The sample included 17 students (10 F, 7 M, 13 BSc, 4 MSc) with a range of ethnic backgrounds including Black, Asian and Mixed backgrounds. The focus groups lasted approximately 90 minutes.
Three major themes that developed from the analysis of the data of participants experiences. The first theme ‘you do feel like an outsider’ focuses on the participants’ sense of belonging in physiotherapy education. ‘Everyone wants to shy away and tip-toe around it’ is the second theme and explores the overt and subtle practices of others (particularly tutors, peers and practice educators) that marginalise BAME students. Finally the theme ‘we don’t have much power and influence’ illustrates the personal strategies that are adopted by individuals from BAME backgrounds to establish a sense of belonging in physiotherapy education. In tandem, these themes drawn from the participant experiences also highlight where institutional structures and practices could be modified to enable BAME student inclusion and these are presented in the discussion.
Theme 1 - ‘You do feel like and outsider’: feeling ‘other’ in reflections of belonging in physiotherapy
This theme explores the perceptions of participants from BAME backgrounds in relation to what they identify as the default physiotherapy student identity as ‘white, middle class, mature and female', that they learn is embedded in a history of physiotherapy as a profession that only becomes apparent at the commencement of the course. The participants indicate the acute realisation that there is less BAME representation in physiotherapy in comparison to other aspects of their lives and prior educational experiences and this amplifies their feelings of being an outsider in physiotherapy education, as this participant identifies:
“at the beginning, when I started….there was a lot of, like, Asian people on other courses –like, medicine and biomed, and then when I was, like, interacting with them, I felt like I was on the wrong side (laughter) like, cos I was in physio, which is the main, like, white people, I was maybe I’m on the wrong course, I should be on the other side” K2, p27
The BAME participants in this study often report that they perceive their professional behaviour is being judged in relation to this default physiotherapy identity and this has significant personal and social implications for them and they articulate this through a process of belonging in physiotherapy education.
“cos you do already feel sort of like an outsider………You’re always conscious of that….. like how are they perceiving me? How am I being, you know” J2, p6
“I mean, when I talk to all the …. the lecturers and staff here, and they talk about their background, where they’re from, you pick up little things here and there that they’re from these nice villages or nice towns and cities where they had a very nice house, erm, front and back garden and, you know, they never had issues with heating or water or, you know, anything like that that you seem to think do you know what, they’re, they’re, they might not understand where I’m coming from” K2,p20
This last statement demonstrates how other aspects of identity such as class and socio-economic status intersect with ethnic background. Participants often expressed other ways ethnic identity intersects with class that further amplifies their feelings of difference. For instance middle class values are expressed through spoken English pronunciation and students from BAME often perceive their verbal expression is in contrast and in some ways not valued or authentic
“I think I was speaking quite normal like I don’t even know what normal is, but I think I was speaking like alright and they [class peers] were just laughing at everything I was saying…….everything I was saying they was like (laughs), everyone started laughing. I was thinking, “I didn’t say a joke here like,” but you know what I just took it” J3 p15
“so now, like, we subconsciously just think, like, if we ever like speak in front of the class and we pronounce something wrong that they’ll really laugh about it afterwards” K2, p54.
The identification of the default physiotherapy identities goes beyond obvious demographic variables, but includes other characteristics and values. The participants describe an ideal ‘extrovert’ physiotherapy type that they express through characteristics such as: being outgoing, flamboyant, socialising and going to the pub, being sporty or proactive and motivated. Some feel vulnerable in attempts to adopt the ‘extrovert’ physiotherapy identity as they may be positioned negatively based on cultural stereotypes
“…..there’s certain, like, things you can’t say and certain, like, ways that you have to sort of, like, hold yourself because as a black person it’s easier to be misconstrued as being either loud or aggressive or rude” J2, p7
In contrast, another participant feels their quiet approach, which they align with their ethnic background, will be judged negatively (isolating myself) in comparison to the default ‘forthcoming’ approach.
“other students who were not of colour but they were more, maybe more forthcoming with their information, very active, umm, in the team in terms of oh, you know, asking what they’re gonna do after work and stuff like that, like I’m very, I’m a, sort of a remote worker, like if I’ve got work to do I’ll just crack on and get on with it, and I think they didn’t really like that and they interpreted that as me sort of isolating myself” K3, p7-8
Overall the participants perceive there is a predominant identity that is privileged in physiotherapy education and as such they are acutely aware of how this positions them as an outsider that in some ways is intensified in the education context and contributes to their feeling of being a less authentic physiotherapy student than their peers.
Theme 2 ‘Everyone shies away and tiptoes around it’ – other peoples responses and behaviours that marginalise BAME
This theme focuses on the participants’ perceptions of the responses of the university staff, practice educators and peers in a variety of contexts relevant to their study as a physiotherapy student. The participants report practices that make them feel included in the physiotherapy community, however these are often isolated and rare. More commonly the participants reflect on practices of ethnic majority staff, peers, practice colleagues that demonstrate ignorance (lack of understanding), denial / avoidance or ‘microaggressions’.
Firstly participants describe a number of responses of staff/peers that they interpret as indicative of a lack of understanding of ethnic/cultural difference. Examples are expressed of where course content highlights ethnic differences and ethnic majority teaching staff discuss it awkwardly or in a way that amplifies the difference.
“when they [lecturers] try to make it, try not to be racist and you can just see it, you can see it, like they’re trying not to do it so hard that it just turns into it, they try so hard, like they try and make it so normal, like, umm, there was one time we were sitting in tutorial class and [lecturer] was like, “Yeah, I’m saying the word ‘black’ you guys shouldn’t be worried I’m saying the word ‘black’…. black is normal…” There was no need for that explanation and [the lecturer] was looking at me, as she was saying she was looking at me as sort of like she was trying to support me, like she’s trying to ……… I’m thinking, “It’s fine like just say it like.” And I was like, stuff like that when you’re trying not to do it, it just turns a lot worse it just becomes a lot more awkward, and everyone, everyone all notices it, everyone’s like, “Woah, that was a bit different.” J3, p12
Rather than respect and value BAME diversity, the students talk of how these examples only tend to ‘put a massive magnifying glass over us’ J3,p11. And as previously expressed the participants identify how this emphasises how staff and peers do not understand their context from their often privileged perspective.
Also when issues related to BAME difference occur, the participants mostly describe responses by staff that are interpreted as dismissive or avoiding. For instance the following example recalls where a student raises concerns about racism.
“There was a module that we had to do. It was, uh, what was it called? Clinical preparations, and I had to do, like, a, a sort of like a going into a place where, like, what are my, what are my threats, what are my, you know, and I mentioned it. I was, like, being someone who is, you know, black I’m scared that there might be racism and I had a white female person in a white coat with me and she was like, “well, that doesn’t happen”. I was like, well, how would you know? How could you possibly know that that doesn’t happen?” J2, p6
And similarly in practice, this black male student recalls an educator response that appears well meaning but avoids confronting the issue.
“so there’s certain umm, patients that won’t even like look at me. And my educator was open she was like, “Oh, you might not want to go into this with me, cos she’s a bit funny.” And I think, “What do you mean?” She’s like, “She’s a bit funny with men.” I was like, “Hmm, okay cool.” And then I realised and there was 3 physios I saw before and they were all men and I was like, “Okay are you sure it’s…” “Okay, yeah, she’s a bit funny with like black men,” J3, p18
There are some behaviours observed in others that some students refer to as ‘microaggressions’. One participant describes these microaggressions as actions of ethnic majority people based on assumptions of race/ethnicity “instead of yourself as a person” J3, p13. Examples include direct physical behaviours such as hair touching
“They’ll say something, they’ll touch my hair. They’ll do that and then I’ll just be like why do you have to do that? Just like, and just, basically just put in a situation where you’re isolated by drawing attention to the fact that you’re different and it just happens all the time and it’s not done because they think that they are … They would never believe that they have these preconceptions….”J2,p19
The findings also highlight examples of where staff and peers prioritise interactions, including verbal and non-verbal communication, with other people more like themselves (eg white).
“so, the woman [tutor] was like, Caucasian, and we were, it was just us three [students who were from BAME background] and we were like, everyone else was Caucasian, she was making eye contact with everyone else except us and we felt really left out (laughter) but I don’t know why she wasn’t making eye contact with us, but, like, is it the race or…..”K2, p12
These highlight where participants feel isolated in physiotherapy education. There are other situations where microaggressions are perceived at having a significant impact on their academic success. For instance students talk about perceptions of lower expectations of Black, Asian and Minority Ethnic students.
“I do feel like sometimes when I’ve got feedback for like an exam, umm, and it’s not been like a terrible grade but I just wanted to do better and one of the lecturers was like surprised that I like, received this grade and I wasn’t happy about it. And then for someone else [another student] like she told me that she didn’t get, like, she basically just passed and it was like, “Oh.” The lecturer was like, “Oh, this isn’t like you, like I’m really surprised that you haven’t, you know, done better. Like what’s the problem?” And I just thought like, “What other reason would there be?” This was right at the beginning as well, like why would he just assume that I didn’t want to do better? J3,p14
This can lead to perceptions of difference in marking practices and this student talks about differences between her experience as a black woman on placement compared to a white peer:
“We literally had exactly the same responsibilities because it was very similar work. It was just in two different wards…..and we took on the same role, blah, blah, blah, and she came out with a grade that was 10% higher than mine……… Yeah, and part of that was the fact that she got on so well with her clinical educator. Like literally, like, (laughter) they could be sisters at this point and they just walk along together and me and my clinical educator we look very different and so it’s just, it’s just interesting. I don’t know why, but maybe due to the fact we didn’t have that immediate connection where we have something to, you can’t, like, look in the mirror and then, like, reflect each other’s thing. Maybe that was a thing…….but I think definitely part of that would be the fact that I already had a barrier or being black and it’s not something that I particularly like” J3,p20.
It is important to recognise that this example is based on the participant’s perception. It is impossible to determine what the clinical educators motives were, but for the student, that shared sense of belonging through ethnicity as well as other factors such as culture, age and socio-economic background was not present. This examples and the others illustrated in this theme indicate that from the participant’s perspective, BAME difference is either dismissed, avoided or illuminated through microagressions in many physiotherapy contexts.
Theme 3 ‘We don’t have much power and influence’ - Personal strategies by students from BAME backgrounds to integrate
This theme arose from the participant discussions and from a recognition that they feel disempowered in physiotherapy education. The participants in the study claim “we don’t have much power and influence” J2,p25 and they highlight an impression that they “don’t know how much can change” K2,p59 and from their position as students it is difficult to challenge because they are always under the gaze of assessment. Nevertheless the findings indicate personal strategies to establish a sense of belonging in physiotherapy education and these are expressed in contrasting ways. Some strategies confront the default physiotherapy identity by asserting their own ethnic identity. On the other hand, the findings demonstrate strategies of self-regulation that either avoid challenge or conform uncomfortably to the default physiotherapy identity.
To establish a sense of belonging students seek out others within their peer group that they feel they will have an affinity based on other aspects of identity.
“when it comes to studying now, you kind of look for the people who look like you to study – it’s really weird, I can’t explain it, I can’t put an exact reason why I do it but I just, it’s just maybe me, I just see it as: if I’m revising with this guy they might know the same amount that I do, we might be on the same equal footings, so let’s revise together because you won’t make me feel stupid” K3, p16
This example illustrates how creating an equal footing is not just establishing academic equivalence, but that it is also social and cultural. These attempts of belonging extend beyond the programme to seek out mentors or role models in practice
“so I didn’t really see it [physiotherapy] as a race issue and even discussing it with family, friends, people that I’d come across, I think the only time that I sort of picked up that there weren’t a lot of female black women that were doing it when I was researching was when I was looking for mentors and people to actually talk to” K3,p5
The following represents one student’s attempts at asserting his own identity in the physiotherapy classroom to challenge the perceived assumptions made related to his ethnicity:
“I like being in a full tracksuit, coming in and then being able to answer every question, just maybe to plant the seed that just because I’m this way doesn’t mean that I’m stupid or anything. I don’t like stereotypes, I like to challenges stereotypes, so I always am conscious of that; I think umm, in the groups, you know, some people might come off as patronising sometimes, umm, the way I say things like, “Water” and I guess like all the time I can’t “War-ter” or “but-ter”, I say, “Water, butter,” it’s just how I speak. Whereas as soon as you say those type of buzzwords, someone else over there might be like, “Okay, this guy can’t even speak properly, I might need to take the reins here.” K3p19
This student also recognises that he needs to regulate his own behaviour and the findings suggest that students use a variety of strategies to modify and regulate their behaviour as this student indicates.
“It’s just you have to………..Regulating your behaviour………Yeah, you’re constantly criticising what you’re doing. You’re constantly being like, okay, I can’t do that, I can’t say that or, okay, I have to be like this or I have to speak like this” J2p7
Others talk of strategies to avoid conflict including; staying silent, ignoring comments, staying calm, not getting upset and just taking it. This black female student talks about how she manages a racist comment in practice:
“I just take it as it’s just the way it is; so it’s kind of like you acknowledge it but you just move on, you don’t really give it too much energy, so, but I dunno if that’s, I dunno if that’s err, the right thing to do or the wrong thing to do, but at the end of the day that’s, yeah…..Yeah, at the time just what else can you do? I mean especially on placement you’re just trying to get through placement to be honest, you’re not really trying to change the world there” K3,p4
Apart from being aware of how they might modify their verbal expression, the students also talk about the impact on how they feel they have to demonstrate skills in a particular ways. In one situation a student reflects on differences between himself, as a black man, within a white placement team and follows this by talking about how he modified his behaviour to manage:
“My reflections, my true reflections, I always write 2, I write the one I’m gonna show, and I write one for myself, cos the one where I can be really honest and even write honest things, speak in a certain way, and umm, you know, it’s normally reflecting on just my experiences with the team, what I need to do next; if everyone focuses on what they need to do to pass the book, whereas I can focus on how I, how I can manage the team type thing” K2, p8
And another talks about how he modifies his behaviour with (white) patients
“And I think in terms of the way you act…….I’ve had like similar things, elderly patients they don’t really want to umm, be, interact with a black person. And then sometimes you will try and change your approach so you’ll be extra … like we’re nice people cos we’re physios, we’ll be extra-extra nice to like an elderly white person trying not to seem aggressive or, but I mean you see other white physios will go in and tell their patients off, shouting at their patients, and it’s like if we ever did that sort of thing……. we’d be seen as aggressive” J3,p19
These personal strategies of managing ethnic difference in physiotherapy education carry the significant emotional labour as another student articulates:
“but I don’t know about you but I think it’s emotional labour to have to constantly chat with people’s microaggressions just because they don’t know. So, like, there are certain things like sometimes somebody will come up and say something ignorant and I’ll challenge it. Don’t say that because of this, this and this. It’s offensive because of this, but once you’ve done that for 20 times a day for the past week, then it comes to, let’s say, the eighth day and you’re like, do you know what I’m gonna let this one slide and then it gets to a thing so, like … I was gonna say it’s about picking your battles.” J2p26
This theme draws on the personal burden that participants from BAME backgrounds experience in physiotherapy education and how they adopt varying strategies which either assert their identity or assimilate by modifying behaviours.