Our study describes the ethics topics of the undergraduate physiotherapy curriculum in South Africa.

The ethics topics on the HPCSA master copy that were similar were coded and allocated to a category (Aveyard, Edwards & West 2005) and were grouped as categories (Corbin & Strauss 2008; Moghaddam 2006). Documents with ethics topics were purposively sampled from the HPCSA and the universities’ curricula. The data on ethics topics obtained from the university curricula documents were recorded and extracted onto a Microsoft Excel file. Each ethics topic was classified under the relevant categories (Aveyard et al. 2005; Hudon et al. 2016). The manual coding used was consistent with inductive thematic analysis, involving moving forwards and backwards with the data, facilitating a rigorous interaction and understanding of the phenomenon as it was uncovered (Concannon, Gillibrand & Jones 2019), culminating in a set of six textual analytical categories. A pilot study was carried out with one university using the data collection tool to identify and assess the practical aspects of carrying out the document analysis.

Ethics clearance for our study protocol and to conduct our study was obtained from the University of Pretoria, Faculty of Health Sciences Research Ethics Committee (reference number: 508/2021 – Line 4). From each of the eight universities, the gatekeepers’ permission was sought to ensure compliance with research ethical principles, data management and conflict of interest as determined by the respective Human Research Ethics Committees (HREC). Permission was granted to access the physiotherapy curricula by the eight physiotherapy training universities in South Africa. No names of the universities are used in the results or discussions to maintain anonymity.

In the patient care category, all South African universities covered the introduction to ethics and bioethical principles (Table 2), in line with the findings of Hudon et al. (2016), which indicated that foundational knowledge is required to introduce students to the language of ethics, build their ethical reasoning skills and help them recognise ethical issues. The commonly covered topics were justice, informed consent, confidentiality, health records, communication and community health. Justice, being the cornerstone of the profession, defines the safe and acceptable performance of physiotherapeutic services that do not discriminate based on race, sex, age, financial status, religion, views or sexual orientation (Pezdek & Dobrowolski 2023). A study carried out by Aderibigbe and Chima (2019) on physiotherapists and assistants in KwaZulu-Natal public healthcare institutions reported insufficient knowledge of informed consent by physiotherapists and assistants despite the HPCSA ethical guidelines, which stipulate that practitioners should always obtain informed consent from patients before providing treatment (HPCSA 2022). By including informed consent among the ethics topics, the universities contribute to the ethical behaviour of physiotherapists, to which Hudon et al. (2016) advocate the patients’ informed consent specific to rehabilitation to be an ongoing process rather than a one-time event.

Fundamental to the patient–healthcare provider relationship and good clinical practice (Varkey 2021) are confidentiality, truthfulness, trust and communication, which were topics covered by the universities (Table 3). Although the International Classification of Functioning (ICF) was not in the HPCSA guidelines, about 50% of the universities included it as part of ethics topics, which according to Hudon et al. (2016) has a philosophy that is underpinned by ethical theories.

In this category, all the universities covered professional competence, which is essential in physiotherapy education programmes to equip students to be autonomous professionals for entry into practice (Murphy et al. 2018) and is a crucial part of professionalism that encompasses the virtues of compassion, discernment, trustworthiness, integrity and conscientiousness (Varkey 2021), as well as maintaining confidentiality and good clinical practice (Naidoo & Vernillo 2014). When professionalism is taught in clinical practice, it builds competent and compassionate care rooted in ethical principles and aids in professional identity formation (Varkey 2021). The HPCSA ethical rules were covered by 87.5% of the universities, emphasising the importance of a statutory council because healthcare professionals are required to register with the HPCSA to practice their profession (Health Professions Act 56 of 1974) and therefore comply with ethical and professional rules. Professionalism in healthcare is shaped by the complexity of healthcare systems in which professionals work and by the society and their expectations and trust in healthcare professionals (Delgado 2021); hence, it must be instilled during training.

There was an unexpectedly low uptake in this category, as only 25% of the universities covered telehealth while another 25% covered social media ethics. Notwithstanding the similar results where Murphy et al. (2018) reported that social media ethics was the least common topic covered across all universities in Canada, the use of social media has increased exponentially throughout the world in building social and professional relationships (Kubheka 2017). Telehealth, which is a non-face-to-face clinical service delivery model (Hays et al. 2020), has an important role in contemporary physiotherapy practice, as it is a modern and innovative way to deliver physiotherapy services (Davies et al. 2023). Therefore, social media and technology ethics must be included in the undergraduate physiotherapy curriculum (Sviland et al. 2022).

Of concern is that 50% of the universities did not cover any ethics topics in this category despite the emergence of social media, which has shifted information-seeking behaviour in society to become the basis for healthcare decisions (Gagnon & Sabus 2015). Arguably, the technology enabled poor ethical behaviour and lack of confidentiality (Kelly 2023). Even though healthcare professionals should not be discouraged from using social media, they need to be aware of any potential ethical pitfalls and the laws regarding defamation and copyright that extend to the content shared via social media (HPCSA 2022). The universities should consider curriculum updates to include knowledge and skills in digital health (Merolli et al. 2024).

Vulnerable groups include people with incurable or stigmatised conditions or diseases, those living with disabilities, and those who are faced with physical frailty because of age (Council for International Organizations of Medical Sciences [CIOMS] 2016). In this category, 50% of the universities covered the HIV/AIDS topic, a stigmatised condition, with those infected being vulnerable because of their disease status (Hlongwa 2016). The stigma may affect the patient’s right to privacy, autonomy in decision-making, and confidentiality (Boldt 2019). The complex multidimensional nature of HIV, which includes a combination of factors such as discrimination and the incurability and communicability of HIV infection, gave salience to ethics in the management of HIV (Sebone et al. 2019).

Fifty per cent of the universities covered the ethics regarding older persons/ageing whose needs are frequently complex because of the presence of multiple co-morbidities, increased prevalence of dementia, and neurodegenerative diseases that impact cognitive function and may result in impaired decision-making capacity (Holmes & Ibrahim 2021). Owing to compromised cognitive function in older persons, bioethical principles, including the principle of autonomy, could be seen as providing this role of articulating the centrality of the person’s interests, yet autonomy arguments may become more complex when the person concerned lacks capacity (Bennett 2019; Van Staden 2009, 2015). Consent to medical procedures and treatment in an ageing population raises a plethora of challenges (Holmes & Ibrahim 2021); hence, students need to be sensitised to the ethical challenges involved in the care of the elderly.

Fifty per cent of the universities covered disability. Nicolaides and Shozi (2021) described people living with disabilities as those who get omitted from many meaningful activities and encounter social barriers that include access to education, health and a range of economic opportunities. People with disabilities require the promotion of quality of life, dignity, maintenance, access, self-determination and cultural proficiency in addition to medical treatment and rehabilitation (Garland-Thomson 2017). In support of the need to include ethics for a vulnerable patient, Aveyard et al. (2005) identified the importance of assessing decision-making ability, the concept of best interests and the role of relatives in decision-making. The remaining 50% of universities will need to be encouraged to include disability in the ethics curriculum.

Sixty-two-point-five per cent of the universities covered the topic of cultural diversity. The importance is because of culturally diverse patient populations (Paternotte et al. 2014), necessitating healthcare workers to be prepared to provide culturally relevant, patient-centred services (Brown, Spicer & French 2021; Van Staden 2020). It is commendable that the universities cover the topic of cultural diversity because a curriculum needs to be responsive to real-life experiences and expose students to community issues, which leads to understanding how cultural and religious beliefs impact health (Molatoli 1999; Rashed, Du Plessis & Van Staden 2015). There is plausible evidence of curriculum transformation gradually emerging at most South African universities, where students are exposed to different cultural environments in rural clinical placements (Mpofu et al. 2014; Müller et al. 2022). This is an improvement from the findings by Ramklass (2009) who reported that the curriculum had responded insufficiently to the changes in the sociopolitical context in South Africa. In the Netherlands, the undergraduate curriculum transformation has taken place to include cultural diversity training for a culturally competent curriculum (Paternotte et al. 2014). Brown et al. (2021) advocate for higher education cultural competence in the curriculum to prepare students for a more inclusive and culturally aware healthcare workplace.

A total of 62.5% of the universities covered research ethics, for which the National Health Act 61 of 2003 of South Africa provides statutory authority for the governance of health research and the research ethics regulatory infrastructure (National Health Act 61 of 2003). Several deplorable cases of abuse of human subjects in research and medical interventions without informed consent occurred in concentration camps during World War II, and this resulted in an upsurge of interest in ethics and led to the rapid development of bioethics, including research ethics (Varkey 2021). This includes, for example, the intricacies of obtaining informed consent for participation in research (Sommers, Van Staden & Steffens 2017). The importance of research ethics was also identified by participants from all professional fields in a study carried out by Aveyard et al. (2005). One of the universities redesigned the ethics curriculum to include integrated components of health research ethics, healthcare ethics, clinical care, health personnel education in ethics, and global and public health ethics (Naidoo & Vernillo 2014). The need to teach research ethics was further highlighted in a study carried out in Cape Town, South Africa, where numerous research ethics transgressions regarding voluntariness, the validity of informed consent processes, equity, access, and a lack of community engagement were reported during the coronavirus disease 2019 (COVID-19) pandemic (Burgess, Rennie & Moodley 2023).

Three-quarters of the universities covered the topic of healthcare systems, which by design should improve community health and reduce the disease burden, recognising equity, need, efficiency and cost-effectiveness (Olver et al. 2019). The universities need to sensitise the students to the distinctive features of South African healthcare systems that are unequal and starkly divided between the under-resourced public and the fee-charging private sector (Burger & Christian 2020). It is also important to highlight the historical inequities because of the apartheid system that contributed to the current health problems of the disadvantaged (especially rural) people (Coovadia et al. 2009). In redressing historical inequities, the physiotherapy department at the University of KwaZulu-Natal effected changes in the curriculum from traditional healthcare to a more comprehensive, community-based care, embracing the notion of disease prevention and broadening access to physiotherapy services in geographical locations that were previously under-serviced (Ramklass 2009). Several South African universities have also responded to the healthcare needs of the country through the inclusion of rural-based clinical practice, which will potentially have long-term benefits for quality care in the health system (Mpofu et al. 2014; Müller et al. 2022; Van Staden 2021). Integral to creating a healthcare system that respects the dignity and rights of all individuals are the principles of equity and fairness (Ahmed et al. 2024; Ujewe & Van Staden 2021a), and healthcare professionals need to recognise the disparities in healthcare delivery as an important aspect of social accountability (Hays et al. 2020).

Half of the universities covered the topic of resource allocation, which determines how the limited resources are distributed across different populations and require the decision-making processes to be ethically sound while addressing the practical constraints of healthcare systems about who gets access to care, how much care they receive, and what kind of care is prioritised (Ahmed et al. 2024). This implies using public health resources responsibly to promote health and reduce illness without wasting resources on treatments that, relative to cost, are marginally beneficial or ineffective (Olver et al. 2019). Curricula need to prioritise skills that address ethical challenges and create opportunities for students to learn about the community, work towards ensuring health equity (Cloninger et al. 2014; Hays et al. 2020) and enact policies that avert a repeat of travesties (Ujewe & Van Staden 2021b).

The academic year in the curricula in which ethics is taught varied from university to university, ranging from the first year, and for the majority, from the second year to the fourth-year level (Figure 2). Dahl-Michelsen and Groven (2017) reported that some institutions introduce ethics in the first year and incorporate elements of ethics into different modules in later years, whereas others introduce ethics in a first-year lecture and then require an ethics seminar in the second year. Similar results of ethics being taught in the second academic year were reported by Marques-Sulé et al. (2021) at the University of Valencia in Spain, who concluded that ethics should be taught in each academic year to make students aware of the importance of ethics. A study carried out in Canada by Laliberté et al. (2015) reported that most ethics teaching was informal, and the content was not often rigorously mapped across the curriculum. One of the South African universities did not teach ethics at the fourth-year level (Figure 2), which raises concern, as fourth-year students are likely to face more ethical issues during their clinical practice.

The ethics topics covered by the universities demonstrated that they focused on preparing the students for clinical practice, although some did not cover technology and social media ethics, which are important as the students use social media platforms to communicate patient information. The topics included diverse cultural populations, health systems and vulnerable groups, creating awareness, building an understanding of the disparities in healthcare, and responding appropriately to the healthcare needs of the communities the physiotherapists serve.

The study’s strength is that it is representative because the data were obtained from all the South African universities that teach physiotherapists. The study compared ethics from established benchmarks, as found in the HPCSA ethical guidelines. The study also followed the systematic analysis afforded by a qualitative document analysis. The universities were found to have covered more relevant ethics topics to the South African context than required by the HPCSA, which enriched the ethics curricula.

While the document analysis method provided a structured approach to identifying ethics-related content in university curricula, several limitations must be acknowledged. Firstly, the reliance on keyword searches based on the HPCSA ethical guidelines may have led to an incomplete representation of ethics education, where course descriptions might not explicitly mention the selected keywords. Secondly, keyword-based analysis is inherently limited by language variation and the diverse ways in which different universities may integrate ethics into curricula, which our keyword list may not have fully captured. Thirdly, course descriptions often provide only a high-level overview of content and may not reflect the full scope of material covered in lectures, seminars or assessments, implying that the ethics-related discussions may occur in ways not visible through documentation alone. This is particularly relevant when considering the role of the hidden curriculum, which encompasses the implicit values, behaviours and cultural norms that students acquire during their education, but which are not formally outlined in course materials. Lastly, the document analysis did not account for the depth of ethics education, even where relevant keywords were found, which does not guarantee comprehensive coverage of ethical issues. Without triangulating the data with teaching materials and interviews with educators, it has proven to be difficult to assess how effectively ethics is taught or integrated into professional identity formation. These limitations underscore the importance of complementing document analysis with additional qualitative methods in future research, such as curriculum mapping, to gain a more holistic understanding of ethics education in health sciences curricula.