Microsoft Word - knowledge, attitude and perception of Nigerian physiotherapists regarding the ethics of professional practice Bangladesh Journal of Bioethics 2018; 10 (1): 11-20 11 Knowledge, attitude and perception of Nigerian physiotherapists regarding the ethics of professional practice Samuel O Bolarinde 1 Henry E. Mba 2 1. PhD Ibadan, Physiotherapy Department, Federal Medical Centre, Owo, Ondo State. Nigeria. Email: sobolarinde@yahoo.co.uk (Corresponding Author) 2. BMR.PT. Ife, Physiotherapy Department, Federal medical Centre, Owo, Ondo - State. Nigeria. Email: Henryfresh14@gmail.com Abstract: Background of the study: Physiotherapists in Nigeria renewed their practicing license annually through the regulatory body and are provided with the professional code of ethics, which stipulate the appropriate conduct, behavior to guide and regulate the practice of their profession; however, the level of knowledge, attitude and perception of the ethical guidelines by Nigerian physiotherapists need to be investigated. Aim of Study: This study assessed the knowledge, attitude and perception of Nigerian physiotherapists about the ethics of their professional practice. Methodology: The cross-sectional study recruited 117 licenced Physiotherapists working in various health institutions in Nigeria. They were recruited for the study during the 2018 annual scientific conference of clinical and academic physiotherapists in Nigeria. Data on demographic, work experience, knowledge, attitude and perception of ethics of professional practice were obtained using a self-administered questionnaire. Data were summarized using descriptive statistics of percentage and frequency distribution. Results: All the participants 117 (100%) had copies of the code of ethics and oath of professional practice. 74.6% of participants had good knowledge of the code of professional ethics while 25.39% had poor knowledge. Only 40.8% (48) of the respondents demonstrated good attitudes toward the code of professional ethics. Similarly, only 43.4% (51) of the respondents demonstrated a good attitude towards the oath of professional practice. 57.0 % of the respondents have heard about ethical misconduct among colleagues while only 13.60% have been involved in ethical misconduct concerning colleagues or patients. A greater proportion of the respondents (78.2%) considered ethics in physiotherapy as very important while 43.4% supported the introduction of physiotherapy ethics as a course to physiotherapy students in year three of their undergraduate training. Conclusion: The majority of Nigerian physiotherapists have good knowledge of the professional code of ethics and oath of professional practice; however, their attitudes towards periodic updating their knowledge on the code of ethics and professional oath remain poor. Clinical implication and recommendation: Ethical matter are very important to the practice of physiotherapy; however, the poor attitudes of physiotherapy toward updating their knowledge on ethical matters call for the need for the regulatory body and the professional association to organise seminars and workshops on ethics in physiotherapy and introduce pre-renewal test on ethics before annual licence renewal. Keywords: Physiotherapy, Knowledge, Ethics, Oath, Practice Bangladesh Journal of Bioethics 2018; 10 (1): 11-20 12 Introduction: Health ethics is a set of moral principles, beliefs and values that guide health care professionals in making choices about medical care.1 Health care professionals sometimes face difficult decisions about medical treatments that involve moral principles, religious beliefs, or professional guidelines therefore health ethics provide the health care practitioners with a thoughtful exploration of how to act well and make morally good choices, based on beliefs and values about life and health.1 The practice of medical ethics globally has been established upon the four moral principles of autonomy, beneficence, non- maleficence, and justice.2 Health care providers are; therefore, expected to not only have the skills and knowledge relevant to their field of professional practice but also possess adequate knowledge of ethical moral principles and legal expectations that arise out of the standard practices.3 The global trends in medico-legal issues and the growing public concern regarding the ethical conduct of healthcare professional demands a high level of professionalism among health care practitioners.4 Physiotherapy as a profession in health care system provides services that develop, maintain, and restore maximum movement and functional ability throughout the lifespan of patients.5 Physiotherapists constitute part of the multidisciplinary team in the management of the sick and mobility impaired persons, offering services in various settings (inpatient, outpatient, hospice, home) in order to alleviate the physical and functional aspects of the patient’s suffering.6 Physiotherapists make decisions that involve ethical judgment in the course of practice; however, such decision-making is not limited to the point of care, it often extends beyond treatment options. A conflict could arise if a physiotherapist’s/ individual’s conviction conflicts with his/her concepts of the requirement of his professional role while some decisions may directly or indirectly be influenced by the web of his/her relationship with other health disciplines or the society.7 Dilemmas may arise when the attitude, values, and goals of the profession conflict with those of another, and if the ethos of the profession and that of the society in which the professional functions are in conflict.8 Therefore, the possession of adequate knowledge of ethical moral principles and legal expectations will be of great benefit. The profession of physiotherapy like other health professionals has a regulatory body that regulates and controls the professional practice of her registrants. The code of practice as written in the Medical Rehabilitation Therapists Board of Nigeria’s (MRTB) core standard of proficiency for registrants of medical rehabilitation therapists (physiotherapy inclusive) stipulate appropriate conduct and behavior expectation for professionals in medical rehabilitation9; hence, Physiotherapists decisions that involve ethical judgment in the course of practice should be guided by the code of professional behavior. The recent increase in the number of court cases against health care professionals in Nigeria may indicate a low level of awareness and inadequate basic knowledge Bangladesh Journal of Bioethics 2018; 10 (1): 11-20 13 of medical ethics. All health care workers are provided by the professional code of ethics to regulate the practice of their profession. Physiotherapists in Nigeria renewed their practicing license annually and are provided with the professional code of ethics/practice in addition to the renewed license; however, do Nigerian physiotherapists actually read, understand and apply the professional code of ethics in their daily clinical practice? This background forms the basis of the present study with an attempt to evaluate the knowledge, attitude and perception of Nigerian physiotherapists in relation to the ethics of professional practice. Methods: The study utilized a descriptive, cross sectional research design of registered Physiotherapists working in both private and public institutions in Nigeria. The study protocol was approved by the Health Research Ethics Committee of Federal Medical Centre, Owo (FMC/OW/380/LXX1V/192). The rationale behind the study was explained to all participants and informed consent was granted from them before their participation. The survey instrument for the study was a four sectioned self-administered questionnaire. Section A obtained information on demographic characteristics and job history, section B on knowledge of ethics and the role of the regulatory body among physiotherapists, section C was on physiotherapist attitude towards ethics and oaths of physiotherapy practice while section D obtained data on the perception of professional ethics among physiotherapists. Data were summarized using the Statistical Package for Social Science (SPSS) version 20.0 software. Descriptive statistics of means, percentages and frequency tables were used to describe the result. Result: A total number of 117 licensed physiotherapists participated in the study. Eighty-one (68.9%) were males while 36 (31.1%) were females. The highest percentage in the age distribution was in the range 21 -30 (56.2%) followed by 31-30 age group (28.1%), while 51-60 age group had the least percentage (2.6%). In terms of work experience, 1-5 years of working experience had the highest percentage (63.8%) among the respondents, while 16- 20 years was the year of experience with the lowest percentage (4.3%). The result also shows that the professional cadre with the highest percentage was a basic grade physiotherapist (58.7%), while the least was a chief physiotherapist and assistant director of physiotherapy services (5.1% each). The socio-demographic characteristics of participants is as shown in Table 1 Table 1: Demographic Characteristics of Participants. N=117 Variables N % (Percentage) Gender Male (M) Female(F) 81 36 68.9 31.2 Age 21 - 30 31 - 40 41 - 50 1 - 60 66 33 15 3 56.2 28.1 12.8 2.6 Work Experience 1-5 6-10 11-15 16- 20 20 and Above 75 15 10 5 12 63.8 12.8 8.5 4.3 10.2 Designation Physiotherapist (PT) Senior Physiotherapist(SPT) Principal Physiotherapist(PPT) Chief Physiotherapist (CPT) Assistant Director (AD) Deputy Director/ Director 69 16 11 6 6 9 58.7 13.6 9.4 5.1 5.1 7.7 Bangladesh Journal of Bioethics 2018; 10 (1): 11-20 14 Table 2 shows the knowledge level of physiotherapy regarding the ethics of physiotherapy and the role of the regulatory body. On the self-rated scale, 18 (15.3%) of the respondents had excellent knowledge of ethics of physiotherapy practice, 36 (30.6%) good knowledge and 11(9.4%) fair knowledge. Table 2 : Knowledge of Ethics and Role of Regulatory Body Among Physiotherapists Questions and Response By Physiotherapists N Percentage (%) 1. 1. How do you rate your knowledge of ethics in physiotherapy from 1 to 5 (1 being the lowest score and 5 the highest)? 1 = Poor 2 = Fair 3 = Good 4 = Very good 5 = Excellent 1 11 36 51 18 0.9 9.4 30.6 43.4 15.3 2. Does the MRTB regulate the relationships between physiotherapists and nurses, doctors and other professionals? Yes No 9 108 7.7 91.8 3. Are physiotherapists, doctors, nurses and other health professionals subject to the MRTB? Yes No 5 112 4.3 95.2 4. Is the MRTB punitive? Yes No 40 77 34.0 65.5 5. Does the MRTB deal directly with professional confidentiality? Yes No 49 68 41.7 57.8 6. Does the MRTB deal directly with physiotherapist’ strikes? Yes No 10 107 8.5 91.0 7. Can Physiotherapists prescribe treatment without prior medical consultation? Yes No 91 26 77.4 22.1 8. Does the MRTB deal directly with physiotherapy fees? Yes No 33 84 28.1 71.4 9. When prescribing an exercise or completing a medical record form illegibly, does the physiotherapist hurt an article of the MRTB? Yes No 52 65 44.2 55.3 10. Can physiotherapists consult or prescribe physiotherapy treatment without a face-to-face consultation? Yes No Overall adequate knowledge 74.6% Overall inadequate Knowledge 25.4% 78 39 66.3 33.2 Bangladesh Journal of Bioethics 2018; 10 (1): 11-20 15 Regarding the regulatory role of the Medical Rehabilitation Therapist Board- the regulatory body of the physiotherapy profession. Nine (7.7%) agreed that the relationship between physiotherapists and nurses, doctors and other health professionals are regulated by the board, professionals are regulated by the board, while 108 (91.8%) disagreed. 40 (34.0%) of respondents perceived the board as a punitive body while 77 (95.2%) disagreed. 49 (41.7%) agreed that the board deals directly with professional’s confidentiality while 68 (57.8%) disagreed. The overall average knowledge shows that 74.6% of respondents have adequate knowledge of the regulatory role of the Medical Rehabilitation Therapist Board, while 25.4% have inadequate knowledge. Table 3 shows the participants’ attitudes towards the ethics of physiotherapy practice. The result shows that all the participants 117 Table 3: Physiotherapists Attitude towards Ethics and Oath of Physiotherapy Practice Questions and Response By Physiotherapists N Percentage (%) 1. Do you have a copy of MRTB Code of ethics? Yes No 2. Have you read the MRTB Code of Ethics in the last three years? Yes, Entirely Yes but Partially No 117 0 48 54 15 100 0 40.8 45.9 12.8 3. How often do you update yourself regarding the subject? Once in a Month Once in 6 Months Once in a Year No Update 10 21 48 38 8.5 17.9 40.8 32.3 4. Have you read the Oath of your physiotherapy practice in the last three years? Yes , Entirely Yes But Partially No 51 23 43 43.4 19.6 36.6 5. How often do you update yourself by reading through the Oath of physiotherapy practice? Once in a Month Once in 6 Months Once in a Year No Update 5 22 34 56 4.3 18.7 28.9 47.6 Bangladesh Journal of Bioethics 2018; 10 (1): 11-20 16 Table 4: Perception of Professional Ethics among Physiotherapists Questions and Response by Physiotherapist N Percentage (%) 1. Do you think that professional attitudes involving ethics are determined exclusively by the character and personality of the individual? Yes exclusively by Character and Personality No, but Influenced by Character and Personality No, Character and Personality are of no concerns 2. Regarding your peers, have you heard of or experienced any examples of what would be considered ethical misconduct on their part? Yes, I have experienced it Yes, I have heard of it No 43 65 9 31 67 19 36.6 55.3 7.7 26.4 57.0 16.2 3. Have you ever done anything that could be considered ethical misconduct with respect to colleagues or patients? Yes No 16 101 13.6 85.9 4. How important do you think is ethics in physiotherapy for your training as a physiotherapist? (1 being the lowest score and 5 the highest). Not important Less Important Important Very Important 0 3 22 92 0.0 2.6 19.6 78.2 5. At what time do you think the teaching of ethics in physiotherapy should be included / addressed in the undergraduate curriculum? Year 1 Year 2 Year 3 Year 4 Year 5 All year 1 24 51 15 1 25 0.9 20.4 43.4 12.8 0.9 21.3 Bangladesh Journal of Bioethics 2018; 10 (1): 11-20 17 (100.0%) have a copy of the code of professional ethics. 48 (40.8%) have read the entire copy while 15 (12.8%) have never read in their last 3 years. Only 10 (8.5%) of the respondents update their knowledge on ethics of physiotherapy practice once in every month, 21(17.9%) once in 6 months, while 38(32.3%) never updated themselves. The result also shows that; 51(43.4%) have read the oaths of physiotherapy practice entirely, while 43(36.5%) have never read the oath of practice in their entire years of practice. 5(4.3%) update themselves by reading the oaths of physiotherapy practice once in a month, 56 (47.6%) never updated themselves by reading the oath of physiotherapy practice. Table 4 shows the perception of the respondent on professional ethics among physiotherapists. The result showed that 43(36.6%) are of the opinion that professional attitudes involving ethics are determined exclusively by character and personality of individuals, while 9(7.65%) saw no role or involvement of character and personality in determining professional attitude towards ethics. 31 (26.4%) have experienced ethical misconduct in their practice, 67 (60.0%) have only heard, and 19 (16.15%) have neither heard nor experienced ethical misconduct. 16(13.6%) have been involved in ethical misconduct with respect to patients / colleagues while 101 (85.85%) have not. 92 (78.2%) viewed ethics as very important in their training as physiotherapists while only 3(2.6%) saw ethics as less important to their training. A greater proportion of respondents agreed that teaching of ethics should be introduced in the undergraduate curriculum at year three of their training, while 25(21.3%) suggested all the five years of training Discussion: The study revealed that the majority of the respondents had very good knowledge of ethics of professional practice and good knowledge of the regulatory roles of the Medical Rehabilitation Therapist Board- the regulatory body for the profession of physiotherapy. This finding is consistent with the findings by Barnie et al 4; Atila et al 10 and Arati and Bhagawati 11 that reported good knowledge of professional ethics among health workers, physiotherapists and nurses respectively. Findings from this study show that all the respondents have a copy of the code of professional ethics. This could be attributed to the annual distribution of the code to all physiotherapists on the annual renewal of practicing licence by the regulatory body. The proportion of respondents that have entirely read the code of professional ethics in the last three years was: however, less than half of the population while a greater proportion has only read partially. This finding corroborates the research of Vieira and Neves 12 and Almeida et al 13 in which a greater proportion of health professionals claim to have partially read the code of ethics of their profession. Regarding the oath of physiotherapy practice, the findings of this study indicated that less than half of the respondents have read the oath of physiotherapy practice once and entirely in the past three years, while only a negligible proportion of the respondents keep updating their knowledge about the oath monthly and biannually. It is Bangladesh Journal of Bioethics 2018; 10 (1): 11-20 18 worrisome: however, to observe from the findings of this study that a greater proportion of the respondents did not update their knowledge by reading through the oath of physiotherapy practice in the last three years. Contending with ethical dilemmas in clinical practice is a daily occurrence in almost all health institutions worldwide.14,15 The poor attitude demonstrated by the respondents toward the update of knowledge on ethical issues remains serious professional negligence which could lead to unpleasant conflicts between the health care practitioners, patients and patients relatives which sometimes end in legal suits and litigations. The study shows that a greater proportion of the respondents (55.3%) perceived that professional attitudes involving ethics are not solely determined by a knowledge of ethics but are influenced by the character and personality of the professionals. These findings supported the findings of Coelho 16 on ethics in physiotherapy and Atila et al10 on perception, interest and knowledge of physiotherapy faculty regarding professional ethics. The two authors concluded that character and personality of the professionals have a higher level of influence over professional attitudes involving ethics than knowledge of ethics. Ethical misconduct among health care professionals may therefore be attributed to the professionals’ character and personality rather than poor or inadequate knowledge of professional ethics. The findings of the study show that 60% of the respondents have heard about professional misconduct among physiotherapists, 26.4% have experienced ethical misconduct while 16.2% have been involved in ethical misconduct involving patients or colleagues. This result indicated that the respondents are aware of ethical misconduct in clinical practise. These findings are similar to the findings of Atila et al 10 that reported 61% as the proportion of physiotherapists who had experienced some form of ethical misconduct by their colleagues. This finding could be attributed to a low level of update of knowledge on ethics of professional practice among physiotherapists. A greater proportion of respondents (92%) viewed professional ethics as very important to the training of physiotherapists. This result corroborated the findings of Atila et al, 10 Arati and Bhagawati11 who reported 78% and 90% level of importance among physiotherapists and nurses respectively. In this study, all the respondents agreed that ethics should be introduced as a course in the undergraduate curriculum of a university’s education. These findings supported the findings of Atila et al10 and Coelho et al16 which reported that the majority of respondents agreed to the introduction of ethics as a course in the undergraduate curriculum of physiotherapy training. Furthermore, nearly 44.0% of the respondent in the present study preferred the introduction of ethics in the third year of training, 20.4% in year two while 21.4% preferred all the five academic sessions of university’s training. The reasons for higher preference for the third year of university training could be attributed to the fact that students begin clinical postings in the hospital where they have more contact not only with their classmates and lecturers; but mainly with patients. Bangladesh Journal of Bioethics 2018; 10 (1): 11-20 19 Conclusions: The majority of Nigerian physiotherapists have good knowledge of the professional code of ethics and oath of professional practice. They however, opined that professional attitudes involving ethics are not solely determined by a knowledge of ethics but are influenced by the character and personality of the professionals. In addition, Nigerian physiotherapists have a positive perception of ethics of professional practice; however, their attitudes towards periodic updating their knowledge on the code of ethics and professional oath remain poor. Ethical matters are very important to the practise of physiotherapy; therefore, courses on ethics, improving professional character and personality should be included in the university training curriculum and be introduced before the clinical year of training. The observed poor attitudes of physiotherapists toward the periodic update of knowledge on ethical matters call for the need for the regulatory body and the professional association to organise seminars and workshops on ethics in physiotherapy and the possible introduction of pre-renewal test on ethics before annual licence renewal. Acknowledgement: The authors acknowledge the technical support received from the staff of the physiotherapy department, Federal Medical Centre, Owo, Ondo -State, Nigeria References: 1. Opoku, J.K and Peter Addai-Mensah An Assessment of Perceptions and Knowledge of Health Care Ethical Principles among Health Care Practitioners in the Kumasi Metropolis. Global Journal of Arts Humanities and Social Sciences 2014 Vol.2(6) pp.77-92. 2. Beauchamp TL, Childress JF. Principles of Biomedical Ethics 5th Edition, Oxford University; Oxford: 2001. Beauchamp, Tom L, and James F. Childress. Principles of Biomedical Ethics. New York, N.Y: Oxford University Press, 2001. 3 Unnikrishnan B, Kanchan T, Kulkarni V, et al., Perceptions and Practices of Medical Practitioners Towards Ethics in Medical Practice - A Study from Coastal South India. J Forensic Leg Med. 2014; 22:51-6 4 Barnie BA, Forson PK, Opare-Addo MNA, Appiah-Poku J, Rhule GP, et al. 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Conhecimento e interesse em ética médica e bioética na graduação médica. Rev Bras Educ Med. 2008;32(4):437-44 14. Goldie J. Review of Ethics Curricula in Undergraduate Medical Education. Med Educ , 2000.34: 108-119. 15. Eckles RE, Meslin EM, Gaffney M, Helft PR Medical Ethics Education: Where Are We? Where Should We Be Going? A Review. Acad Med, 2005. 80: 1143-1152. 16. Coelho PHS. Ética em Fisioterapia: Interesse, Percepção e níveis de conhecimento entre alunos do curso de fisioterapia em uma universidade no interior da Amazônia Brasileira [TCC]. Santarém: Universidade do Estado do Pará; 2014. Authors' contributions: Samuel O Bolarinde coordinated the study, conceived the study, and participated in its design and data analysis, interpretation and revised the manuscript. Henry E. Mba participated in data management and analysis, drafting of the manuscript and revised the manuscript. All authors read and approved the final manuscript. Conflicts of interests: The author(s) declare no conflicts of interests