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Moral distress related to ethical dilemmas among Spanish podiatrists
  1. Marta Elena Losa Iglesias1,
  2. Ricardo Becerro de Bengoa Vallejo2,
  3. Paloma Salvadores Fuentes1
  1. 1Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain
  2. 2Escuela Universitaria de Enfermería, Fisioterapia y Podología, Facultad de Medicina, Universidad Complutense de Madrid, Spain
  1. Correspondence to Dr Marta Elena Losa Iglesias, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Madrid, Spain; marta.losa{at}


Objectives To describe the distress experienced by Spanish podiatrists related to ethical dilemmas, organisational matters, and lack of resources.

Design A 2008 email survey of a representative sample of 485 Spanish podiatrists presenting statements about different ethical dilemmas, values and goals at the workplace.

Results The response rate was 44.8%. Of all the respondents, 57% described sometimes having to act against their own conscience as distressing. Time constraints is the main cause of moral distress (67%) and 58% of respondents said that they found it distressing that patients have long waits for treatment. Distress related to inadequate treatment due to economical constraints or ineffectiveness was described by 60% of the podiatrists. Another 51% reported that time spent on administration and documentation is distressing. Female doctors experienced more distress than their male colleagues. Last, 36% of respondents reported that their workplace lacked strategies for dealing with ethical dilemmas.

Conclusion These study results identify moral distress among Spanish podiatrists mainly related to time constraints, patient demands and lack of resources. Moral distress varies with sex and age. Organisational strategies such as moral deliberation and responsive evaluation offer the potential to address moral distress.

  • Moral distress
  • podiatrists
  • ethical dilemmas
  • applied and professional ethics
  • professional misconduct
  • research on special populations

Statistics from


Multiple studies in Europe, the USA and Australia have shown that ethical dilemmas are increasingly part of the everyday practice of healthcare professionals, such as nurses and pharmacists.1 As the complexity of work in healthcare has expanded—professional governance in relation to conduct and quality in all aspects of healthcare, workload press-ures and financial strain on healthcare systems—so too have the demands on staff to handle medical and ethical dilemmas. Ethical dilemmas can stem from opposing demands, conflicts of interest or a mismatch between demands and resources. Indeed, healthcare practitioners learn to anticipate ethical dilemmas as part of their work, such that discussion of ethical prioritisation has increasingly become a required component of clinical practice. However, while healthcare practitioners anticipate ethical dilemmas, they do not necessarily anticipate the experience of moral distress. Further, when practitioners experience such distress, they do not necessarily have the tools to resolve this distress.

Moral distress

Moral distress conceptualises situations in which a practitioner is aware of the ethically correct action to take, but is unable to act because of internal (eg, fear or other self-limiting thoughts) or external (eg, institutional policies) barriers that create constraints to action.2 Subsequently the mismatch between what one sees as one's moral responsibility and the ability to address this responsibility gives rise to painful feelings that range from frustration, anger, depression and outrage.3 These ‘negative stress symptoms’2 and anguish may also be experienced as a consequence of participating in an action that the practitioner perceives as moral wrongdoing.4 Further, initial moral distress can become reactive distress if it is not resolved, and can contribute to emotional and physical symptoms,5 that, at the least, limit the practitioner's ability to act according to professional and ethical ideals, and at worst contribute to occupational burnout.6 Considering this, it is not surprising that many healthcare professionals experience stress-related disorders.

Moral distress differs from what a practitioner might feel in the context of a moral or ethical dilemma, where ethical principles may be in conflict but the practitioner knows which action is correct.7 For instance, a moral dilemma might involve conflict between the principle of respect for patient autonomy with the principle of justice or solidarity with the weak. Further, moral distress differs from moral uncertainty, in which a practitioner may feel uneasy about which is the best action to take.2

Research on moral distress has been largely based on the assumption that healthcare practitioners hold particular moral values that guide their work. Moreover, some researchers have argued that healthcare itself may be defined as inherently moral work that involves a constant dialogue between general ethical principles and the particular circumstances in which one provides care.8 The moral nature of healthcare work inheres, to some extent, in the physical and emotional proximity between patients and practitioners, which may (though not always) stimulate the capacity to act as a moral agent.9 In this view, moral distress occurs when the agent, or practitioner, recognises an ethical dilemma as such, but is limited in her response by conditions outside her control.

Although most of the research on the determinants and experience of moral distress has been conducted with nurses, there is evidence that many other healthcare professionals also experience moral distress (eg, pharmacists).10 Measures and models of moral distress (eg, the Moral Distress Scale),11 have identified the situations and processes through which moral distress emerge,12 and specified the causes and degree of occurrence.5 However, the level of moral distress differs by healthcare setting, leading researchers to argue that the occurrence of moral distress is tied to the professional context in which moral situations emerge.1 Consequently, these instruments may be inappropriate for non-nursing populations, such as podiatrists.

The aims of this study are to identify the moral distress experienced by Spanish podiatrists. The incidence of foot problems is relatively high, thus, podiatry involves a wide scope of practice and there is strong demand for podiatric services. Yet podiatry remains a poorly understood profession that may be perceived as low status by other healthcare practitioners, and which podiatrists themselves are perceived as lower in status than other healthcare occupations.13



We distributed questionnaires via email to podiatrists across Spain. Contact information for this sample was available from a database created for podiatrists who voluntarily provided contact details to receive information relevant to meetings, courses, and so on. We collected 485 questionnaires between 9 July 2008 and 9 September 2008 from the 1083 podiatrists we contacted (response rate, 44.8%). The data were collected through the following link:


We explored moral distress via a modified questionnaire from a study designed to explore everyday dilemmas that healthcare practitioners experience as distressing.2 Other instruments primarily target nurses and Kälvemark et al's instrument is designed for use in most healthcare settings and with other practitioners.10 We asked our respondents to respond the following topics: job satisfaction, prioritisation dilemmas, interpretation of new regulations on patients' rights, use of the internet for professional updates and continued medical education (table 1). Respondents were also asked to respond to statements about ethical dilemmas, values and workplace goals (table 2).

Table 1

Moral distress

Table 2

Values and goals at the workplace

Statistical analyses

We analysed the data using SPSS V.16.0. Responses are reported as the percentages of podiatrists who chose the different response alternatives (table 3). Each of the grouping variables—sex (female, male) and age (30–39, 40–49, 50–59, ≥60 years)—were cross-tabulated against each of the nine statements on moral distress and the five statements on values and goals, and Pearson's χ2 test was used to test for statistically significant differences. To facilitate interpretation of these rather extensive cross-tables, we also indicate which cells have the largest differences between observed and expected frequencies under the null hypothesis.

Table 3

Responses of the 485 participants to the statements on moral distress and values and goals at the workplace


A total of 485 out of 1083 podiatrists responded to the questionnaire. The sample consisted of 256 women (52.8%) and 229 men (47.2%) for a total of 485 podiatrists. The mean age of the sample was 35 years (95% CI, 34 to 37 years), and was higher for males (39 years; 95% CI, 37 to 40 years) than for females (31 years; 95% CI, 30 to 32 years). Overall, 222 respondents (45.8%) were aged 20–29 years, 137 (28.2%) were aged 30–39 years, 50 (10.3%) were aged 40–49 years, 57 (11.8%) were aged 50–59 years and 19 (3.9%) were aged ≥60 years.

Moral distress

The responses to the nine statements on moral distress are shown in table 3. In all, 57% of 485 respondents expressed moral distress by sometimes having to act against their own conscience. Our respondents reported time constraints as the main cause of moral distress (67%), and approximately two-thirds (58%) said that they found it distressing that patients have to wait a long for treatment and that the care of patients suffers due to time constraints. Of the respondents, 60% identified distress related to inadequate treatment due to economical constraints, and the same percentage reported moral distress related to the lack of effectiveness of the treatment given. More than half of the respondents (51%) reported distress by having to spend too much time on documentation and administration, and 47% found it very or somewhat distressing that the patient who ‘cries loudest’ gets more or quicker treatment than others.

Female podiatrists reported more distress than male podiatrists. Younger podiatrists reported more distress because of time constraints, patient demands, the low priority given to older patients and the abundance of administrative work.

Workplace values and goals

Table 3 also reports responses to statements about values and goals at the workplace. In all, 22% agreed mostly or completely with the statement that they often had to compromise their own values to cope with the demands of the workplace, and 14% felt that ethical problems frequently occurred at work. However, 82% indicated that their own professional values and the values of the organisation were coherent, and a similar percentage (83%) reported a strong identification with the goals and the framework of their work organisation. Finally, 36% reported that their workplace lacked strategies for dealing with ethical dilemmas. Table 3 also indicates differences between groups regarding the five value variables. In particular, female doctors and younger doctors tended to experience ethical problems more often.


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.


Our study identifies moral distress as an issue for Spanish podiatrists, as it is for other healthcare practitioners in Europe, the USA and Australia. As is the case for nurses, moral distress for the respondents in our study is mainly related to organisational issues: time constraints, patient demands and lack of resources. A majority of our respondents reported that their individual values were congruent with institutional values, yet they still experienced moral distress. In addition, a majority of podiatrists in our study pointed to the absence of strategies to deal with moral dilemmas. These findings suggest that while moral distress may be triggered by situational or organisational factors, feelings of moral distress may also arise because practitioners lack strategies to deal with moral dilemmas. Such an interpretation supports the case for organisational responses to moral distress that build competencies through approaches such as moral deliberation and responsive evaluation, and for further conceptual work on the relation between moral dilemmas and moral distress.



  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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