Volume 18, Issue 2 (June 2020)                   Iranian Rehabilitation Journal 2020, 18(2): 125-136 | Back to browse issues page


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Souri N, Nodehi Moghadam A, Mohammadi Shahbolaghi F. Iranian Physiotherapists’ Perceptions of the Ethical Issues in Everyday Practice. Iranian Rehabilitation Journal 2020; 18 (2) :125-136
URL: http://irj.uswr.ac.ir/article-1-1009-en.html
1- Department of Physiotherapy, School of Rehabilitation Sciences, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
2- Social Determinants of Health Research Center, Department of Nursing, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran.
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1. Introduction 
linical judgments are based on the complex forms of reasoning where values are an essential component of the judgment process. In this regard, clinicians must react to respecting their professional values as part of the decision-making process in the face of ethical dilemmas [1, 2]. Values are beliefs we sincerely hold and are part of our moral framework that influences our behaviors. When faced with ethical problems in clinical practice, the alternatives to ethical reasoning are in one situation; we merely follow rules or codes of behavior without being able or willing to apply them to patients’ specific or extraordinary circumstances. However, in other conditions, we primarily follow our personal beliefs or values; if unreflected upon or unchallenged, these values could also sometimes be our prejudices [3].
Considering the characteristics of rehabilitation medicine (interdisciplinary approach, cure duration, & care mentality instead of definitive cure), the effect of the caring environment [4, 5], and asymmetrical power encounters [6], physiotherapy may face numerous ethical issues; such problems could affect the clinical decision-making by the therapists [5, 7]. Ethical issues are relational situations where one needs to weigh alternative actions towards a moral problem. Ethical issues are imbedded in every clinical meeting. However, ethical reasoning models have implied linear progression, characterized by discrete and step-by-step decision making [8]. Callahan argued that the context of making an ethical decision could be complex. Such a matter often involves a complexity of personalities and shifting alliances. These conditions challenge and obfuscate professional and personal obligations and create tension and anxiety [9]. The conflict between personal and professional values may result in emotional perturbations. Such issues could influence physiotherapists’ ethical behavior, including their moral motivation to manage the patients [8]. 
Moral values are native. However, specific studies on the values of medical professions, including physiotherapy ​​in Iran are limited. Generally, research in this regard is rare in Asia [5, 10, 11]. Recent domestic studies have addressed the barriers to meeting patients’ rights [12]; the observance of patients’ rights in physiotherapy clinics [13], and the awareness of the students of the clinical practice [14]. However, the ethical challenges that Iranian physiotherapists encounter in everyday practice and their principal moral values remain neglected.‬‬
During the last 4 decades, physiotherapists have progressively expanded their scope of responsibility as well as their focus on professional autonomy and evidence-based clinical practice. However, as it is emphasized by the American Physical Therapy Association (APTA), the physiotherapy profession must meet society’s expectations and the demands of professional competence, as well as ethical competence. Such measures help to preserve professional autonomy [7, 15]; thus, this background has necessitated to record and evaluate the current ethical situation among physiotherapists. Recognizing the beliefs that guide physiotherapists’ interactions with patients could illuminate the practice of physiotherapy. It could also facilitate future developments in this field. Accordingly, this study aimed to explore Iranian physiotherapists’ perceptions of the ethical issues to provide a baseline for further ethical investigations.

2. Methods 
This basic, practical, and qualitative study were conducted by the deductive content analysis method using the Granheim approach from 2015-2016 [16] (Figure 1). The study participants were selected through a purposive sampling method among female and male physiotherapists in the community; i.e. the research subjects were chosen from those who had experience in clinical work, met the study inclusion criteria, and could express experiences and describe their inner feelings. All study subjects provided a signed informed consent form to participate in this study. The present research was also approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences.

 

The selection and interviewing process continued up to 12 sessions. Accordingly, rich findings were obtained about the professional ethics in physiotherapy and further interviews did not add to the data; i.e. the research team could not find any new data and the data were saturated. The necessary information was collected by semi-structured interviews using open-ended questions. The interview guide was prepared before initiating the interviews (Table 1). In addition to providing oral information, an informed consent form was given to the study participants and signed by them before conducting the interviews. The observance of the principle of anonymity and the protection of interview transcriptions were among other ethical considerations in the research. 
 

After greeting and asking general questions to create an informal environment, the interview questions were asked from the research participants. The questions were initially general in the subject, then became more specific. For example, the studied physiotherapists were asked “what ethical challenges, if any, have you experienced in the private/public clinical care?” During the interview, according to the study participants’ comments, more details were probed about the concept under the study. Interviews were conducted in the research participant‘s evaluation office, and each lasted approximately 20-55 minutes. After performing each interview, the recorded contents were completely transcribed. The interviewer listened to the recorded statements several times and added his observations in each case by field notes. 
To analyze the obtained data, the accuracy of the transcriptions was assured. Analysis began after the first interview, and the researcher initiated coding and categorizing data after two interviews. This measure assisted the researcher to design other necessary questions and direct the study more appropriately. Using the deductive method, primary codes were extracted from the meaning units; Next, they were divided into subcategories, then, into categories and key themes (Table 2). With each new interview, it was possible to revise or even merge the previous categories or create new categories. Then, under the supervision of an experienced observer in the analysis of qualitative data, the classification and naming process of the categories were reviewed.

 

To verify the reliability of the collected data, peer- and member-check methods were used; accordingly, the results of the analysis and categorizations were approved by two of the professors experienced in qualitative research. For the member check, the analysis results and the interviews’ codes were shared with 4 interviewees, and they confirmed them, consequently. In terms of transferability, all research details, from sampling to data collection and analysis, were thoroughly described to avoid any ambiguities. Concerning the reliability of the present study, an external observer, experienced in the qualitative research, assisted us to verify and validate the process of data collection and analysis; as a result, the validity of the study was established. 
The presence of an external observer, who could access interview audio files, transcriptions, notes, analyzed data, study findings, extracted meanings, codes, themes and categorizations, the details of the study process, and the initial intention of the study led to the establishment of the reliability and validity of the study [16].

3. Results 
In this study, 12 clinical physiotherapists working in Tehran and Ahwaz cities, Iran, with an average clinical experience of 11 years were included. The analysis of the obtained data resulted in 458 primary or open codes. Data analysis led to the extraction of the following categories along with their relevant subcategories.
Therapists’ self-interest-craving
This category represents various forms of neglecting the patients’ rights. The relevant subcategories included the following: “kick-backs in patients’ referrals", “profit-based treatment", and “financial interest-seeking". These subcategories are further elaborated in the following parts:
Kick-backs in patients’ referrals: Kick-backs indicate paying commission fees in return for a referral to a doctor, laboratory, radiology, or other treatment centers. Accordingly, patients are ignored in the process of personal transactions of therapists or specialists. Besides, the financial benefits of other healthcare providers are considered. According to this study, this issue may lead to the referral of the patient to an incompetent person. 
A male physiotherapy specialist with 25 years of clinical experience mentioned: “A specialist may refer a patient to a physiotherapist to obtain the commission fees, even if the patient requires no physiotherapy at all".
Self-profit-based treatment: According to this study, in profit-based treatment, the special needs of patients are not addressed. Besides, some patients are admitted without considering the facilities at the healthcare center.
One male interviewee with 21 years of clinical experience stated: “You never hear a therapist telling the patient that ‘it is not related to our field’ or that ‘you do not require this treatment at all’. Misusing the trust of patients in the therapist to gain benefit from further unnecessary treatments was another issue considered by the interviewees.
A female physiotherapy specialist with 7 years of clinical experience mentioned: “My colleague visited a patient who did not need further treatments; however, he recommended other sessions for the patient, and the patient accepted, due to the trust he had in that therapist. The therapist had done so only for the sake of money".
Individual beliefs in professional ethics: This category represents various physiotherapists’ attempts to observe the ethical principles and rights of their patients. Its subcategories include “compassionate attention to the patient", “paying attention to the economic burden of treatment for patients", “responsibility", as well as “spiritual and religious values of the therapist”.
Compassionate attention to the patient: According to this study, compassionate care was defined by interviewers as caring about the patient’s treatment-related benefits, caring about the patient’s recovery in the treatment process, empathetically listening to the patient, and the importance of the patient’s comfort in the cabin. A female physiotherapist with a bachelors degree and 7 years of clinical experience said: “For someone who is in pain, I think a minute or two of caressing, sitting beside him/her, telling him/her it will be fine, do not worry, etc. will do the magic. This sympathy is very critical in the treatment".
Paying attention to the economic burden of treatment for patients: In this study, the interviewers stated that the difficulty in affording for the high costs of treatment and the need to fully recover to return to the routine activities to earn income for some of the poor members of the community caused conflicts for healthcare providers. 
One male physiotherapist with 10 years of clinical experience declared: “Most of our community members are poor. For example, someone who works with the angle grinder to earn a living, and cuts the tendons of his hand by the machine, has to be assisted". 
Responsibility: Allocating the patient enough time, complete dedication in treating the patient, and having a daily concern about the effectiveness of treatment for patients were stated as the main representatives of responsibility in this study. 
One male interviewee with 21 years of clinical experience argued: “My daily concern is to be effective for patients". 
Spiritual and religious values of the therapist: The study participants stated that decisions are made in the absence of ethical training based on the person’s strongest values. Thus, in facing the moral challenges, one’s options for observing professional ethics are not only the personal spiritual inner values but also religious beliefs based on individual values. 
One male participant with 21 years of clinical experience mentioned: “An issue that contributes to the observance of ethical principles is religious beliefs. Most of the matters that the therapist may not consider as ethical codes are covered by a series of generalities derived from religion. For example: Not receiving extra money and bonus, and not involving adverse agreements with other practitioners".
Maintaining professional competence: It includes the following subcategories: “having clinical competence on the provision of treatment; the necessity of safe patient treatment; the necessity of documenting the treatment process; and maintaining professional dignity".
Having clinical competence on the provision of treatment: The physiotherapists must be able to apply what they have learned in managing patients and providing them with the best and most effective treatment. 
One of the therapists with 7 years of clinical experience stated: “Professional ethics include extensive matters... the first of which is having complete knowledge and mastery of knowledge and function". The therapist’s attempt to update knowledge years after graduation by studying individually or participating in workshops is among the determinants of professional competence. Failure in such measures could lead to inappropriate diagnosis and unnecessary interventions, and impose unnecessary financial burdens on the patient. 
A physiotherapist with 7 years of clinical experience argued: “It is unethical if I, as a physiotherapist, do not try to improve my knowledge". 
The necessity of safe patient treatment: The lack of therapeutic skills could damage the patients. According to the obtained data, performing a thorough examination and referring the patient to relevant specialists in case of uncertainty in the diagnosis is effective on the patient’s safety.
One male physiotherapist with 21 years of clinical experience stated: “The first responsibility of a therapist is avoiding to impose more harm to the patient. This is the first condition to make a successful therapy; it is achieved through a precise examination, i.e. not commonly practiced in Iran". 
The necessity of documenting the treatment process: The lack of file documentation can lead to forgetting the patient’s main problem during the treatment process by the therapists. Accordingly, it prevents the patient’s recovery by other professionals.
An interviewee, with 21 years of clinical experience mentioned: ”Basically, we fail to consider the extent to which our measures have been effective for the patient. That is why we have a weakness in recording the patient’s history". 
Maintaining professional dignity: Interviewers in this study stated that order; timely presence in the clinic; the proper appearance of the therapist; the lack of interest in the financial benefits, and no fraudulent actions against insurance departments are affective on the social perspective of the profession. 
One male therapist with 19 years of clinical experience stated: “If you tell a lie to the patient or use a device they do not require, not only the dignity of our profession but also the patient’s rights are undermined. 
Observing patients’ rights: This category includes the daily struggles of physiotherapists to observe the various dimensions of patients’ rights. Besides, it includes the following: “unprofessional therapist-patient communication", “preserving patient’s autonomy", “therapist-patient gender segregation", “trust-building between the therapist and the patient", “the patients’ unawareness of their rights", “privacy", and “gaining informed consent”.
Unprofessional communication between therapist and patient: Providing physiotherapy services to patients requires the establishment of appropriate therapeutic communication between the therapist and the patient. However, numerous participants have no proper understanding of the relationship and receive no training at the university. Many find it difficult to identify the boundaries of a constructive therapeutic relation. 
A female physiotherapist with 7 years of clinical experience mentioned: “Some colleagues misuse this relation, e.g. instead of properly working with the patient, they mostly chat with the patient".
Gender segregation of the therapist and patient: According to the interviewees, most of the patients’ complaints concerned religious beliefs. They complained about the lack of gender separation, the lack of attention to the privacy of the female patients by a male therapist, and the lack of attention to their beliefs in the therapy sessions.
One male therapist with 10 years of clinical work experience declared: “Patients tell us that in other centers, they use curtains instead of doors, i.e. always open". 
Trust building between the therapist and the patient: According to the interviewer’s statements, trust-based relations positively impact the treatment outcome. Observing the patient’s rights could facilitate this trust. Trust formation should be established at the first treatment session.
One male interviewee with 5 years of clinical experience mentioned: “If you consider the patient mechanically at the first session, or even address them as a means of learning, that proper relation will never be established. The patient will not trust you, and any treatment will provide no effect".
Patients’ unawareness of their rights: According to the interviewees, numerous patients are unaware of their rights at treatment sessions; subsequently, this matter develops an option to misuse them. 
One male physiotherapist with 21 years of clinical experience believed: “Unfortunately, in our community, patients are unfamiliar with their rights. This is the case in the majority of medical areas, not just physiotherapy, in Iran".
Privacy: A major right of patients is to keep their personal information and histories confidential. However, the layout of beds in hospitals and the shape of physiotherapy cabins in private clinics may cause some difficulties in this respect. 
A male physiotherapist with 19 years of clinical experience mentioned: “In hospitals, especially in public hospitals where beds are completely close to each other, patients’ privacy cannot be respected".
Preserving patient’s autonomy: Patients should freely choose a therapist and a treatment process; such matters should not be imposed on them; however, in many cases, this will not happen in the health system of the country, especially in hospitals.
One male participant with 21 years of clinical experience stated: “The most important principle to comply with is the principle of patient autonomy, where the patient is entitled to select treatment and therapist. I do not impose myself or a treatment method to the patients".
Obtaining informed consent: Acquiring informed consent is among the first principles that have been considered in the codes of ethics. Furthermore, it has been referred to by numerous participants in the form of information, the explanation of invasive treatments, and the treatment desired by the patient. 
One male therapist with 21 years of clinical experience indicated: “You are not entitled to conduct this in the lack of the patient’s agreement. Additionally, if they are unsatisfied, you have to use other therapies for them".
Insufficient professional ethics education: The lack of professional ethics training concerns major reasons, such as the lack of receiving professional ethics training at universities; the lack of a professional ethics charter for physiotherapists, and neglecting effective methods of professional ethics education. This issue leads to graduating without ethical knowledge. In the below, each subcategory is described as referring to the interviews.
The lack of receiving professional ethics training at universities: Physiotherapy has always lacked a special professional ethics course. Besides, the professors who act as role models for clinical practice have achieved some principles only by experience. 
One male interviewee with 10 years of clinical experiences mentioned: “Training courses are not planned, e.g. they only observe the professor’s treatment with the patient or his/her respect for the patient, and that is how learned it”. 
The lack of a professional ethics charter for physiotherapists: Many respondents referred to the lack of an ethical charter for physiotherapy and a formulated manual.
A female interviewee with 5 years of clinical experience declared: “There is no formulated and comprehensive protocol to guide us".
The effective methods of professional ethics education: Educating in terms of medical ethics plays a fundamental role in the tendency of physiotherapists to observe ethical principles. Some consider the internship period as the optimal time for this training and practical education on professional ethics.
One male participant with 10 years of clinical experience stated: “Those who are instructing students in the internship period should be trained themselves because the students are following them".
The effects of the workplace on ethical conduct: Physiotherapists are part of a specialized treatment team. Daily communication with the members of other healthcare teams generates challenges. The subcategories of “facing the mistakes of the colleagues", “the impact of poor insurance system on patient admission", “the lack of supervision on ethical principles", “the incompetence of the healthcare system” are discussed in this respect.
Facing the mistakes of the colleagues: According to the research participants, the lack of empathy and constructive collaboration between therapists; demoralizing other therapists, and the cost difference in physiotherapy services between various physiotherapy clinics lead to challenges in everyday clinical interactions with patients and colleagues.
A female physiotherapist with 7 years of clinical experience declared: “We rob our colleagues’ patients. We say I’m better than him. I will do something that my colleague is unable to do, and so on".
The impact of poor insurance system on patient admission: Some insurance departments pay the full cost of either essential or unnecessary treatments. This encourages patients to insist on receiving unnecessary treatment and some colleagues to continue unnecessary treatments. In addition, some patients request a greater cost to be mentioned in their receipt (insurance card) to collect more money from the insurance organization. 
One male participant with 10 years of clinical experience stated: “You know an instance of my unethical action? when the patient requested me to write extra charges in his insurance card so that he could receive full reimbursement from the insurance and I agreed to do so".
The lack of supervision on ethical principles: The lack of supervision on ethical principles could lead to poor performance in terms of the observance of professional ethics and patients’ rights.
A female physiotherapist with 5 years of clinical experience declared: “In European countries, patients’ rights are available to them. Patients can sue the professionals for the violation of their rights, and it will be effective. However, in here, not only patients do not know their rights, but also legal authorities do not take those seriously". In the absence of a serious supervision system, the immorality of other therapeutic systems will face the therapist with a challenge in coping with the perpetrator.
A physiotherapist with 19 years of clinical experience stated: “When I face unethical actions, I have no administrative power. I can only make my colleague aware that this is an unethical measure".
The incompetence of the health-care system: The insufficiency of therapeutic facilities in hospitals puts the therapist at a disadvantage in providing the optimal services to the patients.
A male physiotherapist with 5 years of clinical experience mentioned: “If they assign some spaces in the hospital for the physiotherapy equipment, we could achieve better results. Thus, the patients could perform specialized exercises in that area. Unfortunately, this was not the case".

4. Discussion
The present research results suggested that physiotherapists in Iran are experiencing challenges in 6 different categories during daily practice. What has been overlooked in similar studies were subcategories, such as “the incompetence of the healthcare system", “the lack of supervision on ethical principles", and “the impact of poor insurance system on patient admission”. These were among the conceptions that alluded to the conditions governing the current healthcare system in Iran. 
Among the concepts highlighted by several interviewees was paying commission fees to some experts; the lack of paying attention to the patient’s actual needs; paying attention to the financial benefits of other healthcare providers rather than the patient’s rights. Such measures simply indicate the lack of concern to the patient’s best interest. This is while the second clause of the ethical codes of the American Physiotherapy Association emphasizes the need for altruism and service delivery for the best interest of the patient rather than the therapist [17]. According to Abbasi Dezfuli, kickbacks has a more negative effect, compared to other unethical behaviors in medical fields. Such issues may lead to the creation of a mafia trend in society [18]. However, this has did not affect the existing traditions in the current healthcare body. This study implicated the existence of this mafia trend in the physiotherapy community. 
Additionally, The scarcity of moral content in university courses; the lack of dedicated courses for professional ethics training in educational curriculum highlight that the physiotherapy profession has no appropriate training course in the universities of Iran. In line with this finding, Vejdani et al. explored the ethical awareness of the students of the clinical practice at Tehran University of Social Welfare and Rehabilitation Sciences. Accordingly, they demonstrated the lack of educational courses, the lack of knowledge, and the lack of familiarity with the patients’ rights charter, as the major reasons for the unawareness [14].
The obtained data revealed that in the absence of a formal ethical code and the lack of formal education, physiotherapists use their values and religious beliefs in daily clinical exposures with patients. Numerous physiotherapists referred to “the impact of personality on ethics”, “the dependency of moral observation in service provision on the personality of the therapist”, and “observing the ethical imperatives based on the individual’s inner values". It was also suggested by Callahan that making a moral decision may in some cases include personal complexities and individual commitments. Such measures may challenge and compromise the obligations and duties of that individual and lead to tension and anxiety [9]. Likely, the interaction of the personal and professional values ​​of this physiotherapist leads to emotional disturbances. Such problems could affect the moral behavior of the physiotherapist, specifically the moral motivation for treating the patient [19]. This is currently occurring in a physiotherapy society, according to this study.
Described by Rest et al., moral motivation involves prioritizing ethical values to other conflicting values, like self-interest, as well as moral performance [20]. Based on this study, the concepts of the personal perspective of professional ethics and observance of patients’ rights included the intrinsic efforts of therapists to respect the rights of patients without appropriate training in professional ethics. Included in these efforts are obtaining informed consent, maintaining privacy, building patient-therapist trust, the gender segregation of the therapist and the patient, compassion, paying attention to the financial aspect of treatment for patients, and accountability. However, Gharibi et al. evaluated the extent of the observance of patients’ rights from their viewpoint; they evaluated it to be average in the physiotherapy clinic of Tabriz University of Medical Sciences in Iran. They also detected a significant gap between the present and the desirable situation in some aspects of observing the patients’ rights [13].
In this study, the patients’ autonomy was defined as providing the patients with the authority to choose their therapist. Gharibi et al. documented that the patients fail to have the right to choose the health center as well as the physiotherapist [13]. This is inconsistent with Coulter and Jenkinson’s findings; they suggested that most patients declared they had the right to choose their physicians and their healthcare agents. Besides, most of them believed that they received adequate information to make a conscious selection [21].
Informed consent was defined here as giving the patient an explanation of the treatment process and the invasive therapies. However, Delaney emphasized the misunderstanding of the concept of informed consent. She considered the awareness of ethical foundations of this concept as necessary for the proper moral decision-making [22]. This is essential to be considered in later educational courses on ethics.
In this research, the trust-building between the therapist and the patient was described with codes, such as “the effect of observing patients’ rights to the gaining patient’s trust”, “the necessity of mutual trust”, and “generating trust between physiotherapist and patient in the first session”. This result was in line with that of Praestegaard from Danish private clinics. Numerous Danish physiotherapists have defined a trust-based relationship as an attempt to establish a respectful and empathic relationship. Furthermore, they emphasized the need to establish a trust-based relationship with the patient in the first session [7]. The current research results were consistent with those of Praestegaard, in this regard. Investigating the ethical challenges encountered by physiotherapists in private clinics, Potter et al. found that physiotherapists and patients expect respect, trustworthiness, honesty, and sympathy from each other [23-25].

5. Conclusion
The challenges of professional ethics in Iran were grouped into 6 categories in this research. Among these, three subcategories of “the incompetence of the healthcare system", “the lack of supervision on ethical principles", and “the impact of poor insurance system on patient admission” were the special conditions in the healthcare system of the country. Codes, such as “the lack of empathy and constructive collaboration between physiotherapists", “demoralizing other therapists", and “the professional competition of two clinics in one city” also highlight the unhealthy working conditions. They were indicative of the destructive competitiveness of the Iranian labor market; thus, it must be addressed through executive powers and effective therapists training system prompted by further investigations. 

Ethical Considerations
Compliance with ethical guidelines

All study participants signed an informed consent form to participate in the study. Also this study was approved by the Ethics Committee of the University of Social Welfare and Rehabilitation Sciences (Code: IR.USWR.REC.1396.60).
Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. 

Authors' contributions
Conceptualization: Niloofar Souri, Afsun Nodehi Moghadam; Methodology, data analysis: Niloofar Souri, Farahnaz Mohammadi Shahbolaghi; Data collection: Niloofar Souri; Writing, reading, editing, and approving the final version of the manuscript: All authors.
Conflict of interest
The authors declared no conflicts of interest.
Acknowledgments
The authors would like to express their gratitude to the academic members of the Department of Physical Therapy, the University of Social Welfare and Rehabilitation Sciences.


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Article type: Original Research Articles | Subject: Physiotherapy
Received: 2019/04/10 | Accepted: 2019/12/10 | Published: 2020/06/1

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