Your place, not mine

How where we work shapes how we work

Where are you a physiotherapist?

In a clinic room? In a classroom? On Facebook or in an online chatroom? In your friend’s living room? In your head at the gym?

The question of where people practice their physiotherapy has received almost no attention in the literature, but place clearly plays a pivotal role in shaping everyday physiotherapy practice.

For instance, COVID has made everyone realise how important face-to-face contact can be. It’s reminded us how having a specific space to work in defines a lot about the way we teach, learn and work, and the things about our therapeutic places that we might have taken for granted.

And the changing places where physiotherapy has been practiced tells its own history of the profession.

In the 19th century, massage and electrotherapy were administered in the homes of people with enough time and money to afford a visiting therapist (for more on this, see Nicholls 2021).*

By contrast, until the invention of socialised medicine, poor people never saw a physiotherapist. It took the field hospitals and new rehabilitation centres of the First World War for physiotherapy to break this particular class barrier.

But more equitable access created a new divide, as physiotherapists moved into the hospitals of the new welfare state. Gone was the image of the patient receiving the therapist in their own home, on their own terms; now the patients came to us. The new specialist and expert.

And we designed our clinic spaces and our working practices to echo the kinds of objectivity and detachment that was needed to demonstrate our status. Our clinic rooms were sterile, in every sense, because our goal was to show the patient that we were in charge.

But these things have also changed in physiotherapy over the last half century.

When I did my PhD thesis, one of the places I studied was a respiratory clinic that had broken away from the traditional idea that you only ever saw a respiratory physiotherapist if you’d been admitted to a medical ward. Their idea of a respiratory client was radically different, and they designed their clinic space accordingly (Nicholls, 2012).

The decline of the welfare state and boom in private practice, greater customer choice and competition, and people’s desire to receive more from their healthcare provider, have all forced physiotherapists to challenge the idea of where they perform their physiotherapy.

And there are lessons to be learned from how other professions are confronting place in practice. Medicine has been considering the place of place for decades. David Armstrong’s classic study of the shift from bedside to surveillance medicine is a case in point (Armstrong, 1995).

But more recently, this paper by Liz Brewster, Michael Lambert and Cliff Shelton has talked about the role that the placelessness of doctors plays in perpetuating unequal access to healthcare. And this study by Skaiste Linceviciute and colleagues discusses the inherent vulnerabilities of place in the work as a male first responder.

What both of these studies emphasise is that the place, space, architecture, and physical environment of health care work plays a big part in shaping how we practice, and how those we work for experience our care.

References

Armstrong, D. (1995). The rise of surveillance medicine. Sociology of Health & Illness, 17(3), 393-404. https://doi.org/10.1111/1467-9566.ep10933329

Nicholls, D.A. (2012).  Foucault and Physiotherapy.  Physiotherapy Theory and Practice, 28(6), 447-453.

Nicholls, D.A. (2021). The role of neurasthenia in the formation of the physiotherapy profession. Physiotherapy Theory and Practice. doi:10.1080/09593985.2021.1887058

*Gymnastics (‘exercise’ as a concept had not yet been invented) and hydrotherapy were often social, but were still only luxuries for most until the advent of the welfare state.