To look and behave like a professional: the practical accomplishment of hospital-located physiotherapy education. Clare Margaret Kell Presented for the degree of Professional Doctorate in Education School of Social Sciences Cardiff University December 2012 Contents Page Summary iv University Declarations v Acknowledgements vi Chapter 1: Placing the thesis in context 1.1 Introduction 1 1.2 Journeying towards a Professional Doctorate 1 1.3 False starts and lessons in noticing 2 1.4 Orientating the reader to the thesis 4 Chapter 2: Reviewing the literature: a journey in learning about learning 2.1 Introduction 6 2.2 The UK profession of physiotherapy, its pre-registration education and relevance to this study 6 2.3 Troubles arising from an early focus on the pedagogic discourse of Physiotherapy placement education – and some progress 10 2.4 Observations and reflections from reading non-physiotherapy- focussed workplace learning research 18 2.5 From literature review to practice: arriving at a focus for my project 30 Chapter 3: Methodology 3.1 Introduction 33 3.2 Preliminary concerns: challenges of being a good witness 33 3.3 The methodological approach to my study: does it have a label? 36 3.4 Preparations for my fieldwork 42 3.5 Practices in the field 49 3.6 Doing the data justice and not arguing with the members 52 3.7 Chapter conclusion 54 Chapter 4: Experiencing a neuro placement 4.1 Introduction 55 4.2 Setting the scene 55 4.3 The mechanics of the placement 56 i 4.4 The aims and focus of the placement 57 4.5 Experiencing a neuro placement 59 4.6 Typical learning opportunities on this neuro placement 60 4.7 Selecting the field extracts to present in this chapter 62 4.8 The practical accomplishment of neuro physiotherapy education 63 i) Preparing to see a patient 63 ii) Patient-focussed placement interactions 66 a. Settling into the interaction 67 b. Conducting the physical assessment 71 c. Session closure and extraction from the interaction 78 d. Creating physiotherapy work through dialogue and note writing 80 4.9 Chapter summary 91 Chapter 5: Experiencing a musculoskeletal placement 5.1 Introduction 93 5.2 The context and planning of a musculoskeletal placement 94 5.3 Students’ ‘core’ work patient-facing interactions 98 i) The context of students’ typical core MSk placement experiences 98 ii) Preparing to see a new MSk patient 100 iii) The early phases of an MSk new patient assessment 102 iv) The subjective assessment 106 v) The post-subjective assessment debrief 114 vi) The objective assessment 120 vii) The post-objective assessment debrief 132 vii) Closing the patient interaction 135 ix) Writing up and signing off the patient’s treatment record 138 5.4 Reflections from the observation of students at work in ‘core’ MSk patient interactions 141 5.5 A Brief aside: observations of MSk students’ learning in other settings 142 5.6 Chapter summary 143 ii Chapter 6: Doing placement education: comparing interaction practices across settings 6.1 Introduction 144 6.2 The process of data analysis and synthesis 144 6.3 The ‘hows’ of the neurology placement 145 i) The practice of Intercorporeal Knowing 145 ii) The verbal practices of placement educators 148 iii) Interaction practices between group members 152 6.4 The ‘hows’ of the Musculoskeletal placement 158 i) The Placement Educator-led student debriefs 159 ii) MSk student: student interaction practices 173 iii) Further discussion about student: patient interactions 177 6.5 Chapter summary: synthesising some ‘whats’ from the ‘hows’ 181 6.6 Conclusions 189 Chapter 7: Concluding remarks 7.1 A journey in noticing and creating noticing-sensitive data collection tools 191 7.2 The status of the data and its analysis 192 7.3 Placement education: from policy to practice 193 7.4 Implications of this study for the placement education of physiotherapy students 197 7.5 Reflections on this project and recommendations for further study 199 Reference list 202 Appendices 1. Full text of ward-based neuro placement interaction sequence. 212 2. Getting into the neuro placement mind-set: preparing for a close 219 exploration of students’ learning experiences. 3. Learning in neuro by co-working with qualified colleagues. 226 4. Making sense of MSk Placements: exploring the access 230 interviews. 5. The Hydrotherapy experience. 238 6. Techniques practice: teaching professional vision and knowing in 245 practice. iii Summary This thesis provides a window into the world of work-placement-based pre- registration physiotherapy education in the UK. This empirical study followed final year students as they went about their everyday practices on placement in hospital- based settings. Adopting a perspective sensitive to social theories of learning, and drawing on ideas and methods from ethnography and interactional sociologies, the project makes visible some of the complex, but taken-for-granted, interactional practices and processes by which students, their educators and patients co-enact their work of physiotherapy student education. How placement education is actually done - its practical accomplishment - is captured by focusing on the minutiae of participants’ interaction performances. Physiotherapy practice interactions typically involve participants’ use of space, speech, paralanguage, touch and movement of themselves and others. The research required the development of a new method for recording interaction proxemics, kinesics and verbal elements in real time and with only paper and pencil. Created from the ideas of choreographers, social anthropologists and video/conversational analysts, the multi-modal data sets generated by the method bring interactions to life and enable the detailed exploration of participants’ practices. The evidence collected suggests that placement learning experiences are an integral part of professional development framed within a situated learning environment where the dominant discourse is of ‘physiotherapy as science’. The evidence also suggests that students’ placement practices adapt to satisfy the needs of their summative assessment. The thesis considers the impact of placement education interactions on the patients about whom they orientate. The thesis, and the new method it describes, is immediately relevant to the practice of physiotherapy, its education programmes and professional project discussions. The quality of the interaction data presented in this thesis makes physiotherapy practice education accessible and available for others to explore, and the method is suitable for transfer to other studies of human interaction. iv University Declarations This work has not previously been accepted in substance for any degree and is not concurrently submitted in candidature for any degree. Signed …………………………………………………………. (candidate) Date ……31/12/12…………………… STATEMENT 1 This thesis is being submitted in partial fulfillment of the requirements for the degree of PhD. Signed …………………………………………………………. (candidate) Date ……31/12/12…………………… STATEMENT 2 This thesis is the result of my own independent work/investigation, except where otherwise stated. Other sources are acknowledged by footnotes giving explicit references. Signed …………………………………………………………. (candidate) Date ……31/12/12…………………… STATEMENT 3 I hereby give consent for my thesis, if accepted, to be available for photocopying and for inter-library loan, and for the title and summary to be made available to outside organisations. Signed …………………………………………………………. (candidate) Date ……31/12/12…………………… v Acknowledgements My first and greatest acknowledgment must be to the students, physiotherapists and patients who let me into their world to observe the intimacy of their workplace interactions. Without the openness of their welcome and their tolerance of my intrusion there would have been no project. I also acknowledge the support and practical advice I received from the plethora of gatekeepers who protect the sanctity of patient-facing therapy. I thank them for having faith in my project and trust in my ability to deliver it. I am fortunate to have had the opportunity to embark on a programme of study that has had life-changing impact. I shared the first part of the journey with my fellow EdD travellers and I thank them for showing me what I had missed about working inter-professionally. Their accounts and reflections started the process of questioning my underpinning professional lens and the origins of those assumptions which led me ultimately to this thesis. Central to the development of this project, and myself as a social scientist, has been the enthusiastic and unwavering support of my supervisors Professor Tom Horlick-Jones and Dr Jane Salisbury. I thank Tom specifically for his ability to find just the resource I needed to open up new ideas and pathways, for his patient challenges to my early certainties and his unstinting belief in the project. I thank Jane for her invaluable insights and observations about my stick people’s ability to bring alive the minutiae of the healthcare interactions I observed. I am fortunate to have colleagues, old and new, who, over many years, have proved rigorous critics and sounding boards, and provided much valued optimism, encouragement and most recently space to think and write. I am also grateful to fellow conference attendees for their validation and challenge to my evolving ideas and method. Finally, but by no means least, I am especially grateful to Jonathan, Anna, Emily and Ruth for their love, support (and invaluable Mac computer skills), blindness to grumpiness and tolerance of my withdrawal from family life. Thank you for your belief in me and that the price was worth paying. vi Chapter 1: Placing the thesis in context. 1.1 Introduction This thesis completes my study for a Professional Doctorate in Education. I chose to undertake the Professional Doctorate programme in a School of Social Sciences as I wanted to look at my profession, physiotherapy, from a different perspective (as will become clear later in this chapter I did not know what sort of perspective – but I sensed there was more to the world than my physiotherapy training had explored). The intention has always been to offer my learning from the programme and related study to the profession for discussion. This thesis is a significant outcome from my studies but only begins the process of dissemination to my professional community. While located firmly within the world of physiotherapy, the text is also the story of my journey in social science ideas and perspectives and as such I use the first person to write both reflectively and reflexively throughout. In this first chapter I set the scene for the empirical study underpinning this thesis, and orientate readers to the thesis’ intentions and structure. 1.2 Journeying towards a Professional Doctorate I qualified as a Physiotherapist in the UK in 1988. Physiotherapy is a protected title healthcare profession with a focus on human movement and function. The reference to my being a UK therapist is deliberate and orientates readers to my membership of a form of the world-wide profession that defines itself as ‘science-based’ (CSP 2002, p.19). Post- registration I practised clinically in a pattern typical of many new therapists. For the first eighteen months I worked for four months at a time in a range of attachments or placements to hospitals and wards within hospitals. This period, known as the ‘junior rotations’, sends newly qualified staff to a range of therapeutic specialities (labelled by the medically diagnosed conditions of the patients populating those ward e.g. ‘medical’, surgical’ etc.) to deepen the integration of theory with practice that began during their pre-registration education1. A series of applications and promotions saw me move first to the next level of, slightly longer (6 month), rotations, and then to a ‘specialist’ rotation for neurological therapy 1 In its December 2011 submission to the UK Health Select Committee Enquiry into Education, Training and Workforce Planning, the CSP argued that the principle of ‘broad based rotations’ be retained in any NHS Workforce re-shaping as they ‘are needed to ensure that the newly qualified are able to develop their skills in a variety of clinical settings, including to support their subsequent progression to advanced and specialist roles. This ensures that the physiotherapy workforce will have the necessary transferrable skills and flexibility needed to be able to adapt to changes in health care provision rather than specialising too early in their careers’ CSP (2011) CSP submissision to the Inquiry into Education, Training and Workforce Planning. Health Select Committee. 1 as I honed my possible career direction. Taking students as a Placement Educator sparked an interest in education that led me through other clinical posts to the role of ‘Student Teacher’ in a university-based physiotherapy education team. UK pre-registration programmes have university- and work-placement based components with all students required, by the national accrediting body (the Health and Care Professions Council; HCPC), to complete approximately 1000 hours of learning in practice-based settings. Placement education is usually provided by practising physiotherapists who take on the education role in addition to their therapeutic caseload. As a junior academic I sought to understand how curricula impact on students’ learning. Through a series of longitudinal quantitative studies I explored the possible impact of the university-based elements of a pre-registration curriculum on the change overtime of certain dimensions of students’ learning profiles that were considered to be related to their development of the learning characteristics and personal belief systems of lifelong learners. Over the course of ten years my colleagues and I made interesting observations and curricular adjustments (for example Kell 2006) but recognised the need to explore students’ learning in placement settings. Perhaps surprisingly given the significant time allocated to placement learning within pre- registration programmes, little research has been undertaken in the UK into real time placement education practice. My colleagues and I undertook several small-scale projects to begin mapping the complexity of the placement learning environment (Kell and Jones 2007; Kell and Owen 2009), but we knew we needed to experience naturally occurring placement education. The depth and scale of study required at doctoral level provided the context to legitimate the use of sufficient resources to conduct empirical fieldwork. The primary intention of my thesis project was therefore to build on my earlier work and explore students’ learning experience in work-placement settings. 1.3 False starts and lessons in noticing When I started my doctoral studies I no longer practised as a physiotherapist, but my training, clinical work specialising in neurological rehabilitation and later roles as a university- teacher had collectively, over twenty years, influenced profoundly what I valued and noticed about the world around me. While I taught that UK physiotherapy was a science-based profession, I had given no thought to whether or how a perspective of science influenced my daily preparation of lessons, interaction with students and my placing of patients in 2 physiotherapeutic settings. Indeed, I was so blind to my own assumption-making that colleagues recount a conversation I had when preparing to begin my EdD studies in which I assured concerned acquaintances that ‘there can’t be much difference between science and social science’! As one might expect from this starting point, the journey through the taught phase of the doctoral programme was transformative and deeply challenging. Through the course of this thesis I will describe how my learning during these two years opened up possibilities for the thesis but could do little to prepare me for the jolt to my life view that took place when I started trying to put theory into research practice. My journey as a fledging social scientist and the progress of my empirical study are so closely intertwined that this thesis explores both the study and charts and celebrates my personal development. Maxwell Atkinson’s (1978) book arising from his PhD study Discovering Suicide has been particularly influential in helping me develop a writing style for this thesis. Atkinson embarked on a study that he thought would be quantitative in nature and data driven. Early in his project he explored the way that suicide cases were categorised in the data sets he was using and questioned the assumptions leading to this categorisation. Cycles of ‘reading, researching and writing’ saw his thesis project ‘shift from positivism to interactionism to ethnomethodology’ (p. 6). Rather than cleaning his thesis of its twists, turns, false starts and misplaced asumptions, Atkinson wrote his text as a journey in an attempt ‘to preserve the logic of the research as (he) understood it at different stages of its development’ (p. 6). Following Atkinson on his journey is a fascinating read and enabled me to recognise how my background, the challenges of my preconceptions and the pull-up moments that littered the progress of this project, influenced what I did and did not notice about the research environment at different stages of the research process. In this thesis therefore, my research journey and personal development are made visible through the narrative form and ‘voice’ with which each chapter is written. The change in my noticing and critical engagement with my data is particularly evident between the two results chapters (Chapters 4 and 5). Each results chapter discusses the fieldwork data collected in each of the two placement education sites observed in this study. The wealth of data generated by the fieldwork led me to explore and write about each placement site separately. Chapter 4 was thus written in its entirety before I began analysing the fieldwork evidence from the second site. Chapter 4 is descriptive in nature and may at times seem naïve. However, following Atkinson’s (1978) example, I have resisted the temptation to go back and re-write Chapter 4 in light of my thinking by the end of Chapter 5 because such an 3