Ethics as Situated Practice: Ethical Conflicts and Structural Tensions in Occupational Therapy Practice in Spain

Ethical conflicts are an inherent—yet often invisible—dimension of occupational therapy practice. Most available evidence remains qualitative or conceptual, and the empirical articulation of ethical conflicts in Spain is still limited. This study examines the nature, distribution, co-occurrence patterns, and meanings of ethical conflicts reported by occupational therapists in Spain. A concurrent convergent mixed-methods design was used. From a broader national sample of 596 valid responses, the analytical sample consisted of 160 practitioners (84.4% women, reflecting the gender composition of the profession in Spain) who reported having experienced ethical conflicts and provided open-text information. Data were collected via an online questionnaire combining closed items and open-ended narratives. Quantitative analyses included descriptive statistics and Jaccard-based co-occurrence estimates derived from a non-mutually exclusive thematic coding matrix. Narratives were analyzed inductively with a descriptive phenomenological orientation (Giorgi), using thematic procedures as an analytic scaffold (Braun and Clarke). Findings were integrated through joint displays and meta-inference. The most frequently selected primary conflict categories concerned professional competence and practice (19.4%), relationships with family members/caregivers (14.4%), and the user–therapist relationship (12.5%). Co-occurrence analysis indicated that conflicts rarely occurred in isolation and tended to cluster across relational, structural, and professional domains. Integration of quantitative patterns and narrative meanings supported a preliminary interpretive three-dimensional framework (relational, structural, professional) for understanding ethical tensions in practice. Across narratives, participants described experiences interpreted as consistent with moral distress, economic and workload pressures, limited professional recognition, and normative gaps. Ethical conflicts in occupational therapy practice in Spain are best understood as recurrent, situated tensions shaped by relational dynamics and organizational conditions, rather than isolated dilemmas. Supporting moral agency requires organizational supports, spaces for collective ethical deliberation, and context-sensitive ethics education.