Perception, interest and knowledge of physiotherapy faculty regarding professional ethics

This study aimed to evaluate aspects relating to interest, perception and knowledge levels regarding ethics in physiotherapy among lecturers of this course at a university in the Brazilian Amazon region. Eighteen lecturers participated and responded to 21 questions divided in sections related to “interest”, “perception” and “knowledge levels”. The data was considered in terms of absolute and relative frequency. In the “interest” section, 77.77% (n = 14) indicated internet as a primary source of updates regarding the issue of ethics in physiotherapy. In the “perception” section, 94.44% (n = 17) considered the ethical behavior of students in their evaluations. Regarding “knowledge levels”, 83.33% (n = 15) erred to say that treatment prescription can only be established after an appointment. Therefore, it is necessary to enhance knowledge and stimulate ethical considerations of lecturers regarding their ethical behavior for their own growth and the training of students.

Understood as the study of behaviour and character, ethics consists of determining what is good or valuable for individuals, groups and society in general. Thus, ethically considered acts reflect a commitment to standards that are beyond personal preferences, which individuals, professions and societies strive to achieve 1 .
Ethics is inherent in the practice of health professionals in the context of their commitment to patients and in the internal relationships of their own team. Numerous conflicts are embedded in these contexts and require that the analysis of the facts, questions and decisions are based on ethical principles 2 . These decisions will influence the quality of life of individuals and should be guided by ethical sensitivity and moral reasoning, taking into consideration various factors such as the patient's religion, education, culture and experiences 2 . This perspective, allows the physiotherapist a holistic view across the barrier of technicalities that are entrenched in medical science, and therefore legitimizes the importance and effectiveness of humane treatment 3 .
In assisted care and teaching, there is a need for physiotherapist lecturers to include teaching ethics as an educational resource in the teaching-learning process. For this purpose, they address topical dilemmas as case studies in order for students to link practical experiences and theory, both in the present and in the future 4 . Thus, it will be possible to train professionals who will be committed to theorizing about and practicing ethics concerning human beings in the context of globalization.
In short, this study sought to clarify the following question: what are the perceptions, interests and levels of knowledge regarding ethics in physiotherapy among lecturers of the physiotherapy course at the Universidade do Estado do Pará -UEPA (University of the State of Pará) -Campus XII?

Methodology
This is a quantitative, descriptive and cross-sectional study as approved by the Comitê de Ética em Pesquisa do Centro de Ciências Biológicas e da Saúde [Research Ethics Committee of the Centre for Biological Sciences and Health] -Campus XII/UEPA (Opinion No. 907 874) -and was performed at the university. In total, there are 19 physiotherapists lecturers in the physiotherapy course, and the sample was composed of 18 of them.
As a research tool, we used a questionnaire of 21 questions created by the authors, based on an existing questionnaire 5 . The study does not describe psychometric properties, as it did not generate scores. The questions were divided into the following sections: Interest, Perception and Knowledge Levels. Interest encompassed questions 1, 2 and 3; Perception issues from 4 to 12; and, finally, Knowledge Levels, from 13 to 21.
Initially, the researchers asked the UEPA-Santarém secretariat of courses for a list with contacts of physiotherapists lecturers. An initial phone call was made to confirm the participation of each lecturer in the research and then the researchers met with each lecturer for the necessary explanations and the signing of the informed consent forms (IC), in addition to the handling of the questionnaire, which was answered by volunteers and self-administered, that is, without interference from the researchers.
Data from the quantitative assessment, presented in tables, were organized and processed according to measures of descriptive statistics, indicating absolute and relative frequency, obtained by Microsoft Excel 2013. Subsequently, some data was transferred to the BioEstat 5.3 application to analyse the probability distribution of variables through a G test, with p <0.05.

Results and discussion
The research involved 18 lecturers of a physiotherapy degree course, this means, 94.73% of the total population of 19 lecturers. The results of each question, separated by the corresponding sections, are presented below.
The first question reveals that 50% (n = 9) read the complete Código de Ética e Deontologia da Fisioterapia -CEDF -(Physiotherapy Code of Ethics and Deontology) 6 , a result which did not corroborate the research of Vieira and Neves 7 and Almeida et al 8 , in which medical educators claim to have partially read the code of ethics of their profession: 62% (n = 75) and 86.2% (n = 87), respectively. Noteworthy is the fact that if we add the number of educators who partially read the code and those who have never read it, it would amount to the same quantity of lecturers who fully read the code 50% (n = 9).
Although the results do not show levels of statistical significance, it is noteworthy that the lack of knowledge, or ignorance, of some UEPA physiotherapy lecturers regarding the professional rules may result in unethical attitudes towards their peers and students. That is, the impoverishment of their knowledge undermines the quality of education offered to students, which may result in them receiving insufficient and outdated information 5 . Still regarding question 1, the fact that two lecturers (11%) reported they had not read the code of ethics in the last three years makes us reflect on the fact that these lecturers do not exercise the profession in clinical practice, or teach disciplines that are applied to specific physiotherapy techniques, which would still not justify the response, since the focus is on students' training and their professional future.
Regarding the second question, it was found that the largest share, 39% (n = 7), search updates regarding the CEDF every six month. Even if the question does not present a significant level of statistical significance, the data is worrisome because the 28% (n = 5) that do not update on the subject quantitatively represent a number similar to the one of lecturers that update themselves every six months.
This result also does not agree with the study of Vieira and Neves 7 , which reported that most medical lecturers (34.7%; n = 42), in a population of 121 respondents, rarely updated themselves regarding "ethics". In their analysis, Almeida et al 8 and Freire 9 consider the commitment of lecturers in their search of what is new as important, not only to increase the level of knowledge in their training, but for a better basis to share updated knowledge with their students.
In question 3, it was observed that most (77%; n = 14) use the Internet as their primary source of updates regarding "ethics in physiotherapy", which differed from the results of Vieira and Neves' study 7 , in which 60% of medical lecturers cited scientific events, books and journals as their main way to update. Our result can be explained by factors such as the advancement of information technology -which facilitates access to information among the population -in addition to the informational support that the university provides to lecturers. Thus, they can update themselves, and develop new educational strategies that can be used to enrich the teaching-learning process 5 .
In the fourth question, 50% (n = 9) opted for the score "4" regarding the classification of their knowledge on ethics in physiotherapy. This may berelated to Table 1, in which the largest share of respondents (50%) has said they have fully read the professional code of ethics and update themselves on the subject every six months (39%).
In question 5, on being asked whether ethical attitudes are determined exclusively by character and personality, the majority of respondents -94% (n = 17) -answered "No, but are influenced by character and personality" and only 6% (n = 1) chose "No, character and personality are of no concern." Coelho 10 reinforces the need for dialogue regarding ethics among students and lecturers, as his study revealed that physiotherapy course students (74.6%; n = 44) also recognized the influence of both character and personality in their ethical attitudes. Thus, there is a clear need for critical reflection by lecturers regarding their essential nature, in order to change their attitudes and to also direct these changes to the teaching-earning process, encouraging educational strategies that link theory and practice based on existing ethical and moral concepts 11,12 , as each individual considers their choices, attitudes and their way of relating to others in society 13 .  In the sixth question, 61% (n = 11) responded to having already experienced some example of ethical misconduct by their colleagues. In this type of situation, it is possible that patients become victims of professionals' ethical misconduct, which is something that can compromise even the quality of care. In such situations, individuals run the risk of having their right to quality health curtailed due to the negligence of certain professionals 5 .
In fact, health professionals should look at each patient and interpret them as an entity in a social context. That is, as an individual with the right to humane treatment, based on a holistic perspective and not from the historically technicist roots that formed the profession 14 , which, at some point, considered in its practices the separation between body and mind as advocated by Descartes 15 . In the work environment, sometimes the practice of unethical behaviour is ignored by colleagues in order to maintain harmony, to ensure internship positions, or for fear of generating any conflict 16 .
Currently, there is an increasing need for the humanization of work teams, based on respect for each other's individual knowledge and being open to dialogue 16,17 . Moreover, in the presence of students in certain situations, there may be interpretations that omissions and lack of punishment for these types of behaviour may end up being reproduced with a sense of impunity by colleagues 5 . Coelho 10 found that physiotherapy course students already experienced situations of ethical misconduct by colleagues (35.6%; n = 21) or were aware of such practice (35.6%; n = 21).
In question 7, the majority (94%; n = 17) showed that they take into consideration the ethical behaviour of students in their evaluations, while only 6% (n = 1) do not take this parameter into account. The data in question was confirmed by Coelho's research 10 , since the largest share of students (69.5%; n = 41), in the study of the institution in question, stated that lecturers take into account the ethical behaviour of students in their evaluations.
In question 8, 12 respondents (66%) answered "yes" when asked if the evaluations are done in an adequate, fair and impartial way. In contrast, 3 answered "no" (17%), which is considered worrisome. This is evident in the study of Coelho 10 , in which 33.9% (n = 20) of physiotherapy students judged the evaluations of lecturers to be biased and unfair.
The evaluation should be based on respect, fairness, and free from any comparison between students, and in no way classify the students as good or bad 18 . In fact, discriminating and demoralizing the student prevents the teacher from evaluating them democratically; therefore the lecturer's consistency is very important, even if only not to hurt the self-esteem of the student. One option is to carry out joint evaluations, through dialogue, between lecturer and student, as lecturers should try to establish a partnership with students in order to build a shared teaching-learning relationship, and not just focus solely on their own perception of performance of those under their tutelage 9 .
In the ninth question, 10 lecturers (56%) responded "no" when they were asked if they had ever done anything that could be considered ethical misconduct with respect to colleagues or patients. In the context of the study population, possible disrespectful attitudes of some lecturers towards colleagues can lead to the deterioration of the group's cohesion and can generate harmful consequences to the harmonious coexistence and the political and social representation of physiotherapists. This can weaken and disrupt professionals, making it difficult to fight for the collective interest, thereby making room for some circumvention of the rights and demands of the common good for the sake of satisfying personal interests 5 . This reality reveals the difficulty in meeting what Rousseau 19 called a "social contract", which would set an invariable pact between all so that the collective interests were sovereign in relation to the personal needs of individuals.
Knowing that lecturers are seen as ethical and moral reference for students, lecturers need to be aware of their adopted words and actions, and use their own errors to guide students regarding the proper conduct, since it is possible that the students might not have the necessary discernment to do so . The fact that students have witnessed unethical actions by their lecturers was reported by Magellan, Santos and Souza 5 , which showed that 42.16% of medical students had experienced situations of ethical misconduct by their tutors; Almeida et al 7 also reported that 70.6% of students had witnessed the inappropriate attitudes of their educators when dealing with patients. The data indicates the urgent need for further research, as the deteriorating ethical moral may be incipient and might be being legitimized at the university itself.
In question 10, when asked whether they agree or not with the fact that physiotherapy students should be punished if they do something that infringes the principles of ethics in physiotherapy during their academic activities, the majority (78%, n = 14) answered "yes". In the study of Coelho 10  share of the physiotherapy students (77.78%) also said that the student should be punished. The four lecturers (22%) who believe that students should not be punished may at any time make an unfair and biased assessment, and "condone" certain unethical attitudes of students. Our view is that, regardless of whether or not they are punished, students should be advised regarding the best professional conduct and the set limits that constrain them 5 . In this context, we suggest a version of the code of ethics focused on students 20 , or a deep analysis and criticism of the code of ethics in order to introduce the study of ethics from the formative training period to future situations in students' professional lives.
Question 11 referred to the how important ethics is in physiotherapy for the training of physiotherapists, and most (78%; n = 14) attributed grade "5". This data can be connected to some incentives presented by lecturers during the undergraduate course, and today, as faculty, it is up to them to present ethics to students as a fundamental element 22 .
For Freire 9 , the lecturer should not stick to the simple transfer of knowledge, but rather share knowledge with students based on the knowledge and experience of both parties, in addition to encouraging political and ideological criticality. Otherwise, education becomes "monetarised" and petty, as the lecturer would be like a machine that only communicates the information, and the student, a mere deposit of knowledge that only repeats what they were told. The author concurs with Piaget 23 by also stating that knowledge is formed not by the simple reproduction of words, but by the process of building knowledge through assimilation.
Reinforcing the criticality reasoned by Freire 9 , it is very important that UEPA physiotherapists educators engage politically in the fight for their rights, in view of the representativeness of their professional group inserted in the globalized world and the neoliberal system, which reinforces technicality, replacing individual ethics with the ethics of commodification. This statement confirms the idea of Marx and Engels 24 , who value the unity of the working class regarding the political and social transformation that has the potential to enslave and alienate human beings. In the wake of political conscience, the philosophical and anthropological foundation of a multidisciplinary team is essential 5 . Foucault 25 , for example, claimed that the relationship of power by itself already instigates the desire for the pursuit of human freedom, and this is intensified when these relations are crystallized without shared understanding between the parties -that is, the willingness to resist in the face of domination emerges/rises before this context that the author calls "state of domination".
Bringing the discussion of ethics into the classroom means not only contributing to the personal development of the student, taking them out of a state of political alienation -a condition often found in our profession -but it also consolidates the construction of workers that are politicized, committed and prepared to deal with all spheres of health care 12 .
In the last topic on the Perception section, the majority (61%; n = 11) responded that there is a need to teach ethics in physiotherapy in the undergraduate curriculum. Coelho 10 shows the same desire amongst students: 55.9% (n = 33) feel the need for the teaching of ethics in all semesters of their course. The change in the political educational project can meet this demand, as currently the disciplines that focus on ethics are present until the third year, and it is from this year onwards that students have more contact not only with their classmates and lecturers, but mainly with patients during students' internships. One option is to insert curriculum components to discuss ethics in physiotherapy early in the course, using the most diverse teaching-learning methodologies -preferably active -and then to contextualize it in other disciplines so that the subject becomes transdisciplinary until the end of the undergraduate course, based on the teaching tool called transversality 4 , which creates a link between systematically learned theory and day to day community events/experiences 26 .
Another element to be considered is active methodologies, which represent an innovative aspect within teaching 12,27 . This educational resource, which addresses the questioning of reality, was used at the Universidade Federal do Rio Grande do Norte (Federal University of the State of Rio Grande do Norte) -UFRN, where it allowed the correlation of theoretical knowledge with practical experience through teaching methodologies such as discussion forums and case studies. Education through problem-based learning (PBL) is another way of instigating reflection, criticality in coherent discussions and resolution of problematic situations through interaction between groups 4 . Problematization transforms the lives of human beings, demonstrating that it is not a mere historical artifact, but rather the largest holder of the ability to reinvent themselves, to solve problems and to deal with contemporary dilemmas, which results from globalization, and thus to recreate not only their own, but also the narrative of the society in which they are part of 9 .  In the first question from/of this sectionwhether or not the CEDF regulates the relationship between physiotherapists and nurses, doctors and other professionals -the majority (78%; n = 14) chose the wrong alternative. Article 1 of Resolution 424 from COFFITO (Conselho Federal de Fisioterapia e Terapia Ocupacional / Federal Council of Physiotherapy and Occupational Therapy) 6 reveals that the CEDF addresses questions regarding the ethical duties of physiotherapists, and not the relationships of these professionals with any other.
In question 14, the study questions whether other professionals are, or are not, subject to the CEDF, and 17 lecturers (94%) chose the correct option. Knowing they are part of a a professional group -and therefore that they must follow specific rules for the practice of their profession -the participants may have come to the right conclusion, as defined in Resolution 424 from COFFITO 6 .
In question 15, when asked if the CEDF is punitive or not, 11 (61%) participants answered wrongly. Even if the results do not have a substantial level of statistical significance, it is assumed that most of the faculty were wrong to answer the question because the CEDF is a legal provision and addresses the rules governing the profession.
In question 16, 17 (94%) chose correctly when asked if the CEDF deals with professional confidentiality. Educators may have been influenced to choose the correct answer provided in Chapter VI of Resolution 424 6 , because of their experiences, in the classroom, in interships and at work environments, in which information regarding patients and treatments are and should be safeguarded. It is important to highlight that three of the lecturers had not read the CEDF in the last three years.
In the seventeenth question, which deals with working class strikes, 15 participants (83%) answered correctly. The current political and social When questioning whether physiotherapists may or may not prescribe therapy without prior consultation, 83% (n = 15) of respondents chose the wrong option. Again, most physiotherapist faculty participating in the survey have shown lack of knowledge regarding one of the aspects covered in the code of ethics, which concerned the prescription without compulsory prior consultation.
In question 19, referring to the matter of fees in the CEDF, 14 participants (78%) answered incorrectly. As much as fees are a topic of interest for this professional category, and a subject of discussion inside and outside the university, the lecturers still answered incorrectly. The CEDF 6 has a specific chapter regarding fees, establishing what they consider a professional right and indicating what is forbidden to professionals regarding physiotherapy procedures.
When asked whether or not illegible writing corresponds to an offense in terms of the CEDF (question 20), 13 (72%) answered correctly, indicating that most educators in the study knew that, when prescribing an exercise or completing a medical record form illegibly, the physiotherapist hurts the CEDF and, above all, patient rights 5 .
In question 21, regarding the physiotherapist consulting or prescribing physiotherapy treatment without a face-to-face consultation, 15 (83%) chose the wrong alternative. This practice can be harmful to the patient, who runs the risk of not having the complete information about their case, and may even proceed to not making a commitment to go to the clinic, as the physiotherapist is authorized to give distance consultation. In addition to problems regarding the quality and effectiveness of care, professional productivity levels may also be affected, as the trend will be an increase in attempts to get free consultations.
In the Interest section, the results are satisfactory, since 50% of the UEPA physiotherapy faculty have read the entire CEDF and often update themselves on this issue through media such as the Internet. Thus, they demonstrated commitment to monitor developments regarding the legal aspects of the profession, with a view to acquiring new knowledge for themselves and to share them with their students.
In the Perception section, it became evident that several lecturers in the study have high levels of knowledge regarding ethics in physiotherapy and recognize the need for ethics in professional relations, care and the teaching-learning process. Even with this information, together with the findings within the Interest section, it was observed that some lecturers do not value the ethical and moral precepts in their totality. They have attitudes of an unethical nature or fall short when, within the Levels of Knowledge section, they err regarding the questions that indicate the need for a deeper awareness of the CEDF, which is the guiding element of professional practice.
The results related to wrong answers are troubling, since faculty need to know the CEDF for the legal practice of the profession, either as faculty or as physiotherapy professionals. Also noted was the controversial aspect implicit in errors regarding the answers chosen by those who participated in the survey, especially when comparing such results with question 2, in which the majority stated that they update themselves on "ethics in physiotherapy" every six months.
Finally, it is important to report, as the main limitation of this study, the obvious impossibility of generalizing its results, given the relative restriction of the sample, since only one higher education institution was involved in the research. The absence of prior validation of the questionnaire used should also be mentioned, despite the adaptation of other instruments and the idealization of new items.

Final considerations
From the results found in the questionnaires, a lack of knowledge of some resolutions from the COFFITO (Conselho Federal de Fisioterapia e Terapia Ocupacional / Federal Council of Physiotherapy and Occupational Therapy) / CREFITO (Conselho Regional de Fisioterapia e Terapia Ocupacional / Regional Council of Physiotherapy and Occupational Therapy) system was observed. This is a fact that consequently affects the professional routine, permeating the relations of the UEPA physiotherapy lecturers with regard to the physiotherapist-patient and physiotherapist-physiotherapist relationships . Although this lack of knowledge will never fully cease to exist, it is important to identify its presence, indicating, even quantitatively, what are its negative aspects and consequences in an attempt to minimize them, avoiding generating a vicious cycle that would pass from generation to generation.
Finally, raising interest in the ethical debate, comparing specific aspects of opinion and experience of the group of physiotherapy lecturers from UEPA, and investigating the level of knowledge regarding legal aspects of the profession, can be a way to not only point out the deficits, but mainly to contribute to political and social improvements in health and education, in which all involved should reflect on the concepts that will accompany them in their professional training and in the humanized care of others.