Clare was the author of a paper titled ‘Making practice education visible: Challenging assumptions about the patient’s place in placement environments’ (International Journal of Therapy and Rehabilitation, 21(8), 359-366).
Clare is a Senior Lecturer and Programme Lead at Cardiff University in Wales (KellC@cardiff.ac.uk). You can find Clare’s CPN member profile here
Where does your interest in health care education – and particularly patient-centred care in physiotherapy – come from?
This is a hard question to answer because, like many of us I expect, my journey has been round and about! I taught physio for 15 years and was curious about how students learnt and how curricula could impact that learning. In the UK pre-reg students have to do about 1000 hours of learning in placement settings, and it became clear that studying University-based education was only part of (or in fact a third of!) the issue. Thinking about learning in placement settings however proved hard to ‘get at’. Yes we, as academic staff, created the learning outcomes and assessment forms for the placement educators (practising clinicians with their own patient caseloads), and visited students on placement… but what really was going on, how and what were students learning? Linda Jones, Gwyn Owen and I did some preliminary story-collecting work and heard what to us were surprising, or rather undecipherable, accounts from placement educators of their role(s) in students’ learning. I felt I needed to go into the field (no mean feat in the UK where research in NHS hospitals, the site of most placements, requires an arduous research ethics process), and my doctoral research project seemed the perfect opportunity.
So I didn’t set out to explore patient-centred care or the place of the patient in student-present physiotherapy placement interactions – but rather to try and understand, through observation, what might be going on learning-wise on placement.
You talk about the ‘rhetoric of patient-centred professional education’ and patients being unquestioningly ‘present-absent’ aids to learning. Why do you think this is?
I’m sure my response to the first question sounds naïve – and indeed, now I look back, I wonder what I was thinking. My Social Science studies were opening my eyes to issues of power, profession and hierarchy (all I felt confident I saw in Physiotherapy), and to the power of curriculum design to effect change / perpetuation of implicit group norms (Bernstein’s Pedagogic Discourse [PD] ideas having particular resonance). So my initial project idea was to use PD as a framework for tracking the discourse of physiotherapy education from its Field of Production (our UK professional body) to its Field of Reproduction (the educator: learner interface). The idea was to combine a documentary analysis of the various curriculum documents (all liberally sprinkled with terms like ‘patient-centred care’) with interviews and observations of placement educators and their students to explore in action the things outlined in the documents. I knew I wouldn’t be able to use any recording equipment (audio or video) on the wards as this was part of my access approval negotiations, but felt confident that I’d be able to write, in field note form, the ‘education’ practices I observed.
My plans fell apart after my first access interview! Bouncing back to my supervisor (bouncing is something I saw lots of physios do, so expect I did it myself), confident I was on track, he asked ‘So what exactly are you expecting to see?’… I had no idea. I had fallen into the trap of ‘familiarity’ and had forgotten to use the interview to question what words like ‘doing the subjective/ objective’ meant. With no sense of how placement education was done I couldn’t do my study as planned which was framed around this assumption! My new project sought to answer Tom’s question as an ethnomethodologically-informed ethnography of placement education – and it was through following of students on placement that I collected the data that I suggest capture patients being used as live-audio visual aids, drilled for the data that educators and students use to create a case for physiotherapy – which of course they then ‘provide’.
As my papers suggest, there are multiple reasons for this person-absenting. Physiotherapy is certainly ‘precarious bodywork’ (after for example Twigg, Emerson etc) and patients, and therapists need some way of navigating the interaction – and one way to do this is to distance the person from the body – but why was I never taught this / could this distancing be done in a patient-led way? (I do remember having ‘sociology’ lectures – but they were so peripheralised I recall nothing at all!). Further, the UK NHS, in these neoliberal times, operates ‘timed units of activity’: framed in discourses of accounting logic (see for example Broadbent and Laughlin) therapists record what they do every 15 minutes, and ‘patient contacts’ are slotted into these. Frequently students told me that their educators had said that they ‘simply did not have the time’ to talk to their patients if they wanted to ‘get through’ an assessment in time. And then, in the UK, placement education is ‘hot’: students learn while treating / co-treating real patients in real time (unlike medical education for example). Our current cultural systems (not forgetting the impact of evidence-based medicine, and a professional definition of ‘science’) all may compound to oblige educators to be pointing out things to their students, making their thinking processes visible etc. while the person-who-just-happens-at-this moment- to-be-called-a-patient-and-thus-need-some-help-from-a-physio consents (who knows why – another project perhaps?) to be poked, moved and talked about as if they were a test-tube being sourced for data. I have no answers – just lots of thoughts, and would welcome others’ ideas, opportunities to explore further. My project just set out to ‘make visible’ – we need more work to think about ‘why?’.
What appealed about an ethnomethodological approach to the coproduction of knowledge in your study?
Ethnomethodology (EM) is a term coined by Garfinkel (1967) to describe a style of analysis that focusses attention on the social construction of everyday practices. It is interested in exploring the ‘just thisness’ of interactions (Pollner 2012) – how interactions are practically accomplished, in order to explore such questions as ‘what is going on here?’ It was perfect for my project with one drawback – ethnomethodological analysis requires data that is rich in both context and practice description: you need lots of rich data focussing on the minutiae of interaction practice so that you don’t jump to conclusions / use your own experience to judge what the interaction participants you are observing are doing. And I only had pencil and paper with which to collect this data! So I went back to the drawing board – quite literally.
Watching hours of publically available videos of physiotherapy practice, I sensed that eye-contact (kinesics) and nonverbal communication (including physical use and occupation of space – proxemics) were important in how therapy ‘was done’. So I read anything I could lay my hands on that could help me collect this data…. And my proxemics sketches and kinesics staves were born!
How did you find using proxemics sketches as a method?
I am very grateful for my physiotherapy training which has given me an intense sense of curiosity in how people move, and a pretty good ability to ‘see’ elements of that movement. Goodwin uses the wonderful term ‘professional vision’ to describe the profession specific way different groups look at the same situation (Goodwin 1994). Professional vision is both a blessing and curse in ethnographic fieldwork though: it certainly helped me extricate features of each interaction I observed speedily so that I could make field notes and draw proxemics sketches in the full flow of practice, but it can also leave researchers open to charges that they have only recorded as data what they wanted to see. I tried to overcome this charge by reconceiving movement as communication (something I had never thought of before).
The staves and sketches are really easy to do for anyone with a keen sense of noticing. I am writing a ‘proper’ methods paper, but have drafted a working version (available here) too. I am not an artist – and indeed being one may make sketching more difficult. When you look at my sketches, they are not physically accurate, but, building on my professional vision, an inherent sense of base of support and centre of gravity for example, they capture a sense of the spatial (proxemics) features of interactions. I would love all students to learn to draw proxemics sketches- if only to record each other’s postures during skills lessons – the postures I saw their backs in made me gasp – and no one ever corrected them because all eyes were too busy looking at effected body-parts!
Whose work has influenced you most in recent years (who would you recommend others read)?
I’ve mentioned already some key thinkers who helped me to question the norms of physiotherapy interactions, but two authors specifically influenced the creation of the kinesics staves element (recording eye-based communication) of my notation system. Birdwhistell, an American sociologist developed an alphabet-type approach to transcribe video footage onto paper as in the snippet below. Obviously I couldn’t learn this and reproduce it in real time, but his work (outlined in his very readable and enlightening book) did confirm that eye-based communication was essential to capture.
Christian Heath (based at Kings’ College London) has informed my project in so many ways (do read his book about auction houses!), but the way he transcribed his videos of eye-based elements of Doctor: patient consultations by writing each person’s actions one above the other, got me thinking about a musical stave approach. So Birdwhistell + Heath + Kell = Kinesics Staves as below!
What effect has the Mid-Staffordshire inquiry had on the physiotherapy profession in the UK?
This is a question I think I will sidestep by saying I just don’t know. I have been to physiotherapy conferences and gatherings and people are certainly talking about ‘values’ – which is new, and ‘patient self-management’ – also new although I sense perhaps not being used in a patient-led way – but in terms of practice change, I’m not the person to ask! If anyone has access to funding – why don’t we go into the field and see?
What advice would you give to physiotherapists interested in taking a more patient-centred approach to their practice following your research?
There are excellent texts emerging all the time from physiotherapy-based researchers, but I have found it very helpful to read about other professional groups in order to cast new light on my own, so I would encourage people to read these two texts as starters. The first is Lave and Wenger’s excellent short text: ‘Situated Learning’ in which the authors report and discuss fieldwork data from their observations of how learners learn in different professional groups – shocking, humbling and funny in almost equal measure – I wonder which case study you’ll think similar to your experiences of Physio education?
And then Phil Strong’s work, especially ‘The ceremonial order of the clinic’ is deeply thought-provoking as he shares his observations of medical consultations – with and without students present.
For those who want to explore ideas in practice after some reading, perhaps just sit quietly and watch what is going on around you in ward or clinical settings. And rather than seeing all the ‘work’ as things you recognise e.g. there is someone writing in the notes / talking to a relative etc., perhaps look beyond the obvious and ask yourself: ‘What are they writing in those notes? What are the notes for? What work are the notes doing and for whose benefit?’ Or perhaps: ‘Why are the therapist and relative standing in that way? How is the interaction being done? What work is eye contact / removal / body movement playing and for whose benefit?’ Perhaps physio teams / students could explore these and other aspects of their practice together… but the key thing is to start noticing how we do things…