commonly held notions of right and wrong, to act morally on behalf of others, and to be held accountable for these actions (Angus, 2003, in Cherkowski, Walker, and Kutsyuruba, 2015).

Moral agent is a person who is capable of deliberating, thinking, deciding, and acting in accordance with personal and professional moral standards and principles (Carpenter, 2010).

Moral distress can occur when a person knows the ethically correct action to take but is constrained from taking it. The experience of moral distress is associated with uncomfortable feelings such as anger, frustration, perceived incompetency, or powerlessness and can have significant negative impacts on the moral agent such as hindering their ability to advocate for patients or leaving their job or the profession (Baldwin, 2010; Carpenter, 2010).

Ethics is a systematic reflection on different moral positions with the aim of keeping a diverse group collectively able to act (Gillen, 2003)

Professional ethics refers to the study and nature of ethical issues within a profession (Edwards, Wickford, Adel, and Thoren, 2011)

Professional codes of ethics or codes of conduct are formalized and expected standards of professional behavior and values within a profession and are usually developed by a professional association (Edwards, Wickford, Adel, and Thoren, 2011)

Ethical situations encompass the varieties of professional ethical challenges including an ethical dilemma between competing principles, which both seem to be right, ethical distress when constrained form acting in a way that is ethically right, an ethical temptation of choosing between ‘right’ and ‘wrong’ when there is benefit from doing the wrong thing, or remaining silent in a situation when ethical values are challenged (Swisher, Arslanian, and Davis, 2005).

Table 2. Description of samples by World Physiotherapy regions

World Physiotherapy region	Total # of participants in survey, N	Total # of participants who responded to Question 60, N (%)*	Total # of participants who responded to Question 60 with data for analysis, N (%)*
Africa (AR)	141	54 (38.3)	40 (28.4)
Asia Western Pacific (AWPR)	383	113 (29.5)	86 (22.4)
Europe (ER)	534	119 (22.3)	105 (19.7)
North America Caribbean (NACR)	139	48 (34.5)	42 (30.2)
South America (SAR)	15	6 (40)	5 (33.3)
Total	1,212	340** (28)	278 (22.9)

* Percentage calculation based on the total number of participants from the region; **Region/location data were missing for 14 participants who indicated “nothing more to add”

Figure 1. Flowchart of participant recruitment through study.

Figure 2. Categorization of data by relationship to the survey-list of ethical situations.

Table 3. Frequency and category of qualitative coding for each original survey question

Questions of Section 2 with numbers as listed in the online survey	Frequency of allocated codes in numbers	Number of directly associated issues (yellow)	Number of indirectly associated issues (green)	Survey category
37. Physiotherapist aware of misconduct by other health professionals, e.g. incompetency, violating laws and professional obligations	49	29	20	B
34. Bullying or harassment of physiotherapist by other health professional(s)	36	12	24	B
41. Conflict with another health professional about patient’s management	24	13	11	B
17. Mismatch/discrepancy between patient’s or family/ caregivers’ wishes and physiotherapist’s professional judgment	19	10	9	A
39. Referrals, or absence of referrals, from other health professionals that constrain the quality of physiotherapy services	17	11	6	B
44. Physiotherapist prevented by an organization or system from the treating patient based on clinical need, e.g. health insurance will not cover condition, healthcare system policy does not allow	17	6	11	C
22. Discrimination by physiotherapist toward patient on basis of age, gender, appearance, culture or religion, e.g. refusal to treat, lack of respect for cultural beliefs, poor quality treatment	14	4	10	A
52. Lack of evidence available to support effectiveness and safety of physiotherapy practices	14	2	12	D
30. Concerns of the physiotherapist regarding treatment of terminally ill patients, e.g. deciding benefit or harm to the patient, futility of treatment, lack of resources	13	9	4	A
49. Fraudulent billing for physiotherapy services	12	9	3	D
14. Absence of shared decision-making between patient and physiotherapist, e.g. paternalism, not culturally wanted or accepted	11	4	7	A
47. Withholding or limiting physiotherapy services to improve work conditions of the physiotherapy provider or for the convenience of the physiotherapist, e.g. time, location	10	3	7	C
32. Physiotherapist abusing their status/power to influence patient’s behavior for their own interest	9	3	6	A
42. Inappropriate, insulting or offending behavior among colleagues on social media	8	5	3	B
48. Breach of patient confidentiality by physiotherapist	8	3	5	D
54. Physiotherapist overtreating patients for own economic gain	8	7	1	D
57. Conflict in duties toward employer, third-party payer, and the patient	8	3	5	D
15. Failure to gain informed consent, e.g. cultural differences, cognitive impairment, not attempted	7	3	4	A
36. Miscommunication, or lack of communication, between physiotherapists and other health professionals causing errors and affecting quality in patient care	7	1	6	B
45. Scarce resources and time affecting quality of physiotherapy treatment	7	4	3	C
56. Physiotherapy not accessible to all people in society who need it, e.g. due to cost, lack of services in regions, or discrimination by health care system	7	4	3	D
16. Mismatch/discrepancy between the patient’s expectations and the physiotherapist’s expectations of the therapeutic relationship	6	3	3	A
24. A purposeful absence of truth-telling by patient during treatment	6	0	6	A
18. Patient’s privacy and/or dignity not respected during physiotherapy treatment, e.g. not draping appropriately, gossiping about patients	5	2	3	A
25. Violence or threatening behavior by patient toward physiotherapist	5	4	1	A
51. Inadequate/ unlawful record keeping by physiotherapist	5	2	3	D
53. Physiotherapist practicing outside of personal scope of knowledge and skills	5	3	2	D
55. Conflict between physiotherapist’s professional obligations (as per code of ethics) and cultural or personal values	5	2	3	D
19. Sexual harassment by patient during treatment	4	3	1	A
21. Inappropriate relationship between patient and physiotherapist during treatment, e.g. intimate friendship, business partnership	4	0	4	A
58. A lack of advocacy for patient’s interests needs or supports when they are unable to advocate for themselves	4	0	4	D
23. Physiotherapist accepting inappropriate gifts or gratuities	3	0	3	A
26. An absence of purposeful truth-telling by physiotherapist during treatment	3	1	2	A
59. Physiotherapist recommending and selling products for own economic gain	3	2	1	D
20. Sexual harassment by physiotherapist during treatment	2	0	2	A
28. Stopping treatment of a patient when they did not comply with physiotherapist instruction or advice	2	0	2	A
29. Physiotherapist prioritizing patients for treatment based on reasons other than patient’s clinical need, e.g. cherry picking of easier patients, likelihood of improvement, economic potential	2	1	1	A
43. Physiotherapist required by an organization or system to discharge patient from treatment based on reasons other than patient’s clinical need, e.g. insurance limits, health care system policy	2	2	0	C
50. Overcharging patients for physiotherapy services	2	1	1	D
33. Other health professionals seeking financial or other benefit from referring patients to physiotherapist	1	1	0	B
35. Violence or threatening behavior against patients by other health professionals	1	0	1	B
38. Prescription and ongoing provision of analgesics and/or sedatives to patients without appropriate review over time	1	1	0	B
40. Respecting the patient’s therapeutic relationship with other health professionals, when the physiotherapist disagrees with the other health professional’s opinion	1	1	0	B
46. Physiotherapist pressured by organization or system to return patient to sport or work commitments too early	1	0	1	C
27. Violence or threatening behavior by physiotherapist toward patient	0	0	0	A
31. Continuing physiotherapy treatment for patient’s psychological/psychosocial support after treatment goals have been reached	0	0	0	A
	378	174	204

Table

	N or M (SD)
Age	38.90 (12.09)
Gender
Female	188
Male	90
Diverse/other	0
In training vs. working
Training	34
Work	244
Highest education in physiotherapy or other academic discipline
Bachelor/Diploma	101
Graduate diploma	28
Master degree	77
Professional doctorate	29
Research doctorate	12
Other*	30
Type of workplace
Private	195
Government/public	176
Teaching and/or research institution	112
Sports club	43
Self-employed/owner	127
Average type of workplaces M (SD)	3.03 (1,93)
Area where workplace is located
Rural areas	27
Urban area	153
Both areas	98
Paying sources
Private funding (patient or family, organization)	302
Public/governmental funding	125
Combination public and governmental/private	146
Charities	33
Other**	15
Average paying sources M (SD)	2,23 (1,29)
Field of physiotherapy practice
Acupuncture, dry needling	45
Animal	1
Aquatic	43
Cardiorespiratory	92
Education	94
Disability	81
Health promotion	73
Information management	12
Management/administration	80
Mental health	31
Neurology	128
Occupational health/ergonomics	51
Oncology/palliative care	45
Orthopedics/manual therapy	181
Older People	131
Pediatrics	87
Rehabilitation	183
Research	65
Sport	109
Women’s and men’s pelvic health	54
Other***	33
Average fields of physiotherapy practice M (SD)	5,85 (3,63)
Learning about code of ethics/conduct in entry-level education
Yes	206
No	46
Don’t know	26
Learning about ethical decision making/ethical reasoning frameworks in entry-level education
Yes	130
No	100
Don’t know	48

*Participants provided additional information about ongoing training or academic programs, achievement of nonacademic degrees or specialty trainings, self-taught skills and knowledge, and former or nonphysiotherapy-specific education; **Participants reported working pro bono and voluntary, waivering, or subsidizing their physiotherapy fees, and unpaid work delivered by students; *** Participants mostly specified the fields listed in the survey, e.g. scoliosis rehabilitation, musculoskeletal injuries, or pain management.

Gillen E 2003 Ethik und Autonomie [Ethics and Autonomy]: Wissenschaftliches Symposium an der Katholischen Fachhochschule Freiburg 2002. Münster: LIT Verlag.

 Google Scholar

Angus, T 2003 Animals & ethics: An overview of the philosophical debate. Peterborough, Canada: Broadview Press.

 Google Scholar

Cherkowski SL, Walker KD, Kutsyuruba B 2015 Principals’ moral agency and ethical decision-making: Toward a transformational ethics. International Journal of Education Policy and Leadership 10: 5.

 Google Scholar

Carpenter C 2010 Moral distress in physical therapy practice. Physiotherapy Theory and Practice 26(2): 69–78. 10.3109/09593980903387878

 PubMedGoogle Scholar

Baldwin KM 2010 Moral distress and ethical decision making. Nursing Made Incredibly Easy! 8(6): 5. 10.1097/01.NME.0000388524.64122.41

 Google Scholar

Edwards I, Wickford J, Adel AA, Thoren J 2011 Living a moral professional life amidst uncertainty: Ethics for an Afghan physical therapy curriculum. Advances in Physiotherapy 13: 26–33.

 Google Scholar

Swisher LL, Arslanian LE, Davis CM 2005 The realm-individual process-situation (RIPS) model of ethical decision-making. HPA Resource 5(3): 1–8.

 Google Scholar