A qualitative approach using an exploratory descriptive study design was employed. Focus group discussions were selected to collect data. Focus group discussions enable participants to share their perspectives and experiences and facilitate a deeper understanding of perspectives (Gill et al. 2008; Levitt et al. 2017; Mohajan 2018).

The target population included 22 (n = 22) clinical educators employed by the UWC Physiotherapy Department to provide clinical supervision to undergraduate students in clinical practice. Eighteen (n = 18) physiotherapy clinical educators were employed on a part-time basis, and four (n = 4) were full-time academic staff involved in the clinical supervision of undergraduate students as part of their workload. Purposive (non-probability, total inclusive) sampling was used to recruit all 22 participants, who had knowledge of clinical education and the curriculum at the included physiotherapy department. We acknowledge that while our study was limited to clinical educators from a single institution, this approach allowed for in-depth exploration of institution-specific challenges and opportunities. The participants represented diverse clinical experience levels and educational backgrounds, providing varied perspectives within the institutional context.

The total study population of 22 clinical educators was invited via email to participate in our study. Eleven agreed to partake. Two focus groups were conducted; firstly, the session was performed in person at the Department of Physiotherapy at UWC on a day and time that was convenient for all consenting participants (n = 6), and secondly, it was performed virtually using Google Meet (n = 5). The in-person focus group was facilitated by the research supervisor J.P., while the primary author S.G. observed. The online focus group was conducted via Google Meet and facilitated by the primary author S.G. Each focus group session started with a short introduction by the facilitator to outline the key rules for the focus group. Focus groups lasted approximately 1 h and were audio recorded with the permission of all participants. A semi-structured interview guide, informed by existing literature on the topic and aligned with our study objectives, was used to generate open discussion. Pseudonyms were assigned and used throughout our study to protect participants’ identities. At the end of each focus group, participants were thanked for their contribution and informed that the data would be returned to them for review once transcribed. Data saturation was evaluated by examining when no new themes or significant variations emerged from the data. After the second focus group, the research team reviewed all themes and determined that sufficient depth and breadth had been achieved to address the research objectives. While theoretical saturation may not have been fully achieved due to the limited number of focus groups, informational saturation was reached regarding the core themes.

The audiotaped recordings from the two focus groups were transcribed verbatim by an independent transcriber. The audio recordings were cross-checked against the transcripts by S.G. to ensure accuracy. Participants were then given the opportunity to review the authors’ interpretations of the data to verify accuracy. S.G. read through the transcripts multiple times to become familiar with the data. Manual thematic analysis was conducted by S.G., using Braun and Clarke’s (2006) six-step method employing an inductive approach that enabled patterns to emerge directly from the data (Braun & Clarke 2019). Braun and Clarke (2021) emphasise the natural, organic development of themes throughout the inductive, analytical process. Inductive coding was guided by the research aims. The coded transcripts were reviewed by J.P., who was familiar with the topic and had experience in qualitative research. This review served as a form of peer debriefing that offered alternative perspectives on the data and encouraged reflexivity (Braun & Clarke 2019; McMahon & Winch 2018). The codes were then actively developed into broader themes through a process of interpretation and refinement, after which they were reviewed again by J.P. These codes, their categories and the final themes generated are described in Figure 1, Figure 2 and Figure 3.

Throughout the data collection and analysis, S.G. engaged in ongoing reflexivity to ensure that personal interest in PA and EP in clinical education did not unduly influence the process or findings. This aim was facilitated through the use of a reflexive diary, which was regularly discussed with researcher supervisor J.P., to maintain an appropriate level of detachment at critical stages. The trustworthiness of our study was enhanced using Guba’s framework, which includes credibility, transferability, dependability and confirmability. Credibility was supported by participants’ verification of accurate data interpretations. Transferability was supported by providing detailed descriptions of the research context, sampling and analytical process, allowing for assessment of relevance to other contexts. Dependability was achieved through comprehensive documentation of the research process, ensuring transparency and reproducibility. Confirmability was strengthened by maintaining an audit trail that captured the progression of data analysis and interpretive reasoning. The integration of verbatim participant quotations and transparent methodological reporting further reinforced our study’s integrity.

The research was approved by the Humanities and Social Sciences Research Ethics Committee of the UWC (Ethics Clearance Number: HS18/8/10). Participants received information sheets outlining our study’s purpose and procedures. Written informed consent was obtained in hard copy or digitally from all participants. Transcripts were anonymised and stored securely in a password-protected folder on Google Drive to protect confidentiality. Participants were informed that their participation was entirely voluntary, with no impact on their academic status or professional relationships, and that they could withdraw at any time without consequence.

Participants emphasised the evolving professional identity of physiotherapists as advocates for PA promotion and EP, extending beyond traditional rehabilitation to encompass primary prevention, public health leadership and patient empowerment (Figure 1). This expanded role requires physiotherapists to not only prescribe exercises but also foster patient self-efficacy and responsibility for long-term health management. Clinical educators recognised that while PA promotion and EP are core physiotherapy competencies, realising this professional identity requires both advocacy within the healthcare system and effective patient education strategies.

Participants articulated their profession’s essential role in prescribing exercise across diverse clinical contexts:

Beyond individual patient care, participants advocated for a paradigm shift towards preventive care and public health approaches, positioning physiotherapists as leaders in community health promotion:

Central to this expanded professional identity is the responsibility to educate multiple stakeholders about the importance and benefits of PA promotion and EP, extending advocacy across professional boundaries:

Participants recognised that effective EP must ultimately empower patients to take ownership of their health management, particularly given resource constraints in healthcare settings:

This emphasis on patient empowerment reflects the understanding that sustainable health outcomes require patients to become active participants in their care, moving beyond passive treatment recipients to informed self-managers of their PA and exercise routines.

Participants identified challenges in translating theoretical knowledge about PA and EP into clinical practice (Figure 2). While acknowledging that the undergraduate curriculum provides adequate content on EP and theoretical frameworks such as the International Classification of Functioning, Disability, and Health (ICF), both students and clinical educators struggle to apply this knowledge comprehensively in clinical settings. This theme reveals a persistent theory–practice gap that affects both the learning and the teaching of PA promotion and EP competencies.

Clinical educators noted that students often compartmentalise their learning, failing to integrate knowledge across different modules and clinical contexts:

This compartmentalisation extends beyond individual modules, with students struggling to carry forward foundational concepts throughout their academic progression:

While theoretical frameworks like the ICF are taught to guide holistic patient management, participants observed that both students and practitioners often focus narrowly on impairments while neglecting broader functional improvements through EP:

Significantly, clinical educators acknowledged their own knowledge gaps in EP, highlighting that the theory–practice challenge extends beyond student learning to educator preparedness:

To address these challenges, participants suggested that health promotion and EP concepts should be integrated throughout the curriculum rather than confined to specific modules:

Time constraints emerged as a significant challenge, with participants describing the difficulties of incorporating a comprehensive EP into busy clinical practices (Figure 3). In acute care settings, the pressure to facilitate early patient discharge often results in limited time for developing long-term exercise programmes:

The focus on immediate management often overshadows long-term exercise planning:

The emphasis on professional identity and patient empowerment reflects a global shift in physiotherapy practice towards primary prevention and public health advocacy (Dean 2009; WCPT 2019). Our findings align with recent literature, recognising physiotherapists as experts in PA promotion and EP across healthcare settings (Barton et al. 2021; Shirley et al. 2010; West et al. 2021). Furthermore, physiotherapists, as movement specialists, are well placed to combat health risks related to sedentary lifestyles (Lowe et al. 2018; Shirley et al. 2010; West et al. 2021). This shift is timely, given the WHO’s recognition of physical inactivity as a major contributor to NCD mortality worldwide (WHO 2024). Integrating patient empowerment into the physiotherapy role reflects a more holistic view of healthcare – one that moves beyond traditional biomedical models. Participants in our study highlighted that prescribing exercise effectively is not just about clinical skills but also about supporting behaviour change and facilitating the self-efficacy of patients. This attitude reflects a patient-centred approach that acknowledges individuals as active partners in their health management. This view aligns with comprehensive evidence supporting exercise as medicine and emphasising the importance of patient engagement in achieving sustainable health outcomes (Al-Ghafri et al. 2021; Pedersen & Saltin 2015; Varkey et al. 2022). The shift towards patient empowerment is especially important in resource-constrained environments where patients may not have access to physiotherapy services and may need to take responsibility for their own health (Chong et al. 2020; Mokwena & Phetlhe 2015). Therefore, rethinking traditional physiotherapy curricula is crucial. The inclusion of health promotion, patient education and behaviour change strategies in physiotherapy education is imperative to prepare graduates to function as health advocates and leaders in promoting PA and prescribing exercise and is supported by Walkeden and Walker (2015).

The persistent theory–practice gap identified in our study reflects broader challenges documented internationally in health professional education (O’Donoghue et al. 2011; Schwab et al. 2022). However, our findings extend this understanding by revealing how resource constraints in South African healthcare settings compound these challenges. The compartmentalisation of learning observed among students, in which knowledge from early modules fails to integrate into clinical practice, suggests fundamental issues with curriculum design and delivery. Particularly concerning is the acknowledgement by clinical educators of their own knowledge gaps in prescribing exercise. This finding is supported by Barton et al. (2021), who surveyed physiotherapists across 56 countries and found inconsistencies in knowledge, competence and application of exercise guidelines. Similarly, an online survey by Chesterton, Alexanders and Alexanders (2023) found that United Kingdom physiotherapy graduates felt underprepared in EP. Collectively, these studies reveal systemic educational gaps in EP across contexts. In the South African context, where healthcare resources are constrained and the burden of lifestyle-related NCDs is rising rapidly (Patricios et al. 2022), such knowledge gaps among educators create a cascade effect that ultimately impacts patient care quality.

The challenge extends beyond individual knowledge deficits to systemic issues with framework application. While participants acknowledged the importance of the ICF framework for holistic patient management, they noted a persistent focus on impairment-level interventions at the expense of participation and community reintegration goals. This disconnect between theoretical frameworks and practical application reflects what Narain and Mathye (2023) describe as the need for transformation in South African physiotherapy education to better align with primary healthcare principles. These principles emphasise equity, accessibility, community participation and a focus on prevention and health promotion – core values underpinning person-centred, community-oriented care. Aligning physiotherapy education with primary healthcare principles requires curricula and clinical training that integrate prevention, participation and social determinants of health to prepare physiotherapists for practice in resource-limited settings.

The time and resource constraints identified in our study reflect broader challenges in South African healthcare delivery, which extend beyond educational settings. The pressure for rapid patient turnover in acute care settings, combined with limited staffing and resources, creates environments where comprehensive EP becomes secondary to immediate symptom management. This finding resonates with international literature identifying similar barriers to PA promotion in clinical practice (Alshehri & Alzahrani 2024; Lowe et al. 2018). These barriers align with challenges identified in other African contexts, in which physiotherapists report similar time constraints and training needs for effective PA promotion (Abaraogu, Edeonuh & Frantz 2016). The systemic nature of these constraints suggests that they are embedded within healthcare financing models that prioritise volume over quality, creating perverse incentives that undermine comprehensive patient care approaches.

However, our study reveals how these systemic barriers specifically impact clinical education delivery, creating what could be termed an ‘educational poverty cycle.’ Students learning in high-pressure environments with limited time for comprehensive patient assessment and long-term planning are unlikely to develop the skills and confidence needed for effective PA promotion and EP in their future practice. This educational deficit is compounded by the clinical educators, who themselves lack adequate time to model best practices or provide detailed mentorship on EP techniques. The result is a concerning cycle in which systemic constraints perpetuate the inadequate preparation of future practitioners, who then enter the workforce unprepared to challenge or change existing practice patterns, thereby reinforcing the status quo of suboptimal PA and exercise implementation.

The interconnected nature of our themes suggests that addressing challenges in PA and EP education requires comprehensive, multi-level interventions rather than isolated curricular changes. Developing professional identity depends on addressing knowledge gaps, as confidence and competence in EP underpin physiotherapists’ role as health promoters. Without current evidence-based knowledge of EP, clinical educators and students cannot fully realise the preventative and advocacy aspects of physiotherapy practice. Ongoing professional learning and curriculum renewal are therefore essential to strengthening the profession’s evolving identity. Effective knowledge translation, likewise, depends on supportive clinical learning environments that provide students with opportunities to apply theoretical principles of PA promotion and EP under guided supervision. When clinical educators model best practice, foster interdisciplinary collaboration and prioritise reflection and feedback, theoretical knowledge is effectively translated into clinical competence. In their absence, theory remains disconnected from practice. Collectively, these findings point to a systemic need for transformation in health professional education – one that aligns with broader calls that integrate social determinants of health and contextual realities of healthcare delivery (Schwab et al. 2022). Our findings support recommendations for the longitudinal integration of PA and EP concepts throughout physiotherapy curricula rather than compartmentalised modules (O’Donoghue et al. 2011). This integration must extend beyond theoretical knowledge to include practical application opportunities, behaviour change strategies and public health perspectives.

The knowledge gaps identified among clinical educators highlight an urgent need for targeted professional development programmes. Such initiatives should address both technical EP knowledge and pedagogical approaches for teaching these skills in resource-constrained environments. These programmes must incorporate evidence-based EP principles, contemporary behaviour change strategies and innovative teaching methodologies that maximise learning within time-limited clinical placements while ensuring that educators can confidently model and teach comprehensive PA promotion skills.

Addressing systemic barriers requires collaboration between educational institutions and clinical placement sites to develop innovative approaches for teaching comprehensive PA and exercise within existing time and resource constraints. This teaching might include structured protocols for EP that acknowledge clinical realities while maintaining educational objectives. Potential solutions could involve developing standardised assessment templates that efficiently capture PA promotion opportunities, creating digital resources for rapid EP reference and establishing dedicated time slots for PA-focused patient interactions. Collaborative initiatives might also include joint training programmes for clinical educators, shared curriculum development that integrates workplace learning with academic theory and the establishment of community-based learning sites where students can practise PA promotion in less time-pressured environments. Furthermore, partnerships could facilitate the development of technology-enhanced learning tools, such as mobile applications for EP or virtual reality simulations that allow students to practise patient education scenarios. These collaborative efforts should aim to create sustainable models that benefit both educational quality and clinical service delivery, ultimately producing graduates better prepared for contemporary physiotherapy practice while improving patient care outcomes in resource-constrained settings.

Our findings have particular relevance for South African physiotherapy education, given the country’s unique healthcare challenges. The high burden of lifestyle-related NCDs, combined with resource constraints and healthcare disparities, creates both an urgent need and significant barriers for effective PA and exercise implementation. The evolution of physiotherapists’ professional identity towards public health advocacy may be particularly important in the South African context, where physiotherapists are often among the few healthcare professionals accessible to communities. The emphasis on patient empowerment and self-efficacy identified in our study may be especially relevant in resource-limited settings in which the ongoing professional supervision of exercise programmes is often not feasible. Preparing physiotherapy students to effectively educate and empower patients for independent health management could significantly impact population health outcomes.

While our single-institution study provides valuable insights into institution-specific factors influencing PA promotion and EP education, the findings’ generalisability is limited. Future multi-site studies across diverse South African physiotherapy programmes would enhance the understanding of how different institutional and regional contexts influence clinical education delivery. In addition, while data saturation principles guided our analysis, we acknowledge that additional focus groups may have provided further nuanced insights. However, the consistency of themes across both groups and the depth of discussion achieved suggest adequate informational saturation for our exploratory study.

The theory–practice gap identified in our study warrants investigation of specific educational interventions. Future research should explore innovative pedagogical approaches for enhancing knowledge translation and evaluate their effectiveness in improving students’ PA and EP competencies. Additionally, longitudinal studies tracking graduates’ actual exercise promotion and prescription practices would provide valuable insights into the long-term impact of educational interventions.