Working hard to belong: a qualitative study exploring ...
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Preprint:Pleasenotethatthisarticlehasnotcompletedpeerreview.
Workinghardtobelong:aqualitativestudyexploringstudentsfromBlack,AsianandMinorityEthnicbackgroundsexperiencesofpre-registrationphysiotherapyeducationCURRENTSTATUS:ACCEPTED
JohnAnthonyHammondKingstonUniversityFacultyofHealthSocialCareandEducation
[email protected]:https://orcid.org/0000-0001-5246-426X
AnnabelWilliamsBrunelUniversityCollegeofHealthandLifeSciences
SaskiaWalkerKingstonUniversityFacultyofHealthSocialCareandEducation
MerielNorrisBrunelUniversity
DOI:10.21203/rs.2.10636/v3
SUBJECTAREASEducationalPhilosophyandTheory
KEYWORDSPhysiotherapy,student,BlackAsianandMinorityEthnic,qualitative,race
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AbstractBackground
PreviousresearchhasdemonstratedthatattainmentinequalitiesexistforstudentsfromBlackAsian
andMinorityEthnic(BAME)groupsinpre-registrationphysiotherapyeducation.Whileprevious
researchhasexploredstudentsfromBAMEbackgroundsexperienceofuniversity,thecontextof
physiotherapyisuniqueandisunderresearched.Thereforethepurposeofthisstudywastoexplore
BAMEstudentexperiencesduringtheirphysiotherapytraining.Methods
Usingaphenomenologicalapproachpre-registrationBScandMScstudentsfromBAMEbackgrounds
fromtwouniversitieswhohadcompletedbothacademicandclinicalmoduleswereinvitedto
participate.Focusgroupsfollowedatopicguidedevelopedfromtheliteratureandwerefacilitatedby
physiotherapyeducatorsfromoutsidethehostinstitution.Theyweredigitallyrecorded,transcribed
verbatimandanalysedthematically.Analyticaltriangulationwasadoptedthroughouttheresearch
processasamechanismtoenhancerigour.Results
17studentsparticipatedfromarangeofself-identifiedBAMEbackgroundsthatwerealso
representativeofage,genderandcourse.Themesderivedfromthedataincluded:feelinganoutsider
inreflectionsofbelonging,behavioursbyothersthatmarginaliseBAMEandpersonalstrategiesto
integrateinphysiotherapydespitethelackofpowerandinfluence.Collectivelythesethemes
demonstratearangeofchallengeswhichstudentsfromBAMEbackgroundsfacewithinbothan
academicandpracticelearningenvironment.Conclusions
Whilethismaynotbesurprisingbasedonotherdisciplines,thisstudydemonstratesthatstudying
physiotherapyasastudentfromBAMEbackgroundrequirespersistencetoovercomeaseriesof
manyimplicitchallenges.UnderstandingtheexperiencesofstudentsfromBAMEbackgrounds
presentsuniqueopportunitiestoeducatetheprofessionandco-createopportunitiesforamore
diverseprofessionwithpractitionersandeducatorsasrolemodels.Thereisaneedforgreater
trainingforeducatorstolistentothesestudents’voicesandtheirstories,andunderstandwhere
institutionalstructuresandpracticescouldbemodifiedtoenableBAMEstudentinclusionin
physiotherapyeducationandpractice.
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BackgroundInrecentdecades,therehasbeenasignificantfocusonwideningparticipationtohighereducationin
theUKandworldwide,leadingtogreaternumbersofpeoplestudyingahigherdegree.Yettherehas
beengrowingevidenceinhighereducationtosuggestthattherearedifferentiallevelsofattainment
forthosestudentsfromdifferentethnicbackgroundsevenwhenotherdemographicvariablesare
adjustedfor(1,2).Thishasalsobeendemonstratedinhealthcareeducation(3-7)andspecifically
physiotherapyintheUSA(8)andmorerecentlyintheUK(9).
Whilethesestudiesdemonstrateanattainmentgaptheydonotexplainwhythisoccurs.Some
studieshavetriedtoexplorethisthroughvariousmethodssuchassurveys,interviewsandvideo
analysisofspecificinteractions.BroadlythesestudiesidentifythatBlack,AsianandMinorityEthnic
(BAME)individualsaremorelikelytofeelmoreisolatedornotacademicenough(2,10).Findingsalso
demonstrateBAMEstudentsarelesslikelytoparticipateinextracurricularactivitiesduetoculturalor
familyreasons(11).Steele(12)suggestsBAMEunderperformancecanbeenexplainedbythetheory
of‘stereotypethreat’whereanindividualfromanegativelystereotypedgroupmayfeelthreatenedor
anxiousinthecontextofethnicmajorityandthusmayaffectperformance.Otherresearchconfirms
BAMEattainmentdifferencesinclinicalexaminationsandclaimthatnoovertdiscriminationwas
evidentfromeithervideoanalysisoftheexam(13)orcomparisontoanonymouslymarkedwork(14).
Howeverthesefindingsemphasiseadeficitmodelthatlocatestheissuewiththeindividual(15,16).A
deficitfocusmayleadonlytoremedialstrategiestargetingtheindividual(suchassupplementary
courses(17))andignorethebroadsocialfactorsinvolvedinadvertentlyexcusingdiscriminatory
practicesandstructures(18,19).Morerecentlytherehasbeengreateracknowledgementthat
institutionalstructuresandimplicitbiasmaycontributetoattainmentinequalities(20).Asaresult
manyinstitutionshavedevelopedamulti-factorialchangeprogrammetoaddressattainmentgaps
(2,21).Howeverthisbroaderperspectivealsohasitscritiques,suggestingthatachangeprogramme
maystillperpetuateinequalityandmisrecognitionofBAMEexperience(22).
PhysiotherapypresentsauniqueperspectiveduetoitsparticularhistoryintheUKandworldwide
context.Thephysiotherapyprofessionhastraditionallybeenperceivedaswhiteandmiddleclass(23)
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howeverfiguresfrom2017-18demonstrate19%ofallUKphysiotherapyprogrammestudent
enrolmentidentifyfromaBAMEbackground(24).Whilethisisagreaterproportionofthepopulation
thanmostrecentcensusdata(14%)from2011(25),itisstilllowerthantheproportionofBAME
studentsapplying21.53%(24).RecentevidencesuggeststhatapplicantsfromsomeBAME
backgroundshavelittleknowledgeofphysiotherapy(26)andindicateithaslowerstatusintheir
communities(26,27).Thenatureofthephysiotherapycourseandthecultureoftheprofession
presentssomeuniqueissuesforsomeculturalandfaithgroups,suchasexpectationsoftouchand
physicalhandlingofclientsandvaryinglevelsofundressforbothlearningandpractice.Theseissues
havebeenidentifiedpre-entry(26)andthereissomeevidenceofthechallengesattheintersection
ofgenderandcultureduringtheprogramme(28).OnestudybyHaskins(29)demonstratedcovert
biaswhenphysiotherapistsassessedavideorecordingofphysiotherapystudentsofdifferentethnic
backgroundsrecitingidenticalscripts–ratingBlack,HispanicandAsianstudentslowerthanwhite
students.Inequalitymayalsoextendinseekingmeaningfulemployment,wherephysiotherapy
graduatesemphasisetheburdenofassimilationintothepredominantlywhitecultureofthe
healthcareservice(30).Apartfromthesestudies,thereislimitedexplorationofhowstudentsfrom
BAMEbackgroundsexperienceornegotiatethesefactorsthroughouttheirphysiotherapyeducation,
makingitdifficulttoknowwhatandhowtoaddressit.Afocusontheidiosyncrasiesofaprofessional
coursesuchasphysiotherapyhasthepotentialtoilluminatethecomplexintersectionoffactorsthat
influenceexperienceandavoidanassumed‘onesizefitsall’approach.Thisresearchaimstoexplore
thisphenomenonfromtheexperienceandperspectiveofcurrentphysiotherapystudentsfromBAME
backgroundsintheSouthEastUnitedKingdom(UK).
MethodsThisstudywasconductedinparallelwithresearchexploringexperiencesofstudentswithdisabilities
(31).Informedbyphenomenologicalapproaches(32)thisqualitativestudyfocusedontheBAME
students’experiencesthroughoutallaspectsofthecourse.
EthnicgroupcategoriesusedbytheHigherEducationStatisticsAgency(HESA)(33)wereadoptedto
ensureconsistencywithnationaldemographics.InthispaperthetermBlack,AsianandMinority
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Ethnic(BAME)isusedtodescribethosegroupswhodescribethemselvesotherthanwhite.
Categorisationlikethisisnotideal,asmanyheterogeneousgroupsareincludedtogetherandwe
acknowledgethismaybealimitationfromtheoutset.
Sample
ThestudywasconductedattwoHigherEducationInstitute(HEI)’sintheSouthEastofEnglandfor
practicalreasons.Thetotalcombinedpre-registrationphysiotherapystudentpopulationwas
approximately500.Wewereinterestedintheexperiencesofphysiotherapystudentswhoself-
identifiedasbeingfromaBAMEbackgroundandbasedontheproportionof19%previously
identified,apoolof95potentialparticipantswasestimated.StudentsfrombothBScandMScpre-
registrationcoursesatthetwoHEI’swereinvitedtoparticipateinthestudyviaacohortwideemail.
Thosestudentswhovolunteeredandhadcompletedbothacademicmodulesandclinicalplacements
representaconveniencesample(34).
DataCollectionMethods
Tofacilitatecollectiveandsharedresponsespromptedthroughinteraction,focusgroupswere
selected(35).Afocusgroupatthepenultimate(MScyear1andBScyear2)andfinal(MScyear2
andBScyear3)levelwereconductedateachHEI.Theyfollowedatopicguidewhichincluded;
discussionaboutwhatparticipantsconsidertheirownethnicidentity,theirexperiencesinuniversity
andplacementandhowethnicidentit(ies)mayhaveimpacted,andusingourpreviousresearch
findingsasaframework(9)weaskedtheparticipantstoofferexplanationsoftheattainment
differencesandhowitmightbeaddressed.Allfocusgroupswerefacilitatedbyexperienced
qualitativeresearcherswhowerealsophysiotherapyacademicstaff(MNwithAWasco-facilitator,JH
withSWasco-facilitator).WeacknowledgethatnoneoftheresearchersidentifiedfromaBAME
background,howeverarerepresentativeoftheacademicstaffdemographicsineachHEIandmore
broadlytheprofession.Toensurethattheparticipantsfeltabletosharedetailsaboutallaspectsof
theuniversityincludingstaff,theinterviewswereconductedbyresearchersfromoutsidethe
participants’institution.Thefocusgroupsweredigitally-recordedandtoaidcollectivemember
checkingkeypointswerenotedonaflipchartduringthefocusgroups.Thisprocesshelpedtoavoid
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researcherassumptionsbyclarifyingmeaningsandenablingparticipantstoprioritiseareas.
Analyticalstrategy
Digitalrecordingsweretranscribedverbatimandanonymised.Usingathematicanalysisframework
(36)allresearchersreadandfamiliarisedthemselveswiththetranscriptsandtworesearchers(JH,
AW)independentlyassignedinitialcodes,categoriesandsuper-ordinatethemes.Followingcritical
discussionswithallco-researchers,theleadresearcher(JH)reviewedandrefinedthethemesinan
iterativeprocesstoenhancethedepthandtransparencyofanalysis(37).
ResultsThesampleincluded17students(10F,7M,13BSc,4MSc)witharangeofethnicbackgrounds
includingBlack,AsianandMixedbackgrounds.Thefocusgroupslastedapproximately90minutes.
Table1–FocusgroupparticipantdetailsParticipantnumber
FocusGroup^
Gender Course# Yearofstudy Ethnicbackground*
1 J3 M MSc 2(Final) Mixed–WhiteandBlackCaribbean2 J3 F MSc 2(Final) BlackorBlackBritish-Caribbean3 J3 F BSc 3(Final) BlackorBlackBritish-Caribbean4 J3 M BSc 3(Final) BlackorBlackBritish-African5 J3 M BSc 3(Final) OtherBlackbackground6 J3 F BSc 3(Final) BlackorBlackBritish-African7 J3 F BSc 3(Final) BlackorBlackBritish-African8 K3 M MSc 2(Final) BlackorBlackBritish-Caribbean9 K3 M BSc 3(Final) BlackorBlackBritish-African10 K3 F MSc 2(Final) BlackorBlackBritish-African11 J2 F BSc 2(penultimate) Mixed-WhiteandBlackAfrican12 J2 F BSc 2(penultimate) BlackorBlackBritish-African13 J2 M BSc 2(penultimate) BlackorBlackBritish-Caribbean14 K2 F BSc 2(Penultimate) BlackorBlackBritish-African15 K2 F BSc 2(Penultimate) AsianorAsianBritish-Indian16 K2 F BSc 2(Penultimate) Chinese17 K2 M BSc 2(Penultimate) OtherAsianBackground
Legend:^Focusgroup–institutionalidentifiersJandK,numberrepresentsfinal(3)orpenultimate(2)
yeargroup#BSc=BSc(Hons)Physiotherapydegree,MSc=pre-registrationMScPhysiotherapy
degree*ethnicbackgroundself-identifiedbyparticipantwithreferencetoHESAethnicitycategories.
Threemajorthemesdevelopedfromtheanalysisofthedataofparticipantsexperiences.Thefirst
theme‘youdofeellikeanoutsider’focusesontheparticipants’senseofbelongingin
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physiotherapyeducation.‘Everyonewantstoshyawayandtip-toearoundit’isthesecond
themeandexplorestheovertandsubtlepracticesofothers(particularlytutors,peersandpractice
educators)thatmarginaliseBAMEstudents.Finallythetheme‘wedon’thavemuchpowerand
influence’illustratesthepersonalstrategiesthatareadoptedbyindividualsfromBAMEbackgrounds
toestablishasenseofbelonginginphysiotherapyeducation.Intandem,thesethemesdrawnfrom
theparticipantexperiencesalsohighlightwhereinstitutionalstructuresandpracticescouldbe
modifiedtoenableBAMEstudentinclusionandthesearepresentedinthediscussion.
Theme1-‘Youdofeellikeandoutsider’:feeling‘other’inreflectionsofbelongingin
physiotherapy
ThisthemeexplorestheperceptionsofparticipantsfromBAMEbackgroundsinrelationto(whatthey
identifyas)thedefaultphysiotherapystudentidentity,being‘white,middleclass,matureand
female'.Theysuggestthatthisissomethingtheyperceivedisembeddedinahistoryof
physiotherapyandonlybecomesapparentatthecommencementofthecourse.Theparticipants
indicatetheacuterealisationthatthereislessBAMErepresentationinphysiotherapyincomparison
tootheraspectsoftheirlivesandprioreducationalexperiences.Asaconsequencetheirfeelingsof
beinganoutsiderinphysiotherapyeducationareamplified,asthisparticipantidentifies:
“atthebeginning,whenIstarted….therewasalotof,like,Asianpeopleonothercourses–like,
medicineandbiomed,andthenwhenIwas,interactingwiththem,IfeltIwasonthewrongside
(laughter),cosIwasinphysio,whichisthemain,like,whitepeople,IwasmaybeI’monthewrong
course,Ishouldbeontheotherside”K2,p27
TheBAMEparticipantsinthisstudyoftenreportthattheyperceivetheirprofessionalbehaviouris
beingjudgedinrelationtothisdefaultphysiotherapyidentity.Thishassignificantpersonalandsocial
implicationsforthemandtheyarticulatethisthroughaprocessofbelonginginphysiotherapy
education.
“cosyoudoalreadyfeelsortoflikeanoutsider………You’realwaysconsciousofthat…..likehoware
theyperceivingme?HowamIbeing?,youknow?”J2,p6
“Imean,whenItalktoallthe….lecturersandstaffhere,andtheytalkabouttheirbackground,
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wherethey’refrom,youpickuplittlethingshereandtherethatthey’refromthesenicevillagesor
nicetownsandcitieswheretheyhadaverynicehouse,erm,frontandbackgardenand,youknow,
theyneverhadissueswithheatingorwateror,youknow,anythinglikethatthatyouseemtothink
doyouknowwhat?,they’re,they’re,theymightnotunderstandwhereI’mcomingfrom”K2,p20
Thislaststatementdemonstrateshowotheraspectsofidentitysuchasclassandsocio-economic
statusintersectwithethnicbackground,inadditiontotheobviouspowerdifferentialbetweenstaff
andstudents.Participantsinterprettheacademicinstitution,andtheirpeers,placeahighervalueon
(whattheyperceivetobemiddleclassandwhite)modesofcommunicationthatfurtheramplifies
theirfeelingsofdifference.Inaddition,theparticipantsfeeldisadvantagedinthatthisisnottheir
modeofcommunication,whichleadsthemtofeelisolated,disadvantaged,andstigmatisedasthese
participantshighlight
“IthinkIwasspeakingquitenormallikeIdon’tevenknowwhatnormalis,butIthinkIwasspeaking
likealrightandthey[classpeers]werejustlaughingateverythingIwassaying…….everythingIwas
sayingtheywaslike(laughs),everyonestartedlaughing.Iwasthinking,“Ididn’tsayajokehere
like,”butyouknowwhatIjusttookit”J3p15
“sonow,like,wesubconsciouslyjustthink,like,ifweeverlikespeakinfrontoftheclassandwe
pronouncesomethingwrongthatthey’llreallylaughaboutitafterwards”K2,p54.
Theidentificationofthedefaultphysiotherapyidentitybyparticipantsgoesbeyondobvious
demographicvariables,andincludesothercharacteristicsandvalues.Theparticipantsdescribean
ideal‘extrovert’physiotherapytypethattheyattributewithcharacteristicssuchas:beingoutgoing,
flamboyant,socialisingandgoingtothepub,beingsportyorproactiveandmotivated.The
respondentsfeelvulnerablewhenattemptingtoadoptthe‘extrovert’physiotherapyidentityasthey
maybepositionednegativelybasedonculturalstereotypes
“…..there’scertain,like,thingsyoucan’tsayandcertain,like,waysthatyouhavetosortof,like,
holdyourselfbecauseasablackpersonit’seasiertobemisconstruedasbeingeitherloudor
aggressiveorrude”J2,p7
Bycontrast,anotherparticipantfeelstheirquietapproach,whichtheyalignwiththeirethnic
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background,willbejudgednegatively(isolatingmyself)incomparisontothedefault‘forthcoming’
approach.
“otherstudentswhowerenotofcolourbuttheyweremore,maybemoreforthcomingwiththeir
information,veryactive,umm,intheteamintermsofoh,youknow,askingwhatthey’regonnado
afterworkandstufflikethat,likeI’mvery,I’ma,sortofaremoteworker,likeifI’vegotworktodoI’ll
justcrackonandgetonwithit,andIthinktheydidn’treallylikethatandtheyinterpretedthatasme
sortofisolatingmyself”K3,p7-8
Overalltheparticipantstendtoclusteraseriesofcharacteristicsthattheyperceivetobehighly
valuedandcreateanimaginedidentitythatwillbeprivilegedinphysiotherapyeducation.This
resultsinthemfeelingadeficit,andpositionedasanoutsider,whichisintensifiedinphysiotherapy
comparedtootheraspectsoftheirlives.Consequentlythisimpactsonthedevelopmentoftheir
professionalidentityasanauthenticphysiotherapist.
Theme2‘Everyoneshiesawayandtiptoesaroundit’–otherpeoples’responsesand
behavioursthatmarginaliseBAME
Thisthemefocusesontheparticipants’perceptionsoftheresponsesoftheuniversitystaff,practice
educatorsandpeersinavarietyofcontextsrelevanttotheirstudyasaphysiotherapystudent.The
participantsreportpracticesthatmakethemfeelincludedinthephysiotherapycommunity,however
theseareoftenisolatedandrare.Morecommonlytheparticipantsreflectonpracticesofethnic
majoritystaff,peers,practicecolleaguesthatdemonstrateignorance(lackofunderstanding),denial/
avoidanceor‘microaggressions’thatsuggestbothadvertentandinadvertentracism.
Firstlyparticipantsdescribeanumberofresponsesofstaff/peersthattheyinterpretasindicativeofa
lackofunderstandingofethnic/culturaldifference.Examplesareexpressedofwherecoursecontent
highlightsethnicdifferencesandethnicmajorityteachingstaffdiscussitawkwardlyorinawaythat
amplifiesthedifference.
“whenthey[lecturers]trytomakeit,trynottoberacistandyoucanjustseeit,youcanseeit,like
they’retryingnottodoitsohardthatitjustturnsintoit,theytrysohard,liketheytryandmakeitso
normal,like,umm,therewasonetimeweweresittingintutorialclassand[lecturer]waslike,“Yeah,
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I’msayingtheword‘black’youguysshouldn’tbeworriedI’msayingtheword‘black’….blackis
normal…”Therewasnoneedforthatexplanationand[thelecturer]waslookingatme,asshewas
sayingshewaslookingatmeassortoflikeshewastryingtosupportme,likeshe’stryingto………
I’mthinking,“It’sfinelikejustsayitlike.”AndIwaslike,stufflikethatwhenyou’retryingnottodoit,
itjustturnsalotworseitjustbecomesalotmoreawkward,andeveryone,everyoneallnoticesit,
everyone’slike,“Woah,thatwasabitdifferent.”J3,p12
RatherthanrespectandvalueBAMEdiversity,thestudentstalkofhowtheseexamplesonlytendto
‘putamassivemagnifyingglassoverus’J3,p11.Andaspreviouslyexpressedtheparticipantsidentify
thatthisemphasiseshowstaffandpeersdonotunderstandtheircontextfromtheoftenprivileged
perspective.
WhenissuesrelatedtoBAMEdifferenceoccur,theparticipantsmostlydescriberesponsesbystaff
thatareinterpretedasdismissiveoravoiding.Forinstancethefollowingexamplerecallswherea
studentraisesconcernsaboutracism.
“Therewasamodulethatwehadtodo.Itwas,uh,whatwasitcalled?ClinicalPreparations,andI
hadtodo,like….,whataremythreats?,…andImentionedit…..beingsomeonewhoisblackI’m
scaredthattheremightberacismandIhadawhitefemalepersoninawhitecoatwithmeandshe
waslike,“well,thatdoesn’thappen”.Iwaslike,well,howwouldyouknow?Howcouldyoupossibly
knowthatthatdoesn’thappen?”J2,p6
Andsimilarlyinpractice,thisblackmalestudentrecallsaneducatorresponsethatappearswell
meaningbutavoidsconfrontingtheissue.
“sothere’scertainumm,patientsthatwon’tevenlikelookatme.Andmyeducatorwasopenshewas
like,“Oh,youmightnotwanttogointothiswithme,cosshe’sabitfunny.”AndIthink,“Whatdoyou
mean?”She’slike,“She’sabitfunnywithmen.”Iwaslike,“Hmm,okaycool.”AndthenIrealisedand
therewas3physiosIsawbeforeandtheywereallmenandIwaslike,“Okayareyousureit’s…”
“Okay,yeah,she’sabitfunnywithlikeblackmen,”J3,p18
Therearesomebehavioursobservedinothersthatsomestudentsrefertoas‘microaggressions’.
Oneparticipantdescribesthesemicroaggressionsasactionsofethnicmajoritypeoplebasedon
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assumptionsofrace/ethnicity“insteadofyourselfasaperson”J3,p13.Examplesincludedirect
physicalbehaviourssuchashairtouching
“They’llsaysomething,they’lltouchmyhair.They’lldothatandthenI’lljustbelikewhydoyou
havetodothat?Justlike,andjust,basicallyjustputinasituationwhereyou’reisolatedbydrawing
attentiontothefactthatyou’redifferentanditjusthappensallthetimeandit’snotdonebecause
theythinkthattheyare…Theywouldneverbelievethattheyhavethesepreconceptions….”J2,p19
Thefindingsalsohighlightexamplesofwherestaffandpeersprioritiseinteractions,includingverbal
andnon-verbalcommunication,withotherpeoplemorelikethemselves(e.g.white).
“so,thewoman[tutor]waslike,Caucasian,andwewere,itwasjustusthree[studentswhowere
fromBAMEbackground]andwewerelike,everyoneelsewasCaucasian,shewasmakingeyecontact
witheveryoneelseexceptusandwefeltreallyleftout(laughter)butIdon’tknowwhyshewasn’t
makingeyecontactwithus?,but,like,isittheraceor…..”K2,p12
Thesehighlightwhereparticipantsfeelisolatedinphysiotherapyeducation.Thereareother
situationswheremicroaggressionsareperceivedathavingasignificantimpactontheiracademic
success.ForinstancestudentstalkaboutperceptionsoflowerexpectationsofBlack,Asianand
MinorityEthnicstudents.
“IdofeellikesometimeswhenI’vegotfeedbackforlikeanexam,umm,andit’snotbeenlikea
terriblegradebutIjustwantedtodobetterandoneofthelecturerswaslikesurprisedthatIlike,
receivedthisgradeandIwasn’thappyaboutit.Andthenforsomeoneelse[anotherstudent]likeshe
toldmethatshedidn’tget,like,shebasicallyjustpassedanditwaslike,“Oh.”Thelecturerwaslike,
“Oh,thisisn’tlikeyou,likeI’mreallysurprisedthatyouhaven’t,youknow,donebetter.Likewhat’s
theproblem?”AndIjustthoughtlike,“Whatotherreasonwouldtherebe?”Thiswasrightatthe
beginningaswell,likewhywouldhejustassumethatIdidn’twanttodobetter?J3,p14
Thiscanleadtoperceptionsofdifferenceinmarkingpracticesandthisstudenttalksabout
differencesbetweenherexperienceasablackwomanonplacementcomparedtoawhitepeer:
“Weliterallyhadexactlythesameresponsibilitiesbecauseitwasverysimilarwork.Itwasjustintwo
differentwards…..andwetookonthesamerole,blah,blah,blah,andshecameoutwithagradethat
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was10%higherthanmine………Yeah,andpartofthatwasthefactthatshegotonsowellwithher
clinicaleducator.Likeliterally,like,(laughter)theycouldbesistersatthispointandtheyjustwalk
alongtogetherandmeandmyclinicaleducatorwelookverydifferentandsoit’sjust,it’sjust
interesting.Idon’tknowwhy,butmaybeduetothefactwedidn’thavethatimmediateconnection
wherewehavesomethingto,youcan’t,like,lookinthemirrorandthen,like,reflecteachother’s
thing.Maybethatwasathing…….butIthinkdefinitelypartofthatwouldbethefactthatIalready
hadabarrierorbeingblackandit’snotsomethingthatIparticularlylike”J3,p20.
Itisimportanttorecognisethatthisexampleisbasedontheparticipant’sperception.Itisimpossible
todeterminewhattheclinicaleducator’smotiveswere,butforthestudent,thatsharedsenseof
belongingthroughethnicitywasnotpresent.Thisexampleandtheothersillustratedinthistheme
indicatethatfromtheparticipant’sperspective,BAMEdifferenceiseitherdismissed,avoidedor
illuminatedthroughmicroagressionsinmanyphysiotherapycontexts.
Theme3‘Wedon’thavemuchpowerandinfluence’-Personalstrategiesbystudentsfrom
BAMEbackgroundstointegrate
Thisthemearosefromtheparticipantdiscussionsandfromarecognitionthattheyfeel
disempoweredinphysiotherapyeducation.Theparticipantsinthestudyclaim“wedon’thavemuch
powerandinfluence”J2,p25andtheyhighlightanimpressionthatthey“don’tknowhowmuchcan
change”K2,p59andfromtheirpositionasstudentsitisdifficulttochallengebecausetheyarealways
underthepressuretomeettherequirementsofassessment.Neverthelessthefindingsindicate
personalstrategiestoestablishasenseofbelonginginphysiotherapyeducationandtheseare
expressedincontrastingways.Somestrategiesconfronttheperceiveddefaultphysiotherapyidentity
byassertingtheirownethnicidentity.Ontheotherhand,thefindingsidentifystrategiesofself-
regulationthateitheravoidchallengeorconformuncomfortablytotheperceiveddefault
physiotherapyidentity.
Toestablishasenseofbelongingstudentsseekoutotherswithintheirpeergroupthattheyfeelthey
willhaveanaffinitybasedonotheraspectsofidentity.
“whenitcomestostudyingnow,youkindoflookforthepeoplewholooklikeyoutostudy–it’sreally
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weird,Ican’texplainit,Ican’tputanexactreasonwhyIdoitbutIjust,it’sjustmaybeme,Ijustsee
itas:ifI’mrevisingwiththisguytheymightknowthesameamountthatIdo,wemightbeonthe
sameequalfootings,solet’srevisetogetherbecauseyouwon’tmakemefeelstupid”K3,p16
Thisexampleillustrateshowcreatinganequalfootingisnotjustestablishingacademicequivalence,
butthatitisalsosocialandcultural.Theseattemptsofbelongingextendbeyondtheprogrammeas
oneparticipanttalkedaboutseekingmentorsorrolemodelsinpracticeandbeingsurprisedofthe
lackofblackrepresentationtochoosefrom
“soIdidn’treallyseeit[physiotherapy]asaraceissueandevendiscussingitwithfamily,friends,
peoplethatI’dcomeacross,IthinktheonlytimethatIsortofpickedupthatthereweren’talotof
femaleblackwomenthatweredoingitwhenIwasresearchingwaswhenIwaslookingformentors
andpeopletoactuallytalkto”K3,p5
Thefollowingrepresentsonestudent’sattemptsatassertinghisownidentityinthephysiotherapy
classroomtochallengetheperceivedassumptionsmaderelatedtohisethnicity:
“Ilikebeinginafulltracksuit,cominginandthenbeingabletoanswereveryquestion,justmaybeto
planttheseedthatjustbecauseI’mthiswaydoesn’tmeanthatI’mstupidoranything.Idon’tlike
stereotypes,Iliketochallengesstereotypes,soIalwaysamconsciousofthat;Ithinkumm,inthe
groups,youknow,somepeoplemightcomeoffaspatronisingsometimes,umm,thewayIsaythings
like,“Water”andIguesslikeallthetimeIcan’t“War-ter”or“but-ter”,Isay,“Water,butter,”it’sjust
howIspeak.Whereasassoonasyousaythosetypeofbuzzwords,someoneelseovertheremightbe
like,“Okay,thisguycan’tevenspeakproperly,Imightneedtotakethereinshere.”K3p19
Thisstudentalsorecognisesthatheneedstoregulatehisownbehaviourandthefindingssuggest
thatstudentsuseavarietyofstrategiestomodifyandregulatetheirbehaviourasthisstudent
indicates.
“It’sjustyouhaveto………..Regulatingyourbehaviour………Yeah,you’reconstantlycriticisingwhat
you’redoing.You’reconstantlybeinglike,okay,Ican’tdothat,Ican’tsaythator,okay,Ihavetobe
likethisorIhavetospeaklikethis”J2p7
Otherstalkofstrategiestoavoidconflictincluding;stayingsilent,ignoringcomments,stayingcalm,
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notgettingupsetandjusttakingit.Thisblackfemalestudenttalksabouthowshemanagesaracist
commentinpractice:
“Ijusttakeitasit’sjustthewayitis;soit’skindoflikeyouacknowledgeitbutyoujustmoveon,you
don’treallygiveittoomuchenergy,so,butIdunnoifthat’s,Idunnoifthat’serr,therightthingtodo
orthewrongthingtodo,butattheendofthedaythat’s,yeah…..Yeah,atthetimejustwhatelsecan
youdo?Imeanespeciallyonplacementyou’rejusttryingtogetthroughplacementtobehonest,
you’renotreallytryingtochangetheworldthere”K3,p4
Apartfrombeingawareofhowtheymightmodifytheirverbalexpression,thestudentsalsotalk
abouttheimpactonhowtheyfeeltheyhavetodemonstrateskillsinaparticularways.Inone
situationastudentreflectsondifferencesbetweenhimself,asablackman,withinawhiteplacement
teamandfollowsthisbytalkingabouthowhemodifiedhisbehaviourtomanage:
“Myreflections,mytruereflections,Ialwayswritetwo,IwritetheoneI’mgonnashow,andIwrite
oneformyself,costheonewhereIcanbereallyhonestandevenwritehonestthings,speakina
certainway,andumm,youknow,it’snormallyreflectingonjustmyexperienceswiththeteam,what
Ineedtodonext;ifeveryonefocusesonwhattheyneedtodotopassthebook,whereasIcanfocus
onhowI,howIcanmanagetheteamtypething”K2,p8
Andanothertalksabouthowhemodifieshisbehaviourwithwhitepatients
“AndIthinkintermsofthewayyouact…….I’vehadlikesimilarthings,elderlypatientstheydon’t
reallywanttoumm,be,interactwithablackperson.Andthensometimesyouwilltryandchange
yourapproachsoyou’llbeextra…likewe’renicepeoplecoswe’rephysios,we’llbeextra-extranice
tolikeanelderlywhitepersontryingnottoseemaggressiveor,butImeanyouseeotherwhite
physioswillgoinandtelltheirpatientsoff,shoutingattheirpatients,andit’slikeifweeverdidthat
sortofthing…….we’dbeseenasaggressive”J3,p19
Thesepersonalstrategiesofmanagingethnicdifferenceinphysiotherapyeducationcarrythe
significantemotionallabourasanotherstudentarticulates:
“butIdon’tknowaboutyoubutIthinkit’semotionallabourtohavetoconstantlychatwithpeople’s
microaggressionsjustbecausetheydon’tknow.So,like,therearecertainthingslikesometimes
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15
somebodywillcomeupandsaysomethingignorantandI’llchallengeit.Don’tsaythatbecauseof
this,thisandthis.It’soffensivebecauseofthis,butonceyou’vedonethatfor20timesadayforthe
pastweek,thenitcomesto,let’ssay,theeighthdayandyou’relike,doyouknowwhatI’mgonnalet
thisoneslideandthenitgetstoathingso,like…Iwasgonnasayit’saboutpickingyourbattles.”
J2p26
ThisthemedrawsonthepersonalburdenthatparticipantsfromBAMEbackgroundsexperiencein
physiotherapyeducationandwidercontexts,andhowtheyadoptvaryingstrategieswhicheither
asserttheiridentityorassimilatebymodifyingbehaviours.
DiscussionThefindingsrepresentoneofthefirstknownstudiestoexploretheexperienceofphysiotherapy
studentsfromBAMEbackgroundsduringtheirstudies.Weacknowledgethatthisisasmallsample
butasparticipantsarefromtwoinstitutions,thismayhelptoavoidconclusionsthatthefindingsare
specifictoonecontext.Wehavetakenthequalitativedataasawhole,werecognisethesampleis
heterogeneousandinteractionsbetweenotherfactorssuchassocialclass,genderorprevious
educationalbackgroundsmayalsoinfluenceourfindings.Neverthelessthechallengesperceivedby
theparticipantsinthisstudyhighlighttheoccurrenceofinequalityinphysiotherapyeducation.
AlthoughthisresearchdidnotapplyCriticalRaceMethodology(38),theprinciplesofcriticalrace
theory(39)havebeenusedasalenstodiscussthefindingsinthecontextofthestructuraland
culturalaspectsofphysiotherapyeducation.
ThenarrativesofthestudentsfromBAMEbackgroundsinthisstudymightbewhatSolorzanoand
Yosso(38)refertoas‘counter-stories’ofthosepeoplewhoseexperiencesarenotoftentold.
ThereforethesevoicesofstudentsfromBAMEbackgroundsofferawayofexposing,challengingthe
storiesofthemajorityandprivilegeinphysiotherapyastheparticipantshaddesired.The
participants,inthisstudy,discussanacuteawarenessofapositionasan‘outsider’towhatthey
perceiveaswhitedominancewithinphysiotherapyincomparisontootherhealthcareprofession
courses.Theyarticulateattemptstobelonginphysiotherapy,aprofessionwhichtheyperceive
placesvalueonspecificcharacteristicssuchasbeingextrovertandproactive,somethingthatcanbe
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inconflictwiththeirracial/culturalbackgrounds.Theparticipantsthenfeelatadisadvantageand
theyhavetoworkhardertodemonstratethesecharacteristics.Thishaspreviouslybeenhighlighted
byotherresearchers(14,38)wheredemonstrationofidealcharacteristicsissynonymisedwith
right/good,andsimultaneouslyimplieswhatisnotideal/right(inthiscaseintrovert,quiet).Thisleads
toaconstantsenseofneedingtoworktofitinandthesenseof‘notfullybelonging’isparticularly
significantforBAMEstudentsinphysiotherapy.Thesefeelingsreflectotherliteratureinhigher
educationwherestudentsfromBAMEbackgroundshavereportedmarginalisationandisolation
(10,16,40)ornotfeelingacademicenough(2).Oneofthekeyfindingsofourresearchisthatthe
dataindicatesthatthecontextoftrainingtobeaphysiotherapist,andtheprofessionitself,intensifies
thefeelingsofmarginalisationandisolationforBAMEstudents.Thisintensityoffeelinghadnotbeen
anticipatedpriortoengagementwiththeprofessionandwassignificantlyhigherinthiscontextthan
theotherareasoflifeexperiencedbytheparticipants
Asecondthemearisingfromthestudywasinrelationtotheresponsesofothersthroughthe
participant’sphysiotherapyeducationjourney.Theparticipantsdescribedexperienceswhereissues
ofrace/ethnicitywereeitherignoredordeniedandthesereflecttheexperiencesofsocial
marginalisationthatBeagan(40)describesinherstudyofmedicalstudentminoritiesinCanada.
Madriaga(22)alsoarguesthat‘meritocracy’,‘value-neutral’and‘colourblind’discoursespervade
liberalmajorityhighereducationinstitutions,andthattheseupholdwhiteprivilegebybeing
perceivedas‘natural’.Whetherintentionalornot,suchdiscoursesdisregardthosewhoareracialised
asBAME(ibid),andinthecaseofthepresentstudyitappearsthatthemajority(white)staff,peers
andpatientsareindifferenttotherealitiesofthemarginalisedstudentsfromBAMEcultural
backgrounds.Therewereexamplesofblatantracial/ethnicdiscriminationbypatientsinthepractice
context,whichillustratesomeofthechallengesexperiencedbystudentsandeducational
professionals,astheydeveloptherapeuticinteractions.Howevermoreoftentherewerecommon,
minor,everydayactsbasedonstereotypedassumptionsofethnicityorracethatconveydisrespect,
disregardorcontemptthattheparticipantsandothersrefertoas‘microaggressions’(41,42).
Examplesofmicroaggressionshavebeenidentifiedinmedicine(40)andthewiderstudent
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community(41).Theexamplesofhairtouching,avoidingeyecontact,asking‘whereareyou‘really’
from?’andassumingBAMEstudentsmayhaveloweracademicabilityinthepresentstudyarenot
dissimilartothisliterature.Thereforethisdrawsattentiontotheissueofculturalmarginalisationof
BAMEstudentsintheclassroomandpracticecontextofphysiotherapyeducation.Thesourceof
microaggressionsarealsowidespread,includingfellowpeers(11),patients(43)andalsothosein
positionsofpowersuchasteachersandclinicians(14,40,44).Thecumulativeburdenof
microaggressionsentrenchespowerrelationsandresultsininstitutionalracismthatcontinuesto
marginaliseBAMEstudentsinphysiotherapy.
Despitethechallengesidentifiedinthestudy,theparticipantsrevealtheirresourcefulnessin
attemptstointegrateinphysiotherapy.Toavoidtheconsequencesofbeingjudgedbasedon
stereotypedassumptions;thestudentsdescribehowtheymakeeffortstobeproactive,assertiveor
‘extranice’whicharesimilartostrategiesidentifiedinotherworkinphysiotherapyandnursing(30)
andinmedicineandbiomedicalsciences(11).Butlargelythesestrategiesindicateattemptsto
modifybehaviourtobe‘morelikewhite’andincludeotheractionssuchasdressinglikeother
students,modifyingaccentsandavoidingconfrontations.Beagan(40)arguesthatforself-
preservationitiseasiertonotmakeafussandallowincidentstopass,asstudentscanbeperceived
asoverreactiveortoosensitivebytheprivilegedmajoritywhoareignoranttotheissuesfaced.
Solorzano&Yosso(38)highlightthatstudentsofcolourhavenooptionbuttoassimilatetowhite
middleclassculturetosucceedinuniversityandlife.Whilstthisstudyrecognisestheneedforall
traineestoassimilateintothecontextofphysiotherapyeducation,italsorevealssomeoftheunique
tensionsexperiencedbyBAMEstudents.Consequently,thefindingssuggestthesetensionsmakethe
assimilationmoredifficultforBAMEstudents,highlightingtheinequalityofexperiencewithinthe
system.
Thestudentsinthestudywerekeentoputforwardrecommendationsforaddressingtheissuesthey
facedandthesehaverelevanceinthecontextoftheinstitutionsthatparticipatedinthestudy,but
othersmaydrawontheseexamples.Theparticipantsstressedtheneedtoeducatestaffandfellow
peersofthecontextswhereprivilegeanddisadvantagecoexist.Stevenson(18)alsoarguesthat
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academicdevelopmentisnecessarysothatstafflearntorecognisewhiteprivilegeandfeel
empoweredtodealwithissuesofraceandracism.Thestudentswerehappyfortheirnarrativestobe
usedaspartofthesedevelopmentsandweareidentifyingphysiotherapyspecificstaffdevelopment.
Wearealsocurrentlyexploringwaystoco-createteaching,learningandassessmentapproaches
(18,19)withstudentsfromBAMEbackgrounds.Smith(2)hasrecentlyarguedtheimportanceof
greaterrepresentationandrolemodelsandwearealsodevelopingapproachestoestablishBAME
mentors.
ThesepracticesmaygosomewaytogivestudentsfromBAMEbackgroundsagreatersenseof
belonging.Howeverothersarguethatgainswillbeminimalifthewhitedominatenarrativeremains
unchallenged(39)andstrategiesareremedialandshapedonanassumptionofdeficit(19,43),such
asassumingthementorshipprogrammesalonewillsolvetheissue.Thereisalsoneedtorecognise
thesystemofhighereducationrecreatesprivilegeandentrenchespowerinsystematicways(22)and
thusphysiotherapyeducationisembeddedwithinthissystem.Toenablechange,physiotherapy
educatorsmayneedtochallengetheirownandinstitutionalpracticesevenifthismeansawillingness
toletgoofpower.Beagan(40)claimsfromherworkwithmedicaleducationthatbynotquestioning
andchallengingpractices,educatorsarecomplicitinenablingmarginalisationandinequalitiesfor
BAMEandotheridentities.Despitethesecallstoaction,itisnotpossibletoidentifywholescale
inclusiveapproachesfor‘all’,becausealthoughwellmeaning,Madriaga(22)suggestssuch
approachespromotealiberalethicthat‘everybodyisthesame’whichsimultaneouslyignores
experiencesofstudentsofcolour.
ConclusionsThefindingsinthisstudyhelptoidentifyforthefirsttimetheunmoderatedstudentperspective
wherestructures,curriculum,teachingandlearningstrategiesoperatetosimultaneouslyadvantage
ethnicmajoritystudentsanddisadvantageBAMEstudentsinphysiotherapyeducation.Someofthese
arenotdissimilartootherresearch,butthisstudyhighlightssomemicroaggressionsthatare
prevalentinphysiotherapyeducationandhowqualitiessuchasextroversionandproactivenessmay
beprivilegedinphysiotherapylimitingsomeculturalandethnicapproaches.Italsohighlightshow
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studentsfromBAMEbackgroundsdemonstrateresourcefulnessinattemptstobelongin
physiotherapy.YetthereisstillmuchworktodotoempowerBAMEstudentstospeakupand
advocatethattheirvoicesareheard.Studentsstudyingtowardsaphysiotherapydegreearerequired
todemonstrateadeptacademicandclinicalskills,alongsideallqualifiedphysiotherapists,whoare
alsoboundinbothbehaviourandknowledgebyregulatoryframeworks(suchastheHealthandCare
ProfessionsCouncilStandardsofProficiency(45)intheUK).Thecomplexityofthestudent
experiencesinthisstudyarealsoimpactedbythepowerimbalancesinboththeclinicaland
academicworkspace,andintheirabilitytosuccessfullynegotiateandmanagecomplexissues
relatingtoBAMEina‘professional’way.
Wehopethethemespromptcolleaguestorecognisesimilaritiesintheirownenvironmentsanddraw
theirownconclusionsandactions.Fromthesefindingsitisessentialthatacademicpractitionersand
seniormanagerscontinuetointerrogateeducationdifferentialsrelatedtoethnicity.Overtincidents
ofracismshouldalsobedealtwithviaappropriateworkplacepoliciesandeducatorsshould
demonstratepublicintoleranceofracism.Critically,BAMEstudentsshouldbeempoweredtotackle
theseovertformsofracismaswellasthemoresubtleandoppressivemicroaggressions.Astarting
stepcouldbetocommitto,
andinvestin,activitiesthatseektoco-createteaching,learningandassessmentapproacheswith
BAMEstudents.Bydoingthis,BAMEstudentswouldbeempoweredtodisruptandchangeanyovert
orcovertracistpedagogicpractices.Inaddition,thelackofvisiblerolemodelsfromBAME
backgroundsintheprofessionalsoposeschallenges.Wesuggestthatfocusandinvestmentshould
bedirectedtowardstheidentificationandsupportofBAMErolemodelsandmentorswithin
physiotherapyeducation,andacrosstheprofession.Agreaterdiversityinrolemodelsandmentors
mayassistinmakingtheprofessionattractiveandaccessibletopotentialBAMEstudents.However,
encouragingstudentswithgreaterethnicdiversityintotheprofessionwillnotremovethetensions
experiencedbythecurrentBAMEstudentsunlessitalsosupportedbyfurthereducationand
understandingtoaddresstheexistingtensions.
Finally,recognisingthatstudentsfromBAMEbackgroundsarenotahomogenousgroup,we
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recommendthatfutureresearchexploresthespecificexperiencesofparticularethnicorfaithgroups
inphysiotherapyeducation.Similarly,researchexploringtheexperiencesofqualified
physiotherapistsfromthesegroupsisalsowarranted.
AbbreviationsBAME–BlackAsianandMinorityEthnic
BSc–BachelorofScience
MSc–MasterofScience
HEI–HigherEducationInstitution
HESA–HigherEducationStatisticsAgency
UK–UnitedKingdom
DeclarationsEthicsapprovalandconsenttoparticipate:ApprovalgrantedbyCHLSRECBrunelUniversity
London8709-MHR-Jan/2018andreciprocalapprovalatFacultyofHealthSocialCareandEducationat
KingstonUniversityandStGeorgesUniversityofLondon.Allparticipantsgavewritteninformed
consenttoparticipate.
Consentforpublication:Participantsweremadeawarethatanonymisedquotesmaybeusedin
publicationspriortogivingconsent
Availabilityofdataandmaterial:Thedatasetsusedand/oranalysedduringthecurrentstudyare
availablefromthecorrespondingauthoronreasonablerequest.
Competinginterests:Theauthorsdeclarethattheyhavenocompetinginterests
Funding:HealthEducationEnglandNorthWestLondon
Authors'contributions:MN,JH,AW,SWconductedthefocusgroups.JHanalysedthedata.MN,AW,
SWallreviewedthedataandanalysisandparticipatedincriticaldiscussions.JHwroteafirstdraftof
thearticle.MN,AWandSWmadesignificantcontributionstothefinaldraft,whichallauthorshave
approved.
Acknowledgements:Thankstothestudentswhovolunteeredtoparticipateinthisstudyand
offeredtosharetheirexperiences.
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