Moral distress among physiotherapists working with aesthetic sports athletes: a qualitative study

Singh, Radhé

Moral distress among physiotherapists working with aesthetic sports athletes: a qualitative study

Thesis / Dissertation

2026

Publisher

University of Cape Town

Department

Department of Medicine

Faculty

Faculty of Health Sciences

Abstract

Moral distress is the term used to describe a situation in which one is unable to act according to what one feels is morally right and as a result experiences psychological distress. Moral distress has become pervasive in clinical practice, especially amongst the nursing population where much of the literature is focused. This is not to say that other clinicians do not experience moral distress but rather, that despite the growing body of literature on moral distress, little research has been conducted on how it specifically affects clinicians working in aesthetic sports such as physiotherapists. This is somewhat surprising given the recognition that high-pressure environments can become a catalyst for experiences of moral distress. Those environments are present in elite sport generally, and aesthetic sports specifically, where the balance between athlete health and performance pressures often create conflicting tensions for the sports clinician. Physiotherapists working with aesthetic sports athletes—such as dancers, gymnasts, and horse riders—frequently encounter situations where external pressures from stakeholders, including coaches, management, and parents, come into conflict with their personal or professional judgement. Aesthetic sports are disciplines (e.g., ballet, gymnastics) where performance is judged on appearance, form, and precision, creating unique pressures for athletes and clinicians. This qualitative study aims to address the gap in the literature by exploring the experiences of moral distress among a small group of South African physiotherapists working with athletes who participate in aesthetic sports. Physiotherapists were the focus of this study because they play a central role in injury management and return-to-sport decisions, placing them at the forefront of ethical tensions in aesthetic-sport settings. Their continuous involvement in assessment, rehabilitation, and communication with coaches and athletes positions physiotherapists uniquely to experience moral distress in this context. The study was conducted in South Africa to provide context-specific insight into moral distress within local private practice and aesthetic-sport environments. Using a descriptive qualitative research design, eight semi-structured interviews were conducted to gain in-depth insights into the challenges and pressures faced by these clinicians. Thematic analysis of the data uncovered several recurring themes: the varied manifestations of moral distress, the role of stakeholder dynamics, the impact of financial and organisational pressures, the use of frameworks to mitigate uncertainty and the coping mechanisms employed by physiotherapists. The findings of this study contribute to the understanding of moral distress in physiotherapy in South Africa, particularly within the context of aesthetic sports. They also seem to suggest mechanisms to prevent moral distress and propose interventions that could support physiotherapists, including mentorship programmes for less experienced clinicians. Ultimately, this research highlights the multifaceted nature of moral distress and the ethical complexities inherent in return-to-sport decision-making within aesthetic sports. It calls for a holistic approach to mitigating moral distress – one that considers the interplay of individual, organisational, and societal factors. The study provides evidence which can be used to advocate for and foster a more supportive environment for physiotherapists, so as to enable them to navigate morally distressing situations with greater confidence and integrity while prioritising the health and wellbeing of the athletes they serve.

Keywords

physiotherapy

sports athletes

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Masters

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