2.2. LA DIALÉCTICA DEL ESPACIO
2.2.2. El espacio del trabajo y de la técnica
Wherever social relations exist, various forms of domination, subjection and asymmetrical balance of forces operate (Lukes 2005). Within organisations all individuals are embedded within wider patterns of normative control and believe that they are rationally assessing situations and coming to their own conclusions, free of power. Power is exercised non- coercively by educating workers in such a way that they accept their role in the existing ‘order of things’, so accepting the authority of the organisation (Hughes et al 2007). It may be the case that that ‘the way things are’ is seen as natural and unchangeable resulting in a situation where it is difficult to imagine an alternative (Lukes 2005).
2.4.1 Professional socialisation and communities of practice
In the social relations relevant to this study, power imbalances can exist between physiotherapists and clients, institution and employees, institution and clients, educator and student and non-disabled and disabled individuals (disability may be applicable in most of these dyads). In physiotherapy, patterns of behaviour signifying the way things are done (Monrouxe 2010) are taken for granted and accepted. Students are immersed in, and taught to emulate, traits and patterns of behaviour considered desirable during their33 professional socialisation, interacting with significant others enabling them take on the normative behaviour that is the desired outcome (Eisenberg 2012).
Drawing on ideas from work on communities of practice, this situated learning environment has advantages, facilitating students’ learning through active social participation so gradually incorporating them into the ‘webs’ of experts (Hughes et al 2007). More critically, these ‘webs’ can be viewed as being constituted in an environment in which the construction of individual knowledge and identity aligns individual aspirations with organisational goals (Garrick and Usher 2000). As physiotherapists develop expertise in the workplace they are empowered on the one hand and yet ‘seduced into submission’ on the other. The implication here is that they ‘submit’ to a specific way of being, thinking and doing (Hughes et al 2007) that in this situation, equates with recognised physiotherapy identity.
Students in the clinical environment are expected to integrate physiotherapy identity into their personal identity irrespective of pre-existing notions of ‘self’. Professions are
acknowledged as being adept at regulating selection of newcomers, policing boundaries and disciplining practice to manage conflicts and struggles (Hughes et al 2007). This could constitute part of the role of practice educators who are in a position of power when interacting with students.
Because of these asymmetrical power relations, issues of inequality and control may be foregrounded and could be exaggerated as a result of students attending placements for relatively short periods. Practice educators will tend to view them as ‘outsiders’ because placements differ from traditional communities of practice where membership is
established and comparatively unchanging (Owen-Pugh 2007). Arguably, as students move through the programme and undertake further placements, they are seen to be more adept at assuming standard patterns of behaviour, involving recognition of themselves as professionals and being recognised as such by others (Vivekananda-Schmidt et al 2015) who begin to accept them as more established members of the community. In my
experience, however, if students fall outside the expected patterns of behaviour and norms for any reason including disability, practice educators can express anxiety and may perceive that it is more challenging to support them in the clinical setting.
34
2.4.2 Clients, powerful professionals and disabled students
Clients experience the ‘order of things’ in healthcare situations. Medicine purports to be underpinned by scientific method which can foster the idea of body as machine and client as object; focussing on general principles rather than individual circumstances. Scientific method has adopted a positivist approach in which “what is ‘true’ and what is contingent was constructed as stable, permanent and objective” (Eisenberg 2012,440). Arguably this approach plays a large part in underpinning contemporary healthcare practice in relation to the ways that clients may be reduced to malfunctioning machines that need fixing. This also permeates many areas of physiotherapy practice.
If there is a focus on dysfunction, this can undermine engagement with clients’ and therapists’ experiential knowledge with physical diagnosis being incongruent with clients’ experience of illness or trauma (Eisenberg 2012). They can feel well, applying no label of illness or disability to themselves. On entering the healthcare environment, however, they may experience a shift in their pre-existing identities which is unexpected and possibly unwelcome. Physiotherapists can promulgate this objectification of the client by referring to ‘the knee in cubicle three’ or ‘the chest in bed ten’. Clients can be depersonalised by physiotherapists’ use of specialised language imposed upon their own experience (Frank 2013). It may be the case that these fundamental ways of understanding disabled clients are to the fore in physiotherapists’ understandings of disability which may carry over into their dealings with disabled students.
2.4.3 Physiotherapists ‘in the web’
I am not suggesting that physiotherapists, either individually or collectively, approach their day filled with ‘predispositions’ of power which they simply execute. They are social actors subject to social relations which “constitute structures of choices within which people perceive, evaluate and act” (Lukes 2005,9). Most physiotherapists work in institutions where they are subject to power relations to which they largely consent, complying with the dominant behavioural characteristics of the organisation. For those who are subjected (or potentially subjected) to power, there could be an element of fear that there will be repercussions if they do not behave in certain ways. There is a sense in which therapists could be perceived as becoming entrenched or entrapped; not self-entrapped but put into that position by the organisational behaviour and power structures of the NHS. Arguably people are where they are because of context rather than as a result of active intent; but this will influence practice.
35 While alternative paradigms are considered important theoretically as discussed, I would argue that current work pressures and stresses experienced by healthcare practitioners may act as barriers to them engaging effectively with biopsychosocial issues in relation to education and practice. The Kings Fund (2016) reported that nearly 40% of NHS staff report feeling unwell because of stress, resulting in poorer quality client care and lower levels of client satisfaction. It also effects the ability of staff to pay close attention to clients and to respond empathically. While physiotherapists can appreciate critiques of the biomedical approach to the body, work pressures to move clients quickly through the system to discharge may cause them to fall back on mechanistic and reductionist approaches to care so again reinforcing unequal power relations. It is interesting that the public health initiatives discussed earlier have no focus on the application of biopsychosocial principles to relationships with colleagues/students. This absence, plus practitioners’ understandings of disability being largely influenced by therapeutic alliances with clients, may have some bearing on educators’ attitudes towards, and ability to support, disabled students.
Having briefly examined the theory and practice of physiotherapy in relation to
professional identity and power, the next chapter considers disability as a concept and the ways that this may influence the approach of physiotherapists to disabled people. This provides context for chapter 4 which explores the process of ‘becoming’ a physiotherapist and issues relating to disabled students.
36