Bioethics in the physical therapist’s clinical practice: conceptions by faculty members and students

Abstract

This is an empirical, descriptive and qualitative investigation on the approach to values and humanistic aspects in an undergraduate course in physical therapy. The perception of faculty members and students about ethical issues related to professional practice is investigated. Semi-structured individual interviews were conducted with the course coordinator, 12 faculty members and 24 students on their final year of the physical therapy course at a public Brazilian university. Although the theme is not explored in depth during the undergraduate course, the interviewees mentioned ethical conflicts concerning the relationship with other professionals, patients and the health service, as well as the allocation of resources. The students considered that discussions about ethics are treated only implicitly, and among the faculty members there was a consensus that it is necessary to approach the contents of ethics in a more applied manner to the reality of physical therapy

Physical therapy specialty; Bioethics; Teaching; Decision making

Resumo

Trata-se de investigação empírica, descritiva e qualitativa que analisa a abordagem de valores e aspectos humanísticos na graduação de fisioterapia e investiga a percepção de docentes e discentes sobre questões éticas relacionadas ao exercício profissional. Foram realizadas entrevistas semiestruturadas e individuais com o coordenador do curso de fisioterapia de uma universidade pública brasileira, 12 docentes e 24 discentes do último ano do curso. Embora o tema não seja explorado em profundidade na graduação, os entrevistados falaram sobre conflitos éticos referentes à relação com outros profissionais, com pacientes e com o serviço de saúde e à alocação de recursos. Os discentes consideraram que as discussões sobre ética são tratadas apenas de modo implícito, e entre os docentes houve consenso de que é preciso abordar os conteúdos de ética de maneira mais aplicada à realidade da fisioterapia.

Especialidade de fisioterapia; Bioética; Ensino; Tomada de decisões

Resumen

Esta es una investigación empírica, descriptiva y cualitativa, cuyo objetivo es analizar la formación en valores y aspectos humanísticos en la graduación de fisioterapia e investigar la percepción de profesores y estudiantes sobre los problemas éticos relacionados con la práctica profesional. Se realizaron entrevistas semiestructuradas e individuales con el coordinador del curso de fisioterapia de una universidad pública brasileña, 12 profesores y 24 estudiantes del último año del curso. Aunque no se exploraron en profundidad a nivel de pregrado, los conflictos éticos en la atención de pacientes de fisioterapia se ejemplificaron por la relación interprofesional, con el paciente y con respecto a los servicios de salud y la asignación de recursos. Los estudiantes consideraron que las discusiones sobre ética son tratadas solo implícitamente, y entre los profesores hubo consenso en que es necesario abordar los contenidos de la ética de una manera más aplicada a la realidad de la fisioterapia.

Especialidad de fisioterapia; Bioética; Enseñanza; Toma de decisiones

Physical therapy aims to provide individuals with the freedom to live according to their choices and function, being essential for the promotion, prevention and recovery of health regarding human movement. Another important and more current role of physical therapists is to act in palliative care for patients beyond therapeutic possibility.

Due to the physical relationship imposed by physical therapy, from the touch on the other’s body, and its demand of a more constant treatment than other interventions, professionals in this specialty need an excellent communication with patients. Although treatment results may require emotional involvement and interaction between therapists and patients, little attention has been given to the ethical issues related to this relationship¹ .

Physical therapy is liberating as it develops, maintains and restores functional capacity and movement, thus improving quality of life. The human functions with which it works are often not only important, but basic² . It is in the relation between professionals and patients that bioethics and physical therapy grow closer, ensuring the autonomy of patients by offering more and better care opportunities:

If a patient doing physical therapy is a small child riding a bicycle, bioethics is their mother, running alongside with love, on a parallel path, making sure they do not fall, and holding them carefully. The common scope of bioethics and physical therapy is the journey, the autonomy, the ability of the little child to experience the world to the best of their physical potential³ .

Despite the importance of such relation, there are few studies on bioethics and physical therapy as compared to other health professions¹ . In Brazil, research focusing on the interface between these two fields are recent and still incipient⁴ - ⁶ . Besides, many of these studies are descriptive and focused on deontological discussions that contribute little to decision making in health⁴ , ⁶ .

Regarding the incorporation of ethical issues into clinical decisions in the field of rehabilitation, Finch, Geddes, and Larin⁷ reported that there is little understanding in this context, which hinders the effectiveness of care and the training of health professionals in the various disciplines of rehabilitation. Accordingly, the authors call attention to the need for help from bioethicists who address physical therapy issues, as well as physical therapists who better understand the ethical issues of clinical practice⁸ .

Therefore, deeper reflections on the ethical repercussions of work in physical therapy are needed. Thus, this article addresses the role of bioethics in the training of physical therapists, seeking to analyze the humanistic training in undergraduate physical therapy courses and investigate the perception of faculty members and students in the area about ethical issues related to professional practice.

Method

The results of a qualitative, descriptive empirical research conducted at a Brazilian public university, in the physical therapy course, are presented. This course received the maximum score (5) in the National Student Performance Examination in 2016 and was chosen by convenience. The research was approved by the Research Ethics Committee of the Medical School of the Federal Fluminense University/University Hospital Antônio Pedro and developed from April to June 2017.

Semi-structured interviews were carried out individually with the course coordinator, 12 faculty members, and 24 students, and followed the saturation sampling criterion. To adapt and test the data collection instruments, a pilot study was carried out with an analogous population from a course in physical therapy course of another higher education institution.

Initially, the Internship Guidance Committee of the researched institution provided data and contacts of 42 professionals linked to the committee and 31 regular students in the internship fields. The faculty members included acted directly or indirectly in supervised internships, as permanent or substitute professors, with a permanent or temporary labor relationship with the institution.

Internship supervisors without a teaching link with the institution were excluded (case of preceptors belonging to the health care network), as well as faculty members who did not return the invitation e-mails. The course coordinator was excluded from the faculty interview and invited to participate considering their own attributions in a management position. Faculty members on temporary leave were also to be excluded, but there was none in this situation. Figure 1 illustrates the criteria used.

Figure 1
Criteria for selection of faculty members linked to the internship program

To be included in the study, in addition to providing consent, students had to be participating in a supervised internship – which occurs in the 9th or 10th semester of the course – in primary, secondary or tertiary care. Students with no internship experience, even if they were in the 9th or 10th semester were excluded, as well as those who had not studied at the researched institution since the beginning, but no one was in these situations.

The faculty members received an e-mail invitation with information on the research and interviews were scheduled at the university’s facilities according to their availability. Access to the students occurred through contact with the faculty members linked to the internship program, and the interviews, conducted by a researcher, took place in reserved settings in the university grounds, in the university hospital, or in basic health units. The interviews were recorded, transcribed, and read in depth. Bardin’s content analysis was used for qualitative data analysis⁹ . The findings were categorized based on the thematic areas proposed in the interview scripts.

Results and discussion

The categorization of participants considered social role, age and gender. For the faculty members the degree, type of contract, and length of professional experience were also considered; and for the students, the semester of study at the time of the interview ( Table 1 ).

Table 1
Characterization of participants

Social role	Number of participants (gender)	Age	Background	Teaching bond	Time in the position or current semester
Coordinator	1 (male)	35 years old	PhD	Regular	2 years
Faculty members	12 (11 female, 1 male)	x̄ 40.3 years old (27 to 50 years old)	1 post doctoral researcher, 7 PhD, 4 master	9 regulars 3 substitutes	3 (1 to 5 years), 1 (6 to 10 years), 7 (11 to 20 years), 1 (>20 years)
Students	24 (20 female, 4 male)	x̄ 23.4 years old (21 to 27 years old)	–	–	18 (9thsemester), 6 (10thsemester)

Conceptions about training in values and humanistic aspects

Regarding ethics in the professional-patient relationship, 21 students mentioned that the topic was addressed in the theoretical classes of Ethics and Deontology (5th semester). Others reported that it was addressed in the Collective Health class (7th semester), at the beginning of the practical classes of the professionalizing disciplines (6th semester) and when entering internship (9th semester).

Although they occurred at different times during their training, the consensus among students was that the discussions on ethics were superficial and punctual. Some participants stated that the discourses on the subject are often “implicit” and focus on superficial issues related to behavior towards patients. The main issue addressed is non-judgmental actions.

As for more detailed discussions, a female student mentioned that the subject Collective Health works on hypothetical situations involving patients in contexts of social vulnerability. The convergence between bioethics and collective health is known, as both propose epistemological ruptures and question common beliefs¹⁰ . Both fields also include social and subjective determinants in their analyses¹⁰ .

When asked if the subjects that addressed ethical issues were relevant for patient care, 13 students said yes, 8 said no, and 3 said partially. Some critical considerations were made. First, the cases discussed referred to health care in general, and not specifically to physical therapy. Second, ethics as a subject is usually neglected by students and, if it were offered at the end of the course, relating its content to the practice of care would perhaps be more welcome. Finally, students also pointed out that the content on ethics could be better distributed throughout the course and that its approach could be more practical and less theoretical and expository.

From these reports, which corroborate the literature¹¹ - ¹⁴ , it can be inferred that bioethics should be a transversal content in health undergraduate courses, to accompany the different levels of complexity throughout the course and develop a practical knowledge. Cross-cutting themes refer to the contents that permeate several or all subjects in the curriculum. Thus, they are dynamic knowledge that cross-sectionally go through other conventional knowledge of the curriculum ¹⁵ .

In the health field, it is difficult to recognize cross-sectional elements that are the basis of human behavior and, connected to the biological dimension, intersect the health-disease process. Consequently, subjective and social components are important, since they condition both the production of health and sickness process¹⁶ .

According to Burgatti, Bracialli, and Oliveira¹⁷ , ethical decision making and moral judgment should occur progressively during the students’ training. This development would aid conscious decision making based on one’s own principles rather than external determinations. Cross-sectional understanding, given its importance, could support such a progression.

As positive points, the students pointed out the usefulness of reflections on ethics not only for their professional lives, but at the personal level, and the help in the relationship with patients, since these reflections invite them to put themselves in someone else’s shoes without judgments, understanding their limitations to balance their conducts. The students also pointed out that the ethical contents make them reflect on patients’ life contexts and analyze the benefits of the proposed therapies. Some reported that these contents make them aware of the moment to refer patients to other professionals and promote respect for autonomy without impositions. Patients, even the most difficult ones, are then seen as people worthy of respect, who deserve the best a professional can offer. Thus, as one of the students put it, “ such subjects are as important as the ones that make me a physical therapist. ”

However, this last report, while recognizing the importance of ethics content, showed that it is still not seen as part of physical therapy education, but as a complement. Bioethics is thus essential, as it contributes to the free and conscious morality of the students, going beyond the deontological character.

As D’Avila points out, it is recognized that moral formation does not define character, but improves and directs young people whose nature is positive, consolidating their disposition to help their neighbors, not to do evil, recognize the individuality and autonomy of others, respecting them as equal beings ¹⁸ . Thus, since a person is not born ethical, but has a priori conditions for moral development, the construction and introjection of ethical reasoning must be stimulated¹⁹ .

Conceptions on ethics/bioethics and professional practice

Students and faculty members alike believe that professors are a reference for professional conduct. Thus, we sought to address the perception of faculty members about ethics and fundamental behaviors in the professional-patient relationship, to understand the values that have been worked on in training.

Half of the faculty members mentioned the word “respect.” This word, however, took on different meanings in the faculty members’ speech: respect for the human being itself; for the patients’ physical body, as care involves touch; for the patients’ history and emotional aspects involved; how the professional dresses; when informing patients about a procedure; for listening, considering the whole context, without judging; and for religious beliefs, attitudes and practices.

The faculty members also mentioned the importance of informing patients about their health condition, treatment benefits, possibilities and consequences, providing a clear panorama of the diagnosis, prognosis limitations of the offered therapy, sharing decision making. When physical therapists act like this, patients go from object to subject of care, making their own choices after conscious analysis, without impositions. In the practice of physical therapists, simply saying that we aim at patients’ well-being and autonomy is not enough. Every decision process involves more than one parameter. Patients must have an expanded role, take greater part in the decision ²⁰ .

In this sense, one faculty member drew attention to the need to work with soft technologies to create real moments of listening, which, according to another faculty member, requires good communication skills. Merhy²¹ stated that soft technologies are relational technologies that produce spaces for exchange, speech and listening, reception, accountability, bonding and partnership between patients and professionals. The good communication that these technologies build contributes to the exercise of autonomy, favoring access to clear information, which empowers patients to make decisions regarding their health.

Mourthe, Lima, and Padilha¹⁶ advocated the inclusion of emotions in educational activities to expand experiences and demystify the traditional “reason and emotion” dichotomy. Recognizing that bioethics is eminently relational (the relationship between human beings and between humans and the environment), we believe that conscious, balanced and prudent decision-making is a consequence of the capacity for cognitive and affective analysis of care relationships. This perspective leads professionals to understand that the interactions and demands involved in health care are complex and that their performance must consider such complexity. Thus, a medium such as cinema can be a powerful educational tool, considering its ability to recreate credible situations, arouse emotions and encourage the viewer to form judgments²² .

Other relevant points highlighted by the faculty members were: recognizing patients, understanding their expectations and respecting them; having empathy; and worrying not only about the technique, but encompassing the entire context of patients’ lives and those around them. The faculty members also highlighted that the clinical conduct must be the most adequate to improve patients’ clinical condition and always based on safety, correct prescription and ethics. For this, they emphasized that professionals must be accountable for the consequences of interventions and know when to refer patients to another professional; act when you realize that patients are not receiving the treatment they need (even if the problem concerns another area); being able to have tough conversations; not expose patients by talking about them in a pejorative manner; treat the case only for scientific or therapeutic purposes; not make value judgments about them or their family; dedicate the entire moment of care to them; and provide guidelines consistent with patients’ ability to understand.

The faculty members’ speech made reference to a sense of responsibility for the care, behavior and guidelines given to patients, considering their health and life context. The speeches corroborated what the Physical Therapy Code of Ethics and Deontology²³ proposes and referred to the awareness that health and illness are based on valuations that underlie moral actions. If professionals neglect this understanding, they are unable to understand the basics about the human moral dimension²⁴ .

Ethical conflicts and decision making

Another concern of the research was to get to know the interviewees’ perspective on conflicts or ethical issues that permeate physical therapy, investigating how students are advised about such conflicts.

Out of the 12 faculty members, 10 acknowledged the existence of conflicts and two claimed not to perceive ethical conflicts in their area of expertise. Five of them mentioned conflicts with other professionals: physicians (the most mentioned), physical educators and occupational therapists. The discussion focused on the interference of one professional in the conduct of another. Still on this issue, a faculty member regretted the fact that she was unable to make students experience interprofessional work. This interviewee also said she believes that conflict occurs when not all involved provide the patient with their best effort.

Five faculty members also pointed out conflicts between the physical therapist and patients. These participants reported that such conflicts occur because the physical therapist deals with the other’s body, which involves a close physical relationship and requires a friendly environment. Another conflict cited concerns the disagreement between professional and patients on the appropriate time for hospital discharge.

This discussion about discharge has already been raised by Poulis² , who called attention to the lack of a well-established or accepted theory that defines an end point for rehabilitation. According to the author, the objectives of physical therapy are clear, but defining the moment when such objectives are reached is uncertain, so that the physical therapist must have a rigorous and reliable measure to guide their decisions and actions. The difficult thing in this situation is to delimit what is restoration of function and what is improvement. In Poulis’ view, patients must be heard to determine the end point of therapy, which is not to say that they alone can define the end point of rehabilitation. Thus, everyone must work together to clarify possibilities for choices and guarantee the patients’ autonomy.

Another critical point was exemplified with cases in which physical therapy eases but does not cure patients, discouraging them from maintaining the treatment. In these cases, physical therapists may end up blaming themselves for being uable to solve all patients’ problems.

Faced with this type of conflict, one must recover the meaning of physical therapy as a practice that promotes health and prevents the worsening of chronic conditions. This understanding comprises the idea that improving the quality of life does not necessarily mean curing illnesses, but working to ensure patient functionality according to real therapeutic possibilities, which certainly contributes to the well-being of individuals. This understanding makes professionals more able to manage situations at any level of health care, including palliative care. On this issue, a faculty member mentioned conflicts generated by the physical therapist's inability to accept the death of a patient in intensive care, looking for misconducts that could justify this event.

Still on the relationship with patients, two other behaviors considered unethical were mentioned. The first concerns the conflicts generated by interns who try to get rid of difficult patients and spend their care time with inefficient behaviors. The second conduct refers to students who unnecessarily expose patients’ cases, compromising the confidentiality of information and the guarantee of patients’ privacy, which goes against the professional code of ethics.

Faculty members also reported pejorative treatment of disabilities by some students – a problem that shows the need for more space within training to address this issue and discuss the role of physical therapy in minimizing the functional dependence of people with disabilities. It is necessary to understand that there are physical, organizational and attitudinal barriers that limit the free exercise of citizenship of this population. Thus, it is possible to broaden the regard towards society’s awareness of the need for public policies and actions that guarantee equality of freedoms and rights.

Disability generates physical, cognitive and moral changes and the care of people with disabilities raises several ethical challenges to physical therapists. As a result of life-changing illnesses and injuries, many of these patients lose physical skills and undergo changes in their personal identity, which alter social roles (including within the family) and force them to deal with stigmas²⁵ .

Another conflict, mentioned by three faculty members, concerns problems that go beyond the interpersonal sphere and bring to light aspects related to the organization of the health system. Two faculty members reported very complex situations involving access to diagnosis, care, materials, supplies and adaptive equipment in the field of child neurofunctional physical therapy. According to these reports, the problem begins with the families’ difficulty in achieving an accurate diagnosis of the child’s neuropsychomotor impairment, despite the presence of typical pathophysiological characteristics. This difficulty is often due to the family’s lack of contact with the medical professional and the problem extends to the lack of information necessary for parents to be able to access the child’s rights (such as aid and benefits), which raises an issue of social justice. Finally, the situation is even more complex because most mothers are unable to carry out their work activities, as they are fully dedicated to the child.

The faculty members’ report exemplifies the physical therapist’s social role in reducing health inequities. It is the ethical commitment of this professional to be aware of inequalities and help improve patients’ function, so their possibilities of choice and freedom improve²⁶ .

One of the faculty members detailed the problem of access to adaptive equipment:

“So we have to make the request to SUS [Unified Health System] and then it takes time and you need the equipment. And then you can’t help that child succeed, because it depends on this natural path of the SUS and it delays… and it gets worse… in consultation, counter-referral and referral. It is very difficult to have a professional network specialized in neuropediatrics. So, many children out there who need orthopedic surgery cannot get a consultation with an orthopedist. And when they get it, they don't get a place for surgery. Then the condition worsens, something you know could easily be solved if the child underwent operation at the right time. And as professionals, we get enraged! We have to control ourselves not to let this anger out, not to speak, not to comment, knowing that it is harming patients!” (DO1).

Physical therapists, as professionals with competence to diagnose and analyze kinetic-functional disorders and prescribe adaptive orthoses, are responsible for the micro-allocation of health resources, which, according to Freitas and Schramm²⁷ , encompasses the individual selection of people who will benefit from the services and resources available. Professionals working in the public sector are also responsible for managing the priority of waiting lines for physical therapy treatment, which are generally quite extensive. Thus , medical care, in most societies, does not routinely provide physical therapy early enough and in sufficient quantity to ensure that damage is adequately limited and recovery accelerated ²⁸ . This is a serious issue since, as Gaudenzi and Schramm²⁹ point out, the morality of public health actions must ensure: equitable and fair access to a health system with universal coverage; development of human capabilities; protecting the health of those in need; and respect for the fundamental freedoms of all.

Another conflict mentioned by faculty members concerns the quality of physical therapy services and inadequate professional conduct:

“Another ethical issue that I think is fundamental and that happens a lot in physical therapy is inadequate conduct. For example, the prostitution of the profession: you go there, turn on a device and leave the person for 20 minutes! This for me is a very serious ethical issue!” (DO2).

Another ethical problem, considered common by faculty members, refers to the current discussion about the use of social networks and the exposure of patients without proper consent. According to Martorell, Nascimento, and Garrafa³⁰ , such a situation can have negative repercussions for health professionals, patients and society, as it involves breaches of confidentiality and privacy, inalienable rights. The authors cite a number of examples: clinical cases with “before and after” photographs; X-ray exams showing the patient's full name and the responsible physician’s comments; exposure of patient body parts or procedures performed; images of patients in operating rooms; groups of patients in health education/prevention activities; photos of complaints from health facilities with capacity above the limit; and exposure of children, who are vulnerable and unable to make autonomous decisions. There are also reports of inappropriate use of descriptions that accompany the photos on social networks, as well as comments from professional peers or family members congratulating the professional or giving opinions about the cases.

According to Martorell, Nascimento, and Garrafa³⁰ , both the state, through legislation, and professional entities, with their codes of ethics and normative resolutions, must protect victims from image exposure. We also add that, when it comes to services linked to academia, faculty members must make students aware of the ethical repercussions of such attitudes. Nascimento³¹ corroborates this perspective by arguing that teaching bioethics would help combat the appropriation and undue exposure of patients’ image.

Currently, the Federal Council of Physical Therapy and Occupational Therapy, through Resolution 532/2021³² , changed the profession’s code of ethics, authorizing the disclosure of images, texts and audios related to physical therapy procedures, provided there is prior authorization from patients or their legal representative in an informed consent form. The disclosure must also include the name of the professional and their registration number with the professional body, besides the date of the images, texts and audios, with the disclosure of clinical cases authored by third parties being prohibited³² .

A faculty member interviewed also raised the possibility of conflicts in the academic area, mentioning ethical issues related to the authorship of works and the handling of research data. Faculty members were asked about the advisement of students before or during the internship and most reported that there is no specific preparation.

As the internship is a modality of practical teaching that brings academia closer to the health service, exposing students to the complexity of work and decision making processes, the in-depth analysis of ethical conflicts at this stage of training would help to sensitize future professionals to these questions. However, discussions about ethical issues seem to occur only after an event witnessed by faculty members and supervisors or reported by students in a meeting.

Faced with these cases, faculty members report different behaviors. One of them said to call the intern aside, so as not to break the relationship between them, while another said to let the situation happen, to observe how the student reacts and then open space for questioning and discussion. A third faculty member also reported that she often gives examples that she considered “striking” to clarify situations, such as: recording undeveloped behaviors and false information in the medical record; knowingly harming patients with wrong procedures; having access to the service’s queue and changing it; and charging for skipping places in the waiting list.

Two other faculty members said they advise the interns so that, in case of doubt, they resort to the supervisor and not take decisions alone, thus avoiding incorrect procedures. Such conduct, however, may end up not preparing students for autonomous decision making before patients. We must remember that soon such students will be professionals and will not have the immediate support of faculty members. This is one of the reasons students should be taught to be more confident and make their own decisions.

Two other faculty members pointed out that, since practice begins in the 6th semester, students already receive some preparation regarding appropriate attitudes and behaviors towards patients and their families. According to these faculty members, some examples are presented and students receive more detailed information on more complex cases that are linked to practical classes in the subjects they are attending.

Physical therapists better need to understand the ethical problems of daily clinical practice, in addition to special and difficult cases¹ . Thus, it is urgent to include the discussion of these problems in training, so that they understand the work process and know the obstacles for care and make conscious decisions.

When asked if they had already experienced or witnessed situations of ethical conflicts, 16 students answered yes and eight no. Those who answered affirmatively pointed out difficulties related to diagnosis, prognosis, discharge, use of resources without patient acceptance, patients’ social context, management of waiting lists and distribution of health resources. The most cited conflicts were: inappropriate behavior in relation to patients’ involvement; situations related to the care of children and relationships with family members whose attitudes do not always match what the interns expected; palliative care; and difficulty in dealing with death.

Some students reported that, in the face of such conflicts, they are helped by faculty members or health professionals in making decisions, but others questioned the decisions and attitudes of these professionals. Only one student stated that the discussion after the conflict was satisfactory.

According to the coordinator of the physical therapy course, some ethical issues, when misguided, are brought to the attention of the coordination. According to him, these situations generally refer to faculty member-student and student-patient relationships. The coordinator also mentioned that in the course there are subjects focused on ethical and humanistic training, but he recognized that the curriculum does not cover ethical attitudes and aspects of the profession (in comparison with theory).

From the observation, it was neither possible to clearly see the real contributions of ethics content to the training of future professionals, nor the existence of more applied bioethical reflections, beyond deontology. Technological advances have required from the physical therapist a greater mastery of techniques, which directly affects the curricula, and are increasingly restricted and limited in terms of humanistic issues³³ .

The coordinator and faculty members were asked if they believe that students are prepared to make decisions in situations of ethical conflict. Half of the respondents assumed not. Only one answered yes and another five faculty members, besides the course coordinator, think that this depends on some circumstances: character, personal and family background, beliefs and the student’s social context; emotional profile, maturity and ability to manage feelings such as insecurity, fear, frustration and defeat; and severity of each situation.

Respondents mentioned that one of the causes of lack of preparation is content overload, which leaves little time to discuss ethical aspects. Such aspects are discussed only when an event brings them to light.

For most interns, the course’s pedagogical contents and practices do not prepare students for decision making in the face of ethical conflicts. Only four students considered the ethical training satisfactory to face conflicts in practice, another six responded that “in part” and two did not know how to give an opinion.

To create links between the scientific-technological component and the human-social component, attitudinal contents should be addressed in training, going beyond ethics and norms to also encompass individual values, feelings and characteristics of the person³⁴ .

Possibilities of reflection generated by the research

As can be seen in the interviewees’ reports, the training of faculty members in ethics and bioethics would certainly bring greater security to sensitize students about the importance of a broader view of reality. Some faculty members pointed out that such training would allow broader ethical discussions and argued that this topic cannot be concentrated in a single discipline. One interviewee asks:

“How many of us faculty members are trained and able to discuss this a little more in our subjects? Because many times the faculty member of ethics, even if he is from physical therapy or health, (…) is more focused on the theoretical part of ethics. And when we go into the day-to-day professional practice, we can bring up some situations that will be more palpable, more practical for students to think like this: that concept I learned there, here in practice I have to know how to use it, how to think, use this tool to help me reflect and have attitudes that will be ethical” (DO3).

From the speech, one notes the awareness of the need to build knowledge that is complementary and applied to the practice of physical therapists, which requires greater preparation, reading and discussions on the part of faculty members, in an attempt to include the contents of ethics in the disciplines. The faculty member concludes by saying that the present research was an opportunity to reflect on the curriculum, pointing out that a conversation between faculty members would be pertinent to find out how to better address this issue.

In a recent research on professional reorientation in physical therapy, Gauer and collaborators³⁵ argued that, to achieve advances in training, it is necessary to create continuous teaching-learning strategies and plan practices integrated with health services. Accordingly, the literature points out that questioning, as a teaching and learning method in internships, promotes critical reflection on professional practice, services and the health system¹⁷ .

By rehabilitating its citizens, society demonstrates respect for the quality of life² . Education and health care must combine technical and ethical accuracy, which includes the ability to make decisions in the face of conflicts involving personal beliefs and values¹⁷ , ³⁶ . To this end, knowing how to recognize the ethical conflicts existing in each professional practice is crucial. Finally, it is worth noting that physical therapy is a fertile field for bioethics, as physical therapists must protect themselves from negligence and must have answers to all ethical conflicts they encounter ³ .

Final considerations

The present research showed that most of the faculty members and students interviewed could perceive the conflicts faced by physical therapists in the care of their patients. In the interviews, such conflicts were presented as: interpersonal issues with other health professionals and with patients; issues related to physical therapy procedures; and issues related to health services and resource allocation.

Although ethical values and conflicts were not explored in depth in the undergraduate course, they were referred to by faculty members and students. However, the conflicts presented as examples to the students are not usually the most common ones in the physical therapy reality. The reports indicated that the discussion usually focuses on more serious aspects, to the detriment of everyday situations that, at first, may not draw attention, but afterwards may generate insecurity for faculty members and students. The lack of preparation to address these situations can lead to disastrous resolutions or omissions.

Faculty members recognize daily conflict situations, but perhaps because of a lack of more training in bioethics, they do not approach these conflicts with the necessary depth in their courses and internships. This is a serious issue, because ethical discussions, could promote the moral self-development of the students and transform theoretical knowledge into practice, fostering the ability to act in an autonomous and critical manner in their personal lives and at work.

In conclusion, the ethical discussion should be transversal and permeated by the physical therapy practice, since, as exposed, the ethics and deontology subjects do not contemplate the reality of the work process. Thus, bioethics should be understood as a tool to develop critical thinking about complex and broad issues that involve the health-disease process.

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• The study was part of the doctoral dissertation of the first author.
• Approval CEP/UFF 1.995.980

Publication Dates

• Publication in this collection
  18 Oct 2021
• Date of issue
  Jul-Sep 2021

History

• Received
  11 Jan 2020
• Reviewed
  22 July 2021
• Accepted
  23 July 2021