Ethics is a discipline of thought and study regarding the moral principles of human behaviour; it is about right and wrong in conduct, often in accordance with explicit or implicit rules or standards as accepted within a specific context (Kirby 2009). In a health context it focuses on protecting patients’ interests, freedoms and well-being (Verheyden 2012). As a result, the conduct of most practitioners in formally recognised health professions across the world is guided and regulated by ethical standards and codes of conduct to protect the public at large and patients specifically. These standards and codes of conduct define foundational ethical principles, describe professional obligations, aim to raise accountability, commitment and professional integrity, whilst also promoting adherence and compliance to those standards (Banks 1998; Burke et al. 2007; Oyeyemi 2011). Furthermore, the codes can empower practitioners to make informed and reasoned decisions in real-life contexts that pose ethical dilemmas and challenges (Burke et al. 2007; Oyeyemi 2011). However, the written codes in themselves do not ensure ethical practice or avert health professionals from engaging in various forms of unethical behaviour in professional-patient and professional practice contexts; ethical conduct is more than simple compliance to rules and regulations (Banks 1998). Inherent ethical values such as professionalism, honesty and integrity are vitally important in these contexts to guide and motivate each health practitioner's ethical conduct. It motivates health practitioners to maintain the highest possible clinical skill levels and to stay informed of the latest advances, technologies and insights through continuous professional development activities (Scherrer, Louw & Möller 2002). In addition, ethics education must form an integral and compulsory part of all health-related undergraduate, postgraduate and continuous professional development programmes (Health Professions Council of South Africa [HPCSA] 2006). Essentially, ethics education aims to raise students’ and practitioners’ ethical self-awareness, ethical issue recognition, ethical decision making and the application of ethical principles and guidelines (Carlin et al. 2011).

The physiotherapy profession is widely recognised as the field of health sciences that focuses on the assessment, treatment and prevention of human movement disorders. Generally, it aims to restore normal function or to minimise physical dysfunction, impairment and pain in persons of all age groups; the ultimate aim being to facilitate the highest possible level of independence in adults and children (South African Society of Physiotherapy 2014). In terms of a code of ethics for physiotherapists, the American Physical Therapy Association (APTA) subscribes to the following professional core values: accountability, altruism, compassion, excellence, integrity, professional duty and social responsibility (APTA 2012). These values are also important in the South African context. Ethical conduct of physiotherapists registered in South Africa is regulated by the Professional Board for Physiotherapy, Podiatry and Biokinetics of the Health Professions Council of South Africa (HPCSA 2008). The HPCSA has formal jurisdiction to investigate any complaint or allegation of unprofessional conduct by the public or other health care practitioners against registered physiotherapists; this includes the power to institute disciplinary proceedings (Health Professions Act [No 56 of 1974], paragraphs 3[n], 3[o] and 41[1]). An analysis of recent HPCSA guilty verdicts can provide important insights into duly investigated ethics misconduct by registered physiotherapists in the South African health care context. In addition, such an analysis can provide valuable information for continuous professional development ethics training programmes. As such, the objectives of this study were the following:

A mixed methods approach was followed in this study, specifically an explanatory sequential design that is characterised by the collection and analysis of quantitative data followed by the collection and analysis of qualitative data (Creswell 2013). The quantitative component of the study focused on the following annual frequency data (2007–2013) regarding the number of sanctioned practitioners:

The physiotherapists who were found guilty of professional misconduct in terms of the ethical rules of conduct for HPCSA-registered health care practitioners (HPCSA 2008).

Any acts or omissions by HPCSA-registered health practitioners to comply with the ethical rules of conduct for HPCSA-registered health care practitioners (HPCSA 2008) can be found guilty of professional misconduct. The various penalties that may be imposed on guilty practitoners include the following: a caution or reprimand; suspension from practicing for a specified period; removal of name from the register; prescribed fine; compulsory period of professional service; payment of the costs of the professional conduct proceedings or restitution. The execution of all penalties, or parts thereof, may be suspended for a period (Health Professions Act [No 56 of 1974], paragraphs 19[1][g], 19A[1][c], 42[2] and 43[1][b]). The qualitative research component of the study specifically used a historical research approach with archival material as the primary data source (Neuman 1997). The study archive was the annual lists (2007–2013) of the guilty verdict descriptions related to professional standard breaches and ethical misconduct against HPCSA-registered physiotherapists: the annual lists are accessible in the public domain on the HPCSA website (http://www.hpcsa.co.za/conduct_guilty_verdicts.php).

Quantitative data analysis focused on the compilation of frequency tables for the following three variable combinations: annual frequency of sanctioned physiotherapists and guilty verdict cases; annual frequency of penalties imposed on sanctioned physiotherapists; and frequency of transgression categories linked to sanctioned physiotherapists. The qualitative data analysis focused on an investigation of the specific case content for each guilty verdict by means of qualitative content analysis (Neuman 1997). This involved a systematic coding and thematic description of each case. Initially each of the two researchers independently conducted the qualitative content analysis on selected annual guilty verdict documents, followed by several discussions until consensus was reached.

The annual frequency of sanctioned physiotherapists in the period 2007–2013 indicates that on average only 0.05% physiotherapists are annually found guilty of ethical transgressions. The total of 37 transgressions across the study period (7 years) for an annual average of 5709 registered physiotherapists in South Africa is slightly higher than the total of five serious ethical transgressions for the period 2006–2013 (8 years) for approximately 4200 registered practitioners during the same period in New Zealand (New Zealand Health Practitioner Disciplinary Tribunal [NZHPDT] 2014). However, the South African figures compare favourably with the annual frequency of 0.09% sanctioned annual disciplinary enquiries against HPCSA-registered psychologists during 2007–2013 (Nortjé & Hoffmann 2015) and the average annual frequency of 0.17% sanctioned medical practitioners in South Africa during the same period (Hoffmann & Nortjé in press). The overall mean number of guilty verdicts per sanctioned physiotherapist was slightly above one verdict (1.33), suggesting that sanctioned practitioners generally only engage in once-off acts of misconduct. One can at this stage merely speculate on the reason(s) for the lower frequency of misconduct amongst physiotherapists in South Africa when compared to other health care practitioners, but it might be in part as result of any of the following:

A frequency analysis of the penalties imposed on sanctioned physiotherapists across the study period (Table 2) indicates that the HPCSA mostly opted to impose financial penalties (53.6%), whilst suspended suspension penalties from as short as 3 months up to a maximum of 3 years were imposed in 17.9% of the cases. Across the study period of 7 years (2007–2013) only one physiotherapist was removed from the HPCSA register because of multiple transgressions involving inter alia rendering inappropriate treatment to patients, negligent recordkeeping and fraudulently charging patients for non-rendered services (Table 3). Deregistration provides the ultimate protection for society against unscrupulous health care practitioners whilst also making an unambiguous statement about expected professional standards (Godbold 2008). In some of the cases involving issuing misleading, inaccurate and/or false statements, or failure to obtain patient consent to perform procedures or interventions, or making derogatory /abusive remarks towards a patient, the sanctioned physiotherapists were ordered to attend a practice management course (7.4%, n = 2) or to attend a medical ethics and law course (7.4%, n = 2) (Table 3). This is substantially higher than the 1.10% (n = 5) of sanctioned medical practitioners in South Africa who were required to attend a medical ethics course in the period 2007–2013 (Hoffmann & Nortjé in press); however, the low numbers of actual cases for physiotherapists (n = 2) and medical practitioners (n = 5) respectively in this regard indicate that any statistical interpretation should be approached with caution to avoid undue bias. The various penalties imposed to physiotherapists by the HPCSA indicate that the following transgressions are viewed as serious ethical misconduct: issuing misleading, inaccurate and/or false medical statements; false and/or inaccurate medical aid claims involving non-rendered services; over-servicing patients by performing redundant procedures; and failure to obtain patient consent to perform procedures and interventions, especially when it involves risks and potential complications.

The most significant contributions of this study are the results regarding the frequency of transgression categories, the frequency of penalties imposed on the various transgression categories, as well as the specific ethical misconduct by physiotherapists within each transgression category. The most encouraging finding is that ethical transgressions by physiotherapists in South Africa occur rarely; only 0.05% of all HPCSA-registered physiotherapists during the period 2007–2013 were found guilty of unethical professional conduct.

Another significant finding is that more than half (52%) of the penalties imposed on sanctioned physiotherapists were monetary penalties between R1000.00 and R10 000.00, followed by suspended suspensions between 3 months and 3 years (18.5%). However, in the study context of ethical misconduct transgressions it was somewhat surprising that only 7.4% of the guilty verdicts ordered the physiotherapist to specifically attend an ethics course, whilst another 7.4% of the guilty verdicts ordered attendance of a practice management course. This raises some concerns regarding the justification and effectiveness of the imposed penalties to rehabilitate offending practitioners (Godbold 2008), especially as the highest monetary penalties in our study were linked to the most frequent transgressions throughout the study period, namely fraudulent conduct. This suggests that the current monetary penalties are possibly not high enough to be effective deterrents; penalties with more serious professional consequences should be considered, such as actual suspensions which are not suspended, and erasure from the register for a specified period with strict training requirements before re-instatement on the register. However, an analysis of physiotherapist income levels and the potential impact of monetary fines on their expendable income falls outside the scope of this study and should be pursued in subsequent studies. The last significant finding is that fraudulent conduct was by far the most frequent transgression category, specifically issuing misleading, inaccurate and/or false medical statements, as well as submitting false and/or inaccurate medical aid claims involving non-rendered services.

In conclusion, the following three recommendations are suggested to further enhance ethical conduct amongst physiotherapists in South Africa: