1

Preprint:Pleasenotethatthisarticlehasnotcompletedpeerreview.

Workinghardtobelong:aqualitativestudyexploringstudentsfromBlack,AsianandMinorityEthnicbackgroundsexperiencesofpre-registrationphysiotherapyeducationCURRENTSTATUS:ACCEPTED

JohnAnthonyHammondKingstonUniversityFacultyofHealthSocialCareandEducation

j.hammond@sgul.kingston.ac.ukCorrespondingAuthorORCiD:https://orcid.org/0000-0001-5246-426X

AnnabelWilliamsBrunelUniversityCollegeofHealthandLifeSciences

SaskiaWalkerKingstonUniversityFacultyofHealthSocialCareandEducation

MerielNorrisBrunelUniversity

DOI:10.21203/rs.2.10636/v3

SUBJECTAREASEducationalPhilosophyandTheory

KEYWORDSPhysiotherapy,student,BlackAsianandMinorityEthnic,qualitative,race

brought to you by COREView metadata, citation and similar papers at core.ac.uk

provided by Kingston University Research Repository

2

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.

3

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)

4

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

5

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

6

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

7

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,

8

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

9

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,

10

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

11

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

12

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

13

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,

14

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

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

16

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

17

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

18

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

19

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

20

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.

References

21

(1)Mountford-ZimdarsA,SabriD,MooreJ,SandersJ,JonesS,HighamL.CausesofDifferencein

StudentOutcomes.ReporttoHEFCEbyKingsCollegeLondon,ARCNetworkandtheUniversityof

Manchester.2015.

http://webarchive.nationalarchives.gov.uk/20180322111249/http://www.hefce.ac.uk/pubs/rereports/ye

ar/2015/diffout/Accessed16Oct2018.

(2)SmithS.ExploringtheBlackandMinorityEthnic(BME)StudentAttainmentGap:WhatDidItTell

Us?ActionstoAddressHomeBMEUndergraduateStudents’DegreeAttainment.Journalof

PerspectivesinAppliedAcademicPractice2017;5(1):48-57.

(3)Stegers-JagerK,BrommetF,ThemmenA.Ethnicandsocialdisparitiesindifferenttypesof

examinationsinundergraduatepre-clinicaltraining.AdvancesinHealthSciencesEducation

2016;21(5):1023-1046.

(4)Stegers‐JagerKM,SteyerbergEW,Cohen‐SchotanusJ,ThemmenAP.Ethnicdisparitiesin

undergraduatepre‐clinicalandclinicalperformance.MedEduc2012;46(6):575-585.

(5)WoolfK,PottsHW,McManusIC.EthnicityandacademicperformanceinUKtraineddoctorsand

medicalstudents:systematicreviewandmeta-analysis.BMJ2011;342:d901.

(6)WoolfK,HaqI,McManusIC,HighamJ,DacreJ.Exploringtheunderperformanceofmaleand

minorityethnicmedicalstudentsinfirstyearclinicalexaminations.AdvancesinHealthSciences

Education2008;13(5):607-616.

(7)SalamonsonY,AndrewS.Academicperformanceinnursingstudents:Influenceofpart‐time

employment,ageandethnicity.JAdvNurs2006;55(3):342-349.

(8)UtzmanRR,RiddleDL,JewellDV.Useofdemographicandquantitativeadmissionsdatatopredict

academicdifficultyamongprofessionalphysicaltherapiststudents.PhysTher2007;87(9):1164-1180.

(9)NorrisM,HammondJA,WilliamsA,GrantR,NaylorS,RozarioC.Individualstudentcharacteristics

andattainmentinpre-registrationphysiotherapy:aretrospectivemulti-sitecohortstudy.

Physiotherapy2017;doi:10.1016/j.physio.2017.10.006

(10)FrumkinLA,KoutsoubouM.Exploratoryinvestigationofdriversofattainmentinethnicminority

adultlearners.JournalofFurtherandHigherEducation2013;37(2):147-162.

22

(11)ClaridgeH,StoneK,UssherM.Theethnicityattainmentgapamongmedicalandbiomedical

sciencestudents:aqualitativestudy.BMCMedicalEducation2018;doi:10.1186/s12909-018-1426-5

(12)SteeleCM.Athreatintheair:Howstereotypesshapeintellectualidentityandperformance.Am

Psychol1997;52(6):613.

(13)WassV,RobertsC,HoogenboomR,JonesR,VanderVleutenC.Effectofethnicityon

performanceinafinalobjectivestructuredclinicalexamination:qualitativeandquantitativestudy.

BMJ2003Apr12;326(7393):800-803.

(14)WoolfK,CaveJ,GreenhalghT,DacreJ.EthnicstereotypesandtheunderachievementofUK

medicalstudentsfromethnicminorities:qualitativestudy.BMJ2008;337:a1220.

(15)BurkePJ,HaytonA.Iswideningparticipationstillethical?JournalofWideningParticipationand

LifelongLearning2011;13(1):8-26.

(16)MasonC,SparkesVJ.WideningParticipationinPhysiotherapyEducation.Part2:Ethnicityamong

undergraduates.Physiotherapy2002;88(5):276-284.

(17)CondonVM,MorganCJ,MillerEW,MamierI,ZimmermanGJ,MazharW.Aprogramtoenhance

recruitmentandretentionofdisadvantagedandethnicallydiversebaccalaureatenursingstudents.

JournalofTransculturalNursing2013;24(4):397-407.

(18)StevensonJ.BlackandMinorityEthnicStudentDegreeRetentionandAttainment.Higher

EducationAcademy2012.https://www.heacademy.ac.uk/system/files/bme_summit_final_report.pdf

Accessed22Jan2019

(19)SinghG.Blackandminorityethnic(BME)students’participationinhighereducation:improving

retentionandsuccess:Asynthesisofresearchevidence.HigherEducationAcademy2011.

http://www.heacademy.ac.uk/assets/documents/inclusion/ethnicity/BME_synthesis_FINAL.pdf

Accessed22Jan2019

(20)RichardsonJT.Theunder-attainmentofethnicminoritystudentsinUKhighereducation:whatwe

knowandwhatwedon’tknow.JournalofFurtherandHigherEducation2015;39(2):278-291.

(21)McDuffN,TatamJ,BeacockO,RossF.Closingtheattainmentgapforstudentsfromblackand

minorityethnicbackgroundsthroughinstitutionalchange.WideningParticipationandLifelong

23

Learning2018;20(1):79-101.

(22)MadriagaM.AntiblacknessinEnglishhighereducation.InternationalJournalofInclusive

Education2018;doi:10.1080/13603116.2018.1512660.

(23)GreenwoodN,BithellCP.Perceptionsofphysiotherapycomparedwithnursingandmedicine

amongstminorityethnicandWhiteUKstudents:implicationsforrecruitment.Physiotherapy

2005;91(2):69-78.

(24)CharteredSocietyofPhysiotherapy.AnnualQualityReview2017/18.UKQualifyingPhysiotherapy

Education.ReportPD133.2019.

(25)OfficeforNationalStatistics.EthnicityandNationalIdentityinEnglandandWales:2011.2011.

https://www.ons.gov.uk/peoplepopulationandcommunity/culturalidentity/ethnicity/articles/ethnicityan

dnationalidentityinenglandandwales/2012-12-11Accessed23Jan2019.

(26)YeowellG.‘OhmygoshI’mgoingtohavetoundress’:potentialbarrierstogreaterethnic

diversityinthephysiotherapyprofessionintheUnitedKingdom.Physiotherapy2013;99(4):323-327.

(27)BithellCP.Entry-levelPhysiotherapyEducationintheUnitedKingdom:Governanceand

Curriculum.PhysicalTherapyReviews2007;12:145-155.

(28)HammondJA.Doinggenderinphysiotherapyeducation:acriticalpedagogicapproachto

understandinghowstudentsconstructgenderidentitiesinanundergraduatephysiotherapy

programmeintheUnitedKingdom.Doctoralthesis.KingstonUniversity2013.

https://eprints.kingston.ac.uk/27739/Accessed18June2019

(29)HaskinsAR,Rose-StPrixC,ElbaumL.Covertbiasinevaluationofphysicaltherapiststudents'

clinicalperformance.PhysTher1997;77(2):155-163.

(30)HammondJ,Marshall-LucetteS,DaviesN,RossF,HarrisR.Spotlightonequalityofemployment

opportunities:Aqualitativestudyofjobseekingexperiencesofgraduatingnursesand

physiotherapistsfromblackandminorityethnicbackgrounds.IntJNursStud2017;74:172-180.

(31)NorrisM,HammondJA,WilliamsA,WalkerS.Studentswithdisabilitiesexperiencesofpre-

registrationphysiotherapyeducation:Aqualitativestudy.BMCMedicalEducation.InReivew.

(32)FinlayL.Phenomenologyfortherapists:Researchingthelivedworld.Chichester:Wiley-Blackwall;

24

2011.

(33)HigherEducationStatisticsAgency.Who'sstudyinginHE?:Personalcharacteristics.2018;

https://www.hesa.ac.uk/data-and-analysis/students/whos-in-he/characteristics.Accessed18Nov2018.

(34)EtikanI,MusaSA,AlkassimRS.ComparisonofConvenienceSamplingandPurposiveSampling.

AmericanJournalofTheoreticalandAppliedStatistics2016;5(4):1-4.

(35)HollowayI.Basicconceptsforqualitativeresearch.Oxford:BlackwellScienceLtd;1997.

(36)BraunV,ClarkeV.Usingthematicanalysisinpsychology.Qualitativeresearchinpsychology

2006;3(2):77-101.

(37)CohenL,ManionL,MorrisonK.ResearchMethodsInEducation.Abingdon,UK:RoutledgeFalmer;

2000.

(38)SolórzanoDG,YossoTJ.CriticalRaceMethodology:Counter-StorytellingasanAnalytical

FrameworkforEducationResearch.QualitativeInquiry2002;8(1):23-44.

(39)GillbornD.Educationpolicyasanactofwhitesupremacy:whiteness,criticalracetheoryand

educationreform.JournalofEducationPolicy2005;20(4):485-505.

(40)BeaganBL.‘Isthisworthgettingintoabigfussover?’Everydayracisminmedicalschool.Med

Educ2003;37(10):852-860.

(41)EllisJM,PowellCS,DemetriouCP,Huerta-BapatC,PanterAT.Examiningfirst-generationcollege

studentlivedexperienceswithmicroaggressionsandmicroaffirmationsinapredominantlywhite

publicresearchuniversity.CulturalDiversity&EthnicMinorityPsychology2019;25(2):266-279.

(42)BoysenGA.Teacherandstudentperceptionsofmicroaggressionsincollegeclassrooms.College

Teaching2012;60(3):122-129.

(43)BeaganBL.Teachingsocialandculturalawarenesstomedicalstudents:"it'sallverynicetotalk

aboutitintheory,butultimatelyitmakesnodifference".AcadMed200306;78(1040-2446;6):605-

614.

(44)NationalUnionofStudents.RaceforEquality:AreportontheexperiencesofBlackstudentsin

furtherandhighereducation.2011.

https://www.nus.org.uk/PageFiles/12238/NUS_Race_for_Equality_web.pdfAccessed21Jan2019.

25

(45)HealthandCareProfessionsCouncil.Thestandardsofproficiencyforphysiotherapists.2013

https://www.hcpc-uk.org/standards/standards-of-proficiency/physiotherapists/Accessed19Aug2019