Discussion

To our knowledge, this is the first known attempt to describe ethical conflicts experienced by Spanish podiatrists. Previous research has mostly focused on moral distress experienced by nurses in high intensity settings such as critical and acute care, characterised by ethical dilemmas such as end-of-life situations or confidentiality. In contrast, our study focused on identifying—and found evidence of—moral distress in the everyday practice of podiatrists. More than half of the podiatrists (57%) agreed with the statement, ‘I must sometimes act against my conscience’. As found in studies that focus on nurses, the triggers of, or preconditions for moral distress, included external constraints such as organisational pressures (time, economics, resources, administrative burden) and how patients are treated and prioritised.

Our respondents identified time constraints as a trigger of moral distress, especially where patients have to wait a long time for treatment and where the care of patients suffers due to time constraints. This finding is in accord with previous studies which found that healthcare providers experience heavy moral strain due to lack of time to attend to individual patients and other issues.10 11 For instance, a recent prioritisation study on older patients found that both doctors and nurses saw lack of time as the most emotionally distressing factor.14 Unsurprisingly, podiatrists also reported distress related to inadequate treatment and economical constraints. Although organisational reform in European healthcare has targeted efficiency, lack of resources continues to be identified by practitioners as a source of moral distress.

Patient demand was also a source of distress. The podiatrists in our study report distress related to patient demands, in line with findings from a study of Finnish general practitioners, of whom approximately 30% reported ethical problematic decisions related to patient demand.15 Strengthened patients' rights, expanding health consumerism in Europe and better accountability and transparency are new demands that may give rise to moral distress.16 Prioritisation of older patients is another cause of distress among podiatrists, especially in relation to unsatisfactory services for older patients, an escalating dilemma among European practitioners. Further, one in two practitioners found it morally distressing when stronger patients are prioritised at the expense of weaker patients. Older patients constitute a majority of patients for podiatrists, and geriatric healthcare is a field that has been, in theory, prioritised in many European countries for more than 2 decades. However, there is a growing gap between needs and available resources that may anticipate a rise in moral distress in this area.

In addition to meeting patient demand, healthcare personnel carry a heavy administrative burden, which male podiatrists in particular reported as a source of distress. Documentation of medical practice is necessary for transparency, accountability and quality improvement. Yet time spent on these tasks leaves less available time for direct patient care. There were other gender differences in our study, in terms of how care situations were expressed or experienced. In our study, while men reported more distress triggered by administrative burden, women reported more distress linked to concern about patient requirements, particularly for older patients. Further, male podiatrists identified the lack of strategies to resolve ethical problems more frequently than women. As with other studies, there were age differences17; older, more experienced podiatrists were more ethically aware than younger colleagues. While the level of moral distress in our study is higher than in other European studies,18 the age and sex distributions of responses are similar.

The podiatrists in our study, like other healthcare professionals,8 are morally engaged and concerned about values, including quality of care, respect and dignity. Yet, while our study found evidence of moral distress, 1–28% of the podiatrists answered, ‘do not know’ to questions on moral distress. This finding suggests that for some podiatrists, as with other practitioners, it can be difficult to recognise or acknowledge moral distress.3 This absence of vocabulary for, or ability to recognise, moral distress creates a challenge for creating strategies to deal with it. Moreover, while a majority of the podiatrists in our study (80%) reported that their individual occupational values were aligned with the values of their work organisation, they also reported situations that create feelings of moral distress. This finding may be significant in two ways. First, when an organisation's values are similar to those of its employees, employees are likely to experience higher satisfaction and lower levels of burnout.19 Podiatrists may be more at risk for burnout than other healthcare workers,20 thus the congruence between individual and institutional values might create a fertile starting point for developing organisational strategies to deal with moral distress. Second, this finding suggests that even when individual and institutional values are aligned (or where internal constraints seem few), practitioners still report feelings of moral distress. Comparative research shows that, as with the podiatrists in our study, although practitioners describe experiencing ethical dilemmas, very few have strategies to resolve them.21 Moral distress could, thus, be triggered by external constraints that limit action, but they could also be triggered by a lack of competency to deal with moral dilemmas. This finding further supports the need for organisational strategies to address moral distress in the healthcare workplace.

At the level of the individual, practitioners point to coping strategies such as informal talk with colleagues. However, individualised coping strategies are insufficient because as we have seen, distress is linked to the way in which healthcare is organised and may also emerge through professional conflict, such as when doctors and nurses have different patient priorities. At the institutional level, certainly, there are many established ethics committees in Europe. Yet few ethically problematic cases are deliberated by such committees,22 perhaps because they are characterised by lack of openness to outsiders and healthcare practitioners may be conflict averse. Moreover, ethics committees may presuppose what ethical dilemmas are likely to be, while research on moral distress suggests that it is situational and relational.9 Therefore, substantial work remains for these committees to be able to meet the needs of healthcare workers, patients and their relatives.

Practitioners in all healthcare environments have to manage the interests of patients in a context of available organisational resources, and the practitioner's own conscience.23 Moreover, working as a healthcare practitioner is stressful, for instance, because they may work very long hours. However, practitioners are likely to feel moral distress only if they are worried that long hours impact negatively on the quality of their care.24 Moral distress, it would seem, is embedded in the everyday practice of healthcare practitioners and as such, beg for solutions or strategies that take such practice into account. Our findings support the case for a wider response to moral distress, through organisational strategies that shift responsibility from individual practitioners, such as moral deliberation and responsive evaluation. Moral deliberation provides a systematic approach that is tied to the professional context in which moral situations emerge.8 Similarly, responsive evaluation is a tool that is tied to practice improvement, with the goal of achieving ‘good care’ by a process of facilitated reflection,25 through which practitioners are encouraged to create ongoing conversation about their practice. Both strategies offer the potential to address moral distress by creating a ‘morally open space’ that invites reflection and experiential sharing across professional cultures.7

Limitations of this study include a moderate response rate and possible selection bias favouring podiatrists who had lingering, unresolved moral distress. Further, the way that the statements are posed implies that the situations described may cause distress, which may have influenced the answers in a positive direction. A thorough investigation of the international literature reveals the existence of many other factors associated with moral distress that were not evaluated in the present study. We recommend including other variables and younger podiatrists in future studies that measure the impact of moral distress.