Luleå University of Technology

Department of Health Sciences

Physical Therapist 180 study credits

Exploring my cultural understanding of physiotherapy in a

different culture

- An Autoethnographic Minor Field Study conducted in India.

Erik Unevik

Bachelor thesis in physiotherapy

Course: S001H

Term: Fall 2010

Supervisors: Anita Melander Wikman, PhD Senior lecturer, Jenny Wickford, PhD RPT

Examiner: Gunvor Gard, PhD Prof

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Acknowledgements

First of all I would like to say Dhanyavad! To all Indians that I have met when conducting

this fantastic life-changing study. I never felt alone a single moment during my visit and

without your fantastic hospitality I would never had managed this thesis.

I would like to thank all Indian physiotherapists, students and other medical personal in the

settings I were placed in that treated me as an equal to you. And to all Indian friends that I

gained when living in the settings, which gave my visit an amazing dimension by the side of

my project work.

I want to give a special thanks to my contact persons, directors, principals and Indian

supervisors that showed the greatest of understanding and never hesitated to help me with

queries for my thesis. My Swedish supervisors Jenny and Anita, your dedication to my work

has been tremendous guiding me on this sometimes shaky-narrow auto ethnographic path,

where the connection to physiotherapy sometimes has felt being located on another planet. As

this thesis was funded by the Swedish international developing agency (SIDA) under the

scholarship Minor field studies (MFS) I feel most thankful to have such a government that

supports students to take an interest in developing issues around the world.

I feel grateful for having such a supportive family, girlfriend, friends, classmates and

stimulating study environment that has placed me so far up on Maslow’s staircase. Without

you, I would never have dared to reach for the final step where I am now when writing this,

self-fulfillment.

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Abstract

Background: Cultural factors are important aspects in physiotherapy, as our world globalizes

meetings between healthcare givers and patients from diverse cultures increases. When different

cultures meet in treatment situations problems can emerge that could impede the relationship between

the physiotherapist (PT) and patient. There are tools for the PT to increase success in these t meetings,

but insufficient research regarding PTs own personal experiences when meeting different cultures.

Aim: The aim of this thesis was to describe my own experiences and reactions as a PT student

when meeting a different physiotherapy culture. Methodology: The study was conducted in

India at four different PT clinical settings during seven weeks. Autoethnographic

observational method was used with a theoretical framework for cultural competence in the

data collection to connect the subjective experiences of the settings. The field data was

analyzed with a qualitative content analysis to find recurring themes. Findings: The analysis

resulted in five different themes: Reflecting on the structure of the physiotherapy context,

reflecting on the physiotherapy work, Reflection on patient’s in physiotherapy work, Being in

the field and Being a student with minor experience and knowledge. Conclusion: Facing a

different culture with minor clinical and life experience lead me to experience confusion of

languages, fear of losing face, getting my cultural beliefs questioned but as well my progress

to enhance communication. The conducting and analyzing process of this thesis in helped me

gain further insight of the importance of cultural factors and diversity in physiotherapy.

Keywords: Culture, Reflection, Autoethnography.

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Table of content

Acknowledgements .................................................................................................................... 2

Abstract ...................................................................................................................................... 3

Table of content .......................................................................................................................... 4

Introduction ................................................................................................................................ 6

Aim ........................................................................................................................................... 10

Research methodology ............................................................................................................. 10

Autoethnography .................................................................................................................. 10

Context ................................................................................................................................. 10

Data collection: .................................................................................................................... 12

Communication domain ................................................................................................... 12

Data analysis ........................................................................................................................ 12

Ethical considerations .......................................................................................................... 13

Findings .................................................................................................................................... 13

1. Reflecting on the structure of the physiotherapy context ................................................. 13

1.1 The working place hierarchy ...................................................................................... 13

1.2 Disposition of time ..................................................................................................... 14

1.3 Arrangement of patients visits .................................................................................... 15

1.4 Status of the Indian physiotherapy profession ........................................................... 15

2. Reflecting on the physiotherapy work ............................................................................. 16

2.1Treatment situations .................................................................................................... 16

2.2 Different views in treatment modalities ..................................................................... 17

2.3 The Indian physiotherapy program and students performance .................................. 18

3. Reflection on patient’s in physiotherapy work ................................................................ 19

3.1 explanatory models for diseases and injuries ............................................................. 19

3.2 Compliance ................................................................................................................. 20

4. Being in the field .............................................................................................................. 21

4.1 Emotions of frustration and powerlessness ................................................................ 21

4.2 Fear of losing face ...................................................................................................... 22

4.3 Senses of ethnocentrism and culture shock ................................................................ 23

5. Being a student with minor experience and knowledge ................................................... 24

5.1 Confusion of languages and lacking clinical knowledge ........................................... 24

5.2 Feeling misplaced ....................................................................................................... 26

5.3 Trying to enhance communication ............................................................................. 26

Discussion ................................................................................................................................ 28

Findings discussion .............................................................................................................. 28

Reflecting on hierarchal systems and time disposal ......................................................... 28

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Reflecting on my changing understanding of physiotherapy work .................................. 29

My preparations for the Indian travel ............................................................................... 31

Being a novice and communication difficulties ............................................................... 31

Methodological discussion ................................................................................................... 32

The value of reflection and this experience ..................................................................... 34

Conclusion ................................................................................................................................ 36

References ................................................................................................................................ 37

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Introduction

Our world is becoming more globalized and diverse in an increasing speed. In year 2050

experts predict that 58 % of the American population will consist of non-white minorities

(Black & Purnell, 2002). In 2009 14, 3 % of the Swedish population came from foreign

countries (Statistics Sweden, 2010). Due to the increasingly multi-cultural society that we live

and work in, it is of great importance that health care givers are able to adapt and

accommodate for different cultural perspectives on health and illness (Lundberg, Bäckström

& Widén, 2005). In contrast to our diverse world, the physiotherapy profession is relatively

homogenous. In 2003-2004 80, 9 % of the graduating physiotherapists (PT) in USA were

white (Black & Purnell 2006, p. 7), and in 2007 the percentage was 76 % in the UK (Norris &

Allotey, 2008). Cultural diversities between professionals and patients must be taken into

consideration in education and in treatment situations. Leavitt (2010) argues that:

“An understanding of socio-cultural variables in the health care setting and an individual’s

client´s world view is expected to lead to an improved clinical encounter with better functional

outcomes for the patient and a more rewarding personal experience for the physical therapist”.

(p. 228)

The concept of culture is multifaceted. Different authors have different ways to explain

the phonemae (Black & Purnell, 2002, 2006; Higgs, Jones, Loftus & Christensen, 2008;

Hofstede, 2001; Leavitt, 2010; Cushner & Brislin, 1996; Gard, Cavlak, Thrane Sundén &

Razak Ozdincler, 2005; Meadows, 1991; Wickford, 2010). Hofstede (2001) describes culture

as follows: “Culture is to a human collectivity what personality is to an individual.” (p.10).

As stated by Leavitt (2010), culture is a natural part of our existence:

“At birth, humans must begin to adjust to a natural environment in which oxygen sustains life and

to a social environment in which culture sustains life. Only when deprived of oxygen or of their

usual cultural supports do people realize how crucial both are to existence.” (p. 19)

We are not born in a culture, nor do we inherit a culture; it is something that we learn. Culture

is a result of communication between humans which give them explicit and implicit tools to

deal with the common reality, such as: norms of acceptable behaviour, values, customs,

beliefs, feelings (Black & Purnell, 2002; Cushner & Brislin, 1996; Gard et al., 2005; Leavitt,

2010).

Culture can as well be materialistic. Culture is not solid, it is constantly evolving and

changing through history when humans communicate and share above-mentioned examples

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as they version is better than others (Cushner & Brislin, 1996). All these tools give us

“glasses” for how we will review events in our lives. Our cultural outlook lays embedded

until we face people from other cultures or travel to countries with other cultures. When

leaving a person’s own culture, deprived of the person’s cultural oxygen, the person can

experience a cultural shock. A form of physiological disorientation having one´s own cultural

values constantly questioned over time (Leavitt 2010, p.236).

When physiotherapists and patients from different cultures meet in the clinic, a lot of

cultural challenges can emerge. For example, PT’s mostly derive from the western individual

culture that encourages patients to take an active individual role in rehabilitation, letting

patients reflect on and criticise given treatment options and promotes increase in self-

efficacy and patients formulation of individual goal settings. The patient could originate from

a collectivistic culture which values the family’s participation more and where health care

givers are more authorial in the rehabilitation process and therefore the patient could find it

unfamiliar to take on a bigger participation role and un authorial behaviour from therapists

can be misunderstood as indecisive (Black & Purnell, 2006; Leavitt, 2010). The patient could

hold different cultural understandings of health and illness rather than the western biomedical

model. Other Communication challenges can emerge, as aspects of: different languages,

cultural interpretations of touch, time punctuality, different norms for the usage of body

language and acceptable greetings, spatial distance, clock versus social time, willingness to

share thoughts and feelings to name a couple (Black & Purnell, 2006).

Norris & Allotey (2008) states that most physiotherapists are embedded in the western

cultures ideals, where although the vast majority of the world’s population 80% does not hold

these values. Clinical encounters between PT’s and patients from a different culture can be

very successful and lead to enrichment and appreciation for diversity. But cultural

misunderstandings in these situations can also impede the process and at worst be detrimental

and impact the relationship between therapist and patient. Such events can have a negative

effect on the quality of the care the patients receive from the therapist (Lee, Sullivan &

Lansbury, 2006).

In the clinical setting poor language communication between PT and patients could lead to

that the patients does not understand advices or given treatment, the PT’s lacking

understanding of patients cultural beliefs could lead to that patients feel disrespected and

refrain from seeking medical care in the future (Lee et al., 2006; Meadows, 1991). The PT

could use the situation to gain further insight in the patient’s cultural explanatory model for

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his or hers behaviour. But without proper education of cultural aspects, the PT could as well

use conscious or unconscious defensive coping strategies:

Assumed similarity, where the therapist tries to mentally minimize the cultural

differences to the patient and ignore them (Taylor, 1998).

Reflecting on the situation with ethnocentrism which means that a person values his or

her culture superior to others and values them thereafter (Leavitt, 2010; Black &

Purnell, 2006).

Generalization and stereotyping are related strategies to mentally simplify the

diversity in our complex world (Leavitt, 2010, p. 28).

Lee et al. (2006) showed in a small study that quality of care provided to non-English

speaking patients by PT’s in Australia could be less due to their perception of the patients.

Researchers stress the need for health care givers to develop understanding of cultural aspects

when meeting patients from a different culture (Chevannes 2002; Jaggi & Bithell, 1995; Lee et

al., 2006; Lundberg et al., 2005). Leavitt (2010) cites Purnell & Palunka (2003) who define a

cultural competent health care giver as:

“A culturally competent health care provider develops an awareness of his or her existence,

sensations, thoughts, and environment without letting these factors have an undue effect on those

for whom care is provided. Cultural competence is the adaptation of care in a manner that is

consistent with the culture of the client and is therefore a conscious process and nonlinear”.

(Leavitt, p.40)

There exist different theories and models for physiotherapists and health caregivers for

developing their cultural competence; The Purnell model for cultural competence, Leiniger´s

Sunrise enabler for the theory of culture care diversity and universality, Berlin & Fowkes

LEARN model & Stuart & Liebermans BATHES model are a few examples (Leavitt, 2010, p.

41-43).

In this thesis Purnell’s model for cultural competence (Purnell, 2002) will be used.

Purnell’s model is a patient centred holistic model divided into 12 different domains

divided into subcategories. He argues that culture consists of both primary and secondary

characteristics. Primary characteristics are: race, gender, age, nationality, and religious

affiliation. Secondary characteristics are: socioeconomic status, level of education, urban

versus rural residence, length of time from country of origin, education, occupation, marital

status, parental status, physical characteristics, sexual orientation, enclave identity and

gender issues. Black & Purnell, (2002) discuss Purnell’s model and argue that

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physiotherapists should aim at three domains: communication domain, Domain of health care

practice and Domain of health care practitioners. Black & Purnell (2002) suggest four steps

for the developing of cultural competence:

The first step is to first notice and evaluates one’s own culture values and ethnocentric

view of life. The physiotherapist needs to put reflective effort to recognize these, as it

is almost impossible to identify miscommunications and personal bias without

reflection of one’s own.

In the second step the professional seeks information about the patient’s cultural

values that could be relevant to ease the cross cultural clinical meeting. Learning some

basic skills in verbal and nonverbal communication, studying general research work in

this field as Purnell’s model and/or other theories to gain further knowledge.

The third step is to learn to value diversity and not just accept them between cultures.

The therapist must learn to respect other cultural viewpoints and even appreciate the

opportunity to gain knowledge from patient’s culturally outlook.

When the therapist reaches the fourth step he or she is ready to apply gained cross

cultural skills in action. The therapist can rely on his or her professional judgement

and line of action in clinical practice and at the same time incorporate it with the

cultural beliefs that the patient possesses.

As our world globalizes the exchange where health care givers tries to contribute in

developing countries will increase. In 2002 eight Australian physiotherapy students conducted

a one week clinical practice visit to Jamaica. Five months after returning home the students

described their experiences as: Receiving an expanded world view, expanded worldview for

physiotherapist practice, change within themselves and as physiotherapy students (Sawyer &

Lopopolo 2004). Similar experiences have been shown when health care givers practicing

abroad (Higgs et al., 2008, p. 467; Leavitt, 2010, p. 189; Humphreys & Carpenter, 2010;

Sandin, Grahn & Kronvall, 2004; Tesoriero, 2006; Walsh & Dejoseph, 2002). Gained cultural

understanding, awareness, cultural competence, recognition of one’s own ethnocentrism,

reflection on one’s own cultural values has also been experienced (Humphreys & Carpenter,

2010; Sandin et al., 2004; Tesoriero, 2006; Walsh & Dejoseph, 2002).

The tales of own experiences from physiotherapists contributing overseas remain

insufficient according to Humphreys & Carpenter (2010). Norris & Allotey (2008) stresses

the need for studies on the impact practicing physiotherapy has on the therapists themselves,

they also request more detailed ethnographies of physiotherapy practice. An awareness of self

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is an important prerequisite for understanding others, not the least in a new cultural context

(Wickford 2010); in other words, cultural understanding necessitates self-awareness, which

purposes that one should be aware of one’s own existence, sensations and feelings in a

context but not letting them have an influence on people from a different background (Black

& Purnell, 2006).

Aim

As part of exploring my own cultural understanding, this thesis aims to describe my

experiences and reactions when meeting a different physiotherapy culture than my own.

Research methodology

Autoethnography

When placed in India, I choose to use autoethnography as method to study my exploring path.

In an autoethnographic study (AEG), the author tries to get cultural understanding from

analysing one’s own experiences (Chang, 2008). An AEG emphasis on the research process

(Graphy) on the cultural context the research is conducted in (Ethno) and one self’s

experiences (Auto). An AEG study is research friendly and it enhances cultural understanding

of self and others (Chang, 2008). The narratives and open reflections in an AEG could

“promote knowledge translation by inspiring readers to reflect on and re-contextualize the

writer´s experiences in view of how they themselves experience the life and culture of their

surroundings” (Gallé & Lingard, 2010, p. 727).

Context

I conducted observations for seven weeks in the fall of 2010. I was placed in two Private

hospitals of high class in a big city, a teaching hospital in a rural setting and healthcare centre

in the vicinity of the teaching hospital (Table 1). In the hospitals I was placed both in

outpatient settings and in intense care units (ICU). At the teaching hospital, all students had

daily clinical practice exposure in the mornings 9-13 AM and thereafter lectures in the

afternoon. Internal ship students did treat patients all day. Patients there were treated for free

by the students under supervision from Master students and lecturers.

Data was also collected from; a hospital where I was treated for acute gastroenteritis, a

charitable trust located in the big city where physiotherapy practice was a part of the services,

home visits for patients and I accompanied a visit to a Sugar factory to overview working

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conditions.The spoken language was Hindi in the area where the private hospitals were

located, and Marathi when placed in the rural setting.

Table 1. My field placements.

Introducing me

According to Gallé & Lingard (2010), it is in an autoethnographic study necessary to give a

brief introduction for the researcher’s life, so the reader can understand the underlying context

of the author’s presentation of the data. Experiences from the past are connected with ongoing

self-exploring in the present, which forms the result in an AEG (Chang, 2008, p. 140)

I conducted this fieldwork when I was in the last term of the physiotherapy programme of

3 years, where I have experienced a total amount of 20 weeks clinical practice in my

curriculum at a neurological rehabilitation hospital ward, in municipal centre for handicapped

and in a outpatient health care centre. I have had many brief travelling experiences in the

world to different continents, but my dream had always been to combine my profession with a

foreign placement. I thought that a person develops through challenging experiences, and

when I had the chance to conduct this work I became very enthusiastic. I had no earlier

experience with qualitative work, and never heard about the methodology AEG before one of

my supervisors introduced me to the topic. I did not have any preconceived thoughts of what

to expect from India, rather that one of my personal aims were to develop my skills in English

and especially my medical English vocabulary. I also hoped that I would find interesting

information regarding Black & Purnell’s (2002) domains and to develop my cultural

understanding.

Time

duration

Placement Outpatient

clinic

Drop in

arrangements

for patients

Time based

scheduling

for patients

(ICU)

Week 1-2 Private hospital of high class in a

big city

X X X

Week 3-4 Private hospital of high class in a

big city

X X X

Week 5-7 Teaching hospital in a rural setting X X X

Week 6-7 Rural health care centre X X

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Data collection:

I collected data through being a participating observer (Hammersley & Atkinson, 2007) in

the different earlier described contextual settings, using Black and Purnell’s model (2002) as a

theoretical framework. I sometime rarely swapped into being a complete participant as a PT

student and together with other PT’s and students helped treating patients. Often Indians in

the setting treated me as a student rather than a as an observer. The data collected were

scribbled field notes, collected during approximately six hours each day when observing

clinical practice in the contextual settings. The professionals that I observed and interacted

with for the data collecting were: PT’s, PT students, patients, patient’s relatives but as well

other medical professionals as doctors, nurses and dieticians I encountered in the settings.

The observations were subjective reflections based on the impression and emotions I got in

the moment they were observed. I typed out my field notes after every day’s fieldwork on my

laptop and where I reflected on the observations (Self- reflective data (Chang, 2008, p. 95)).

My personal travel journal was as well included into the data collection.

The three Domains used as methodical framework from Black & Purnell (2002) were:

Communication domain

My personal experiences of how I communicated with patients in the clinic and how I

experienced the Indian therapists communication with patients. Which included: Volume of

Speech, spatial distancing, eye contact, body language, conversational silence, nonverbal

communication, arrival punctionality, format for names, physical touch, across genders.

Domain of health care practice

My personal experience of the reactions and the emotions that arose when I encountered

clinical practice with patients that may have had different cultural values of:

How the body works, view of one selves rehabilitation potential in the cultural context

(Individual – collectivistic), explanatory models of disease and disabilities that may differ

from my own, Compliance of the patient (uses religious belief of fate – on selves individual

capability).

Domain of health care practitioners

The experience I get of the physiotherapists status in India, my experience of the Indian

health care culture, the role family members had in the care process.

Data analysis

Once data was collected, I used a qualitative content analysis method to analyze the latent

content of my field notes (Granheim & Lundman, 2003). I read the collected data a first time

to get an overview. After a second reading, I extracted meaning units that shared a

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commonality and that were relevant for the thesis aim. The meaning units were developed

into categories and relating categories were then developed into themes. Recurring meaning

units were not condensated or abstracted as they were already interpenetrated to a higher

logical level due to that they were composed by me. During the analyzing process I shared

reflections and discussed my findings with one of my supervisors during the analyzing

process as a way to achieve trustworthiness (Granskär & Höglund-Nielsen, 2008).

Ethical considerations

PT’s, students, patients and the clinical settings were described in such a manner that the

person’s and the settings identity were not exposed. The personal I encountered in the settings

were informed of the thesis aim and that my notes would be anonymous.

Findings

The analysis process resulted in 5 themes: Reflecting on the structure of the physiotherapy

context, reflecting on the physiotherapy work, Reflection on patient’s in physiotherapy work,

Being in the field and Being a student with minor experience and knowledge.

All my findings will consistent of my observations, reflections and dialogues with Indian

physiotherapists, students and patients. Quotations will be used to bring out an observation or

reflection from my findings.

1. Reflecting on the structure of the physiotherapy context

The theme represents my experiences and reactions of the Indian physiotherapy clinics

working structure in terms of; hierarchy, time disposition, arrangement of patient visits and

my experience of the physiotherapy professions status.

1.1 The working place hierarchy

The hierarchy were in many cases manifest and it was easy to read of hierarchal linage at the

different settings, which I found unfamiliar and exciting at the same time from my cultural

outlook. I was always expected to summon superiors by “Mr” or “Mrs” while working. But

it happened one time that a student called me sir, I reflected upon that as: “Maybe that is

related to my skin colour or that the manager introduced my project in a very good manner

which may have got my status a bit higher” (Field journal 1/11). The working places

hierarchy seemed much more manifest when placed at the rural setting I noticed differences

between students and master students, as master students wore doctor’s coats with long

sleeves, when the bachelor students wore coats with short ones.

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I met different head physiotherapy directors/principals/department heads who treated me well.

It was mandatory for students and physiotherapists to stand up when a person of higher rank

entered the room. When I had been placed at my second private hospital in the big city for a

couple of days I got the chance to meet the head director. I was eager to introduce myself, and

all actions got to a hold as he entered the room. It was my first negative experience of meeting

a person of higher rank. When he got a glimpse of me I burst out: “Hi, my name is Erik the

Swedish physiotherapist student. I don´t get any more space for saying anything else as he

just nods his head and walks on with his inspection” (Field journal 23/11).

The relation and body language between physiotherapists and medical doctors made me

reflect on the ranks between them. Especially when placed at one of the ICU the power

relationship made an impression on me when I and PT was standing in front of a patient that

was lying in a bed connected to a respiratory tube and the PT was examining the patients file:

Two doctors approaches us wearing ordinary jeans and shirts, which I find remarkable as I seen

doctors wear this outfit quite often in the ICU. One of the doctors dresses up with a plastic

chaperon and the PT now approaches the doctor with a humble body language and starts to talk to

the doctor with a inferior voice tone in Hindi. The age difference between the two could almost be

the double and the PT seem to suggest something and the doctor looks at the patient and nods his

head and does not look that much at the PT. (Field journal 11/12)

1.2 Disposition of time

The working hours consisted mostly between 9-17. For an outsider it took some time to get

accustomed to the time for lunch. When attending the ICU in one of the hospitals the working

schedule was a bit unfamiliar with what I have been accustomed too:

We left the PT reception 9 AM for the ICU. Around the time of 10:30-1100 all the PT’s has treated

their patients, all together it could be around 4 PT’s. After that we all go to a locker room where

we sit and relax. The PT’s and students discuss patient cases and discuss a big variation of topics

in very a familiar mode. They are very interested in me and want me to tell things about Sweden

and want me to sing in Swedish! The same PT that told me that he had working hours between 8-16

told me that he has to get up at 05 AM every morning to attend home visits for some patient; he has

different home visits after working hours and estimates that he reaches his apartment around 9-

9:30 PM every night. I could not believe what he was saying but another PT told me that she

usually gets home around the same hours. We are just sitting there till it’s time for lunch at 1.30

PM. After the lunch it’s time for another coffee and we go up to the ICU again for a second round

at around 2:30. So we had a lunch break for around 4 hours one could say. Today it was extreme

but the same pattern of time disposition has not been unusual earlier days here. (Field journal

11/11)

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1.3 Arrangement of patients visits

In one of the outpatient clinics I was placed the staff regulated time scheduled visits for the

patients. On the two other outpatient clinics they used a drop in system so the patients could

come for a visit any time of the day. The two different systems had an impact on the working

structure as where drop in systems were practiced it often emerged situations where the PT’s

and students did not have any working tasks. When placed at the rural health care centre I was

told that PT’s and students were trying to arrange patients to come at time scheduled

appointments. But the arrangement was hard to manage due to that patients showed up

anyway whenever they felt like it. The visits were connected to doctors referring and when

earlier visitors felt that their pain aches became unbearable so it was worthwhile to come back

and receive treatment.

When attending the hospital that had arranged time schedules I had discussion with a

student that valued their system. I was not aware at the time that it could exist different ways

of schedule patient meetings so I did ask him how it could be arranged at different clinics. His

answer was judgmental: “In places where there exists a drop in system, it is much harder for

PT’s to prepare themselves for the meeting” (Field journal 4/11). An underboss told me at

the clinic that it was okay for patients to arrive 30 minutes late to an appointment and that’s a

big difference between the health care cultures of India and the western world (Field journal

4/11).

1.4 Status of the Indian physiotherapy profession

There existed a discrepancy between my view of the Indian physiotherapists status and the

experience that students had about their own profession. I was from time to time admiring the

Indian physiotherapist’s status. When looking in my field notes I reflected: “It feels really like

that Indian physiotherapists has more power than Swedish ones when they are using the

medical doctors guilds seal: the stethoscope” (Field journal 9/11). When observing that PT´s

and even students were allowed to conduct extubations and intertubations in the ICU I was

full of awe I had not heard that Swedish PT´s were allowed to conduct such operations. I also

made a note about the dress code that Indian PT´s wore at all most my working locations.

Male personal always wore formal pants, black shining leather shoes and a shirt under the

white doctor’s coat. One therapist told me that the dress code was an advantage as it could

signal their status and that the patients would find them more professional.

In dialogue with some PT students they were not that full of confidence regarding their

status. Some students connected their low self confidence in their status to a understanding

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that the majority of the population was not aware of their existence or services. When placed

at the rural healthcare centre the internal ship student treated many pregnant patients and I

afterwards gave her credit for her dedication. She motivated her dedication was to give the

patients a good impression of physiotherapy: “Ha-ha, Butt these patients do not know

anything about physiotherapy, so of course I do want to give them a good impression of it so

maybe some of them can spread the word to their friends” (Field journal 20/12).

2. Reflecting on the physiotherapy work

This theme represents my findings from treatment situations, cultural differences in Indians

handling of patients, views of the usage of treatment modalities and Indian students

knowledgebase, self-confidence and my views on the Indian curricula.

2.1Treatment situations

Common was that wherever I was placed the patients were training in the treatment rooms;

Squats, balance training, training against PT’s physical resistance, training active exercises

lying on the plinth beds etc. I observed and reflected upon a couple of situations where the

training was not focused on to get the patient fatigued or conducting repetitions to failure, the

assessment was more like passive treatment. Usually physiotherapists gave the counterbalance

for the training as the clinics holding of and the usage of strength training machines were not

that common.

I found the element of using cell phones by both students and PT’s quite extensive at both

hospitals in the big city. In the rural setting it was prohibited and at one of the hospitals in the

big city too I think.

Wherever I was placed in India, I observed that many students and PT’s counted every

single repetition in each set, which I in the beginning of my fieldwork found very professional

as it signalled that the caregiver putted a commitment for the patient. But in the longer run I

noticed many situations where the counting could be a disadvantage when the caregiver

counted the repetitions with an uninterested voice tone. The worst case I reflected upon

happened when a PT supported a patient’s standing hip abductions in a treatment room:

The PT sits in front of the patient with sunken in posture and supports the patient’s movements without

any dedication; it looks like he holds his hand over the hip if the patient would lose his balance. After

a while the PT grabs his cell phone and starts to send text messages but still counts the patient’s

repetitions, I have never heard a PT count repetitions in such a drowsy non caring manner. (Field

journal 23/11)

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There were situations in different outpatient clinics that I found unfamiliar from my Swedish

outlook when PT’s conducted different interventions with patients when a mass of people

were observing the situations. In one situation for instance when a neurological patient

conducted gait training through the main hall at the clinic there were 15 persons staring at this

person when he took his stumbling steps and after a while lost his balance so the near located

protecting PT’s got him on his feet. I reflected “That I would never put my patient in such an

awkward situation in Sweden” (Field journal 2/11).

2.2 Different views in treatment modalities

In the first two hospitals I observed that it was very common to treat patients passively with

Interferential, Ultra sound and manual techniques as mobilizations and stretching.

In the teaching hospital at the rural setting it was like ways with a big focus on joint

mobilization and manipulations. Many PT’s and students were interested in what kind of

modalities we treat or patients with in Sweden and which were the differences between what

kind of treatment we gave our patients compared with the ones given in India. I discussed all

these matters with students and PT’s under numerous occasions:

Student: Which is the biggest difference between our healthcare cultures in your opinion?

Erik: Physical training, we place bigger emphasis to let the person rehabilitate them self more

individually in a gym under supervision and follow-up´s for example, you focus more on passive

modalities such as interferential and ultrasound.

Student: Yes, it seems that in many parts of the world physiotherapy is done in that way. In these

countries people are aware of ultrasound and interferential effects. Here are people just happy if

we connect them to a blinking machine…

Erik: I think that most Swedish patients are happy to get passive treatment, but my experience is

that Swedes are bit more compliant to given training programs.

Student: if we give patients programs then 90% of them will not follow them. (Field journal 23/11)

One time when I am discussing the differences with a student when a patient is being treated

with interferential at the time, another student enters the room:

Student I: I think that mobilizations are great. They are effective and the patient thinks that you

have done a miracle afterwards.

Student II: I don’t know.. Of course they believe that they are a blessing for starters but then they

return to us and believe that they should not do anything for themselves to get better.

Stud I: But we have to do them, because they work.

Erik: I think that the best would be if we Swedes would focus a bit less on training and do a bit

more mobilizations and that you Indians focus more on training and less on mobilizations.

Student I: It sounds great, but I do not think that will work practical. Patients are not motivated for

training, at least not here… (Field journal 10/12)

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2.3 The Indian physiotherapy program and students performance

The Indian physiotherapy programme is 4 years long plus 6 months of internship.

Their master program is 2 years long, but a PT told me that there were on-going discussions

about prolonging it to 3 years. I became jealous of their extensive curricula compared with the

Swedish bachelor one of 3 years. When placed at the teaching hospital, one day I was sitting

together with a couple of first or second year students and observing gait training for a

neurological affected patient who was supervised in the training by internal ship students and

Master students. Suddenly he lost his balance and fell on the training track:

All 15 persons in the Ward now switched all their focus on the patient. The students that are sitting

in their benches look curios and astonished. The supporting master student and two other minor

students do not look dejected but rather try to cheer the patient up.

Reflection: It struck me that this must be a priceless opportunity for minor students to observe gait

training for a neurological affected patient and to experience the dangers of things that can go

wrong. The students can experience this actually before they study neurology in their curriculum,

amazing! (Field Journal 9/12)

In most situations I felt that the Indian student’s knowledge was superior to mine both in the

big city and at the rural setting, Especially in ICU settings. I noticed that students had superior

knowledge of many manipulation techniques that I had never seen, the students had

knowledge of surgical operations and many times in my field journal I noted the students

were able to evaluate x-rays. Time after time Indian students showed skills in self-confidence

towards patients. Showing no signs of being nervous towards patients in the ICU, outpatient

clinics, rural health care centres or in situations where they have to perform workshops in

front of fellow students.

In discussions with students I realized that different cultural aspects affected their coming

carer options. The family played a big role in the choosing of the profession. One student told

me that she would go for masters directly after bachelors due to that in India it is expected

that persons get married early and are after that expected to have children. All impressions of

the students’ knowledge base and the arrangement of their curriculum led me to start

reflecting upon and questioning my own, after my first week placed at an ICU I reflected:

“The knowledgebase that the Indian physiotherapists and students possess in respiratory

physiology is just crazy. When they discuss it in Hindi it sounds like a Dr. House episode and

I just want to melt through the floor and disappear” (Travel journal 20/11).

I had a discussion with an internship student at the rural setting regarding my view of what the

Indian curriculum consist of in relation to the one I have received in Sweden:

19

Intern: How was your experience at the ICU?

Erik: I do not really know what to say… We don´t have that big focus on ICU practice in our

curriculum. When I was up there (The ICU) I could only depend on a basic course of physiology

and one foundation course in respiratory training. But for example I did see a patient that was

unconscious, and they (the PT’s) asked me how I could treat such a patient. I did not have any clue

as we are not taught how to auscultate and conduct suctioning’s. I do know how to conduct

contracture prophylaxis to obstruct contractures and venous thrombosis and how to treat a wake

patient in some degree, but with an unconscious patient I really don´t know…

Intern: But how and when do you meet your patients then?

Erik: Not like you that have the opportunity every day. We have 1,5 years theoretical practice

thereafter 10 weeks of clinical practice and after one more term we have more 10 weeks more of

clinical practice.

Intern: And no internal ship?

Erik: Correct, one is sort of scared to face a patient after 1,5 years without hands on. I feel kind of

irritated over our current curriculum that lacks your extra year, radiology, pharmacology, internal

ship, opportunities to get Maitland and Mulligan as well from Kaltenborn. Our curriculum as I feel

when I´m here just sucks.. (Field Journal 23/12)

3. Reflection on patient’s in physiotherapy work

This theme describes findings in cultural disabilities and patient’s compliance to

physiotherapy interventions.

3.1 explanatory models for diseases and injuries

The only common disease that I experienced was connected with Indian lifestyle were Knee

Osteo Arthritis (KNO). It was by superior the most common musculoskeletal disability that I

did meet in the clinics.

The reason KNO was that common could be explained by Indians cultural Daily living. They

squat a lot when standing still, when using the toilet, sweeping the floor etc. When discussing

cross cultural explanatory models of disabilities with a student I got to know that Indian

squats when attending religious activities, and that could as well predispose KNO or affect a

present condition as one student explained: “I tell the them not to squat, but they do it any

way when they pray in the temple, and to give priority for non squatting as they will not be

able to appreciate the praying ceremony squatting due to the pain they get in that position”

(Field journal 10/11).

I tried my outmost to find patient cases that could have different explanatory models to

their diagnosis rather than the western medical model, but it became clear that the all the

patients I encountered had similar explanatory models as I have experienced from Swedish

patients. When discussing these topics I got some second hand information from PT’s and

20

students that relatives to psychiatric patients for example could believe that the relative’s

condition was a curse.

3.2 Compliance

I found different factors that affected patient’s compliance for return visits at the clinic or

given training programs. In some PT’s and students view I got the image that many patients

were not eager to follow training programs and expected to receive passive treatment. As one

PT putted it at a private hospital: “If we do not give them passive treatment they will not come

back. We could give the thousands of exercises but it is…” (Field journal 22/11). At the rural

health care center the internship student explained that there are many patients that come to

her just to get treatment by the short wave therapy machine (SWT). She explained a specific

case for me:

Intern: You maybe did notice the patient that did get treated by the SWT machine and there after

just left?

Erik: Hmm, maybe…

Intern: I did tell her to get seated afterwards but she just left.

Erik: Do you not get frustrated by this?

Intern: They say that they are only here for the “Shajke/heat” (My translation). After that they

think that everything will be alright, they only come here to get treated by the machine. (Field

journal 15/12)

I found that patients socioeconomic status was a factor for the regularity of patients return

visits. I got impressed that the patients could have return visits roundly 5-7 days per week at

the outpatient clinics in the big city. I did meet the backside of this system when placed in the

rural setting, I heard about situations from PT’s where patients appreciated physiotherapy

treatment but choose to not come back due to that they could not afford the given treatment. I

discussed this issue with an intern at a private outpatient clinic which increased my

understanding:

Erik: I have been curious about how it is possible for your patients to return for visits like 3 to 7

days per week. In Sweden we are just happy if we get our patients to the clinic for let say; 3 days a

week even considering the fact that we have free health care!

Intern: It depends on what kind of treatment that the patient needs, my patient here for instance

need treatment almost every day. But we have patients that return here every day even though they

do not really require it.

Erik: If I give you a Swedish patient for example, let say that he is 35 years old and are full-time

employed worker. The guy could lose a lot of working hours if he would come to us every day…

Intern: Yes, but here does their insurance cover the lost working hours for visits!

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Erik: Oh, well that explains everything. The puzzle starts to fit. It sounds terrific that you have this

system.

Intern: No! It´s really not. All persons who can afford the insurance gets their treatment paid. But

think of the lower classes, they do not get any quality treatment at all.

Erik: Ah, good point. (Field notes 24/11)

4. Being in the field

This theme concerns the different feelings that emerged when conducting an auto

ethnographic fieldwork in a different cultural clinical setting. They evolve around the

frustration and powerlessness I could feel over my thesis and the role an observer, fear of

losing face, senses culture shock and ethnocentrism when facing different cultural values in

the clinic.

4.1 Emotions of frustration and powerlessness

As I did attend a big diversity of different clinics and departments when conducting my

research I had to learn the working schedules, names of important persons, dynamics of the

working place, explain the aim for my thesis for PT’s and students, get new friends etc. In the

beginning of this process people were a bit questioning and curious of this new foreign person

walking around with his notebook and writing. There was always a frustrating process at

every new clinical setting that lasted through a couple of days where I could feel the tension

when I walked into a treatment room.

I got frustrated many times over the collecting of data for my fieldwork. As the focus was

to explore my cultural understanding, I did find it monotonic when studying treatment

situations that were very similar to the way we conducted them in Sweden. And the longer in

my research I went, the more frustrated I got. When placed at one of the private hospitals in

the big city I went in to a treatment room and found a PT treated a patient’s back problem

with interferential. Upon this situation I reflected: “Fucking interferential” (Field journal

23/11). It emerged situations where all treatment given in the clinics were passive by different

modalities which could lead to that there were periods for 30-60 minutes where I did not have

anything to observe. I reflected upon these situations with frustration over my fieldwork:

“To observe a physiotherapists dialogue with a rock would give me more information than this. I

am extremely bored and my anxiety is slowly creeping upon me, how in hell will I be able to stand

this to 3 PM when the clock is only 10:20 AM?” (Field journal 24/11)

Many times I felt powerless when trying to explain my research topic to Indians. Even though

many Indians did not seem to be accustomed to qualitative research method or what I was

22

doing, they showed me a lot of hospitality and respect. In my reflections I noticed that I

sometimes just resigned my confidence regarding my fieldwork. For example a middle boss at

one of the ICUs in the big city did not clearly understand my research topic when I tried to

explain it for 5 minutes. But afterwards I just reflected that “He seems a bit doubtful that I can

understand” (Field journal 9/11).

When observing in treatment rooms when PT’s and students were not aware of my

research topic, I could feel the tension arise. If it was a situation where there was no room for

me to explain my topic I could just leave the treatment room and wait for a better opportunity

to explain my intentions. In one situation when I failed to do so, it led to an awkward

situation. Afterwards I reflected:

This whole tense situation became partly due to miscommunication. When I sometime come lurking

behind the veil PT’s and students just goes into a defensive mode, which of course is all natural

when a white guy shows up with a notebook and starts to make paragraphs. When these kinds of

situations emerge I just get more frustrated, insecure and irritated to ask more questions. But the

majority of the situations is not like this luckily. (Field Journal 8/12).

4.2 Fear of losing face

The most common situations that got me anxious were when there was a possibility that I

would seem stupid or could lose face. When conducting a thesis that is very hard to explain

for others, alone in a total new culture, alone in a working place where you want to show

yourself from your best side there is a lot of situations that provokes negative emotions and

stress.

In one situation I was sitting and observing a treatment situation at the ICU in the big city

where two PT’s and one student treated a patient. Suddenly the middle boss asks me in a

kindly manner:

PT: What are you writing there Erik?

Erik: Eh.. I´m writing on the situation where you and the other PT’s were acting friendly and

joking around like a big family.

PT: We actually had a discussion regarding a patient’s progress. We tend to have these kinds of

discussions 30 minutes in the mornings to see what we can do better.

Erik: Okay Sir, I did actually write that down.

After this treatment we go away from the patient and they seem to discuss the case, I really

hope that I will not get a question, but he then the middle boss asks me:

PT: We just discussed intracranial pressure and which factors that affects that. What is your

opinion?

23

Erik: Ehm… When you get a wound to the head and blood starts to pour and flow…

PT: No, You study this and we will discuss this tomorrow, ok?

Erik: Yes sir.

Reflection: In this situation I felt totally humiliated in front of the middle boss, the other PT’s and

students which stood there. I do know that he did not want to wish me any harm but you just feel

stupid and scared when you can’t meet the expectations. (Field Journal 10/11)

In some cases PT’s thought of me as an ordinary student and treated me thereafter. There

emerged situations where PT’s wanted to test my clinical knowledge which frightened me.

When standing in the reception at one of the outpatient clinics in the big city one of the PT’s

suddenly asked me:

PT: Erik, Which are the insertions of the anterior cruciate ligament?

Erik: Em… to the medial femur condyle…or… (Feeling really scared)

PT: (Interrupts). Maybe you can study until tomorrow and give me the answer?

Erik: Not to be rude mam, but I am not here for this kind of purpose. I am placed here to collect

data for my bachelor thesis.

PT: But this is basic knowledge that you learn in your first term that you should know. Can you

please do this little homework for until tomorrow?

Erik: Yes mam. (Field journal 8/11)

After this situation for the remaining time of my research I was sometimes afraid to ask PT’s

about information regarding patient cases that could ease my understanding of them. When

asking questions I showed a weaker side of me and I was scared to lose face and get more

homework which I did not have time for. My strategy was thereafter to choose wisely which

PT’s or mostly students I did observe treatment situations with so I could feel comfortable.

Students had a tendency not to test me for knowledge, and be more open minded if there were

situations I did not get the total extent of.

4.3 Senses of ethnocentrism and culture shock

There were a couple of situations where I thought the Swedish healthcare culture and

physiotherapy practice was superior to the Indian one. As when I met a 90 year old man in a

treatment room who according to him had come almost daily to the same clinic for 9 years to

get passive treatment for KNO and some other muscular - skeletal diagnosis. The patient told

me that his interferential treatment did only help him for a couple of hours and for me it

seemed crazy to let a patient come receive similar treatment for over 9 years. I reflected:

Should this kind of treatment not be considered as a defeat for a health care system? (Field

journal 25/11). Something that I did react to the most was passive modalities. When placed in

24

the big city I saw many PT’s treat patients with Hot Wax surrounding different joints. After a

while I could not bear myself and asked a nearby student what this kind of treatment was for:

Student: What? You don’t use this kind of treatment? It´s a superficial warmth treatment. You pour

on the Wax and let it become numbed.

Erik: Okay, so for how long do you treat the same patient with this technique?

Student: Around 10 minutes so it could become totally numbed.

Reflection: Holy shit what a lousy treatment this Wax. In that case, I could as well place the patient

in front of hot fire or in a sauna. But I have to obtain myself here and not get to ethnocentric. I

have to realize that Indian patients and PT’s do not see anything wrong in these treatments and I

have to try and adjust myself to their methods. (Field journal 24/11)

One example which affected me the most was when I, a lecturer and a couple of student did

visit a sugar factory in the rural setting. The working conditions for the workers were rough

from my perspective. In discussion with the lecturer I got my physiological outlook

challenged when realizing that it seemed impossible to change the workers working-

conditions to the better and realizing that these conditions were allowed in Sweden roundly a

century back. In another situation at the rural setting I discussed with a student regarding her

patients understanding of Pilates exercises. Her reasoning stunned me at the moment:

Student: Do you like Pilates?

Erik: Yes I do

Student: Have you tried it?

Erik: Yes I have, but only training on the ball, not the whole concept.

Student: Ok, We have some difficulties to give this kind of exercises to patients because their IQ is

not that high.

Erik: I see…..

Student: yea, they are not that educated, so they do not understand that well due that their IQ is

low.

Erik: Yes, if you are not that well educated I guess it´s hard to understand that kind of exercises.

Reflection: It sounds frightening when she sort of generalize that a selection of patients here has

low IQ. But maybe she meant something different due to that she did not talk about it in a

depreciative manner. She maybe connects low IQ with low education. (Field journal 9/12)

5. Being a student with minor experience and knowledge

The theme represents how my lacking working experiences, language skills and clinical skill

could lead to misunderstandings and feelings of being misplaced in the research context.

5.1 Confusion of languages and lacking clinical knowledge

There was a big diversity of situations where I did not understand what Indians were trying to

communicate to me for multiply reasons. Hard Indian Dialects/accents, to high speed of the

25

output sentences, my lacking knowledge of English when translating English medical phrases

to Swedish, and my lacking English vocabulary when trying to communicate the translated

message. Seldom were there only one of these reasons that affected a situation, rather was it a

mixture of them together at the same time. Most situations where I had a hard time to

understand a situation were at the ICU due to my lacking experience and knowledge from that

field. In other cases my delivery of sentences or Indians lacking of interpenetration of my

dialect or grammatical formulation was the problem, but sometimes I could not really figure

out in where something had gone wrong in a situation. As an example one time at a ICU a PT

and a student had ambulated a patient to a chair, it was clear that the person would need help

to get back to his bed after sitting in the chair. But after the patient was ambulated we just left

the department so I did feel that I needed to ask him if we would help him back to the bed:

Erik: But, will we ambulate the man back to his bed or will the nurses take care of him?

The answer I got was that the PT here was responsible for motor functions at this hospital, and

asked me if that was not the case in Sweden.

Erik: Yes, it is like that. (I slowly repeated my question)

After that they still did not understand what I meant and was looking at each other a bit skeptical

and an awkward silence arose. After that I did let go of my inquiry. (Field Journal 10/11)

They biggest factor that affected interpenetration of situations was the local languages Hindi

and Marathi. PT’s and students did though a marvelous job with translating for me in such

situations to ease my observations.

Many times when I did not grasp the whole scenario, I was too shy to ask again as I did not want to

show myself stupid. In a situation at an ICU the PT walks to a bed where a patient is lying awake. The

PT takes a firm grip around the patient’s chest and says some words in Hindi that I supposed was

meant to calm the patient, before he started to mobilize the patient’s lungs with his hands. Afterwards

he explained to me what she was doing with the patient, but I did not grasp fully what he was saying

due to the Indian dialect and as I did lack the clinical knowledge to understand the clinical course of

events that just had happened:

PT: His condition was a lot better than I thought. He has a done a test for *********, okay? The

patient has secretion in the lower low ******. I have concluded that and his general condition

have been stabilized.

Erik: Did you conclude that by palpating his lungs?

PT: No, with x-ray, auscultation, and a ***** machine.

Erik: Okay (Field journal 9/11)

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5.2 Feeling misplaced

When placed at different ICUs I sometimes really felt misplaced when observing PT’s and

students working at a higher knowledge level than me. I had a bad conscience over lacking

clinical knowledge when observing in that clinical environment. For example I followed a PT

to a bed where we find a patient which seemed to have big troubles with the breathing:

The PT keeps eye contact with the patient while palpating the lung and seems listening for

his breathing. Sporadic the both of us look at the cardiorespiratory values at the monitor. I

do really feel misplaced when I only understand 2 of the 4 values on it and not a single

word of what the PT and patient are discussing. (Field Journal 5/11)

There were a lot of situations that I failed to grasp the content of. I felt misplaced in these

kinds of situations as I could not see and reflect upon what everybody else in the situation

seemed to understand. In one situation a patient in the ICU had electrodes placed at his

stomach which led to a machine that printed out paper which seemed to show the ECG. A

man stood at the patient’s side analyzing the paper that was printed out. Suddenly the person

turns to the patient and slaps him in the face a couple of times and says something dramatic in

Marathi. I did not grasp the intention of this, maybe he was fainting. Upon this situation I

reflected: “Everybody else standing in the near area does not seem to notify this situation as

anything special and must understand the reason for the man’s behavior. I do feel unsafe and

stupid when I can´t understand the logics of these kind of situations” (Field journal 22/12).

Other times when I was new at a department and did not know anybody there, the personal

did joke around with each other while I just stood there trying to seem relaxed but inside I just

wanted to melt through the floor.

5.3 Trying to enhance communication

While conducting my observations I slowly realized that the work that PT’s conduct is not totally

based on what we say to patients but rather on what we do with them manually in treatment situations.

That eased my observations when I did not understand the language as I could almost always grasp

something out every treatment situation given by just observes nonverbal communication. I found that

all these factors could give me understanding of a happening scenario and of what the verbal

communication between PT and patient could be about. PT’s and students mostly used English terms

when discussing and explaining treatments modalities and diagnosis for colleges and patients, the

English words used became a frame for me to rely on for understanding the rest of the happening

scenario.

27

In the beginning of my observations I did not have any Hindi vocabulary but as I did observe

countless of treatment situations, I did find recurrent phrases in given situations that I started to

interpret. I remember the first time in a treatment room when did understand a single word without

asking any Indian: “The patient is instructed to turn to her side and conduct abductions. For the first

time I did understand a treatment related word in Hindi “Turn to the side/Cawert, a breakthrough!”

(Field journal 4/11).

As this situation did take place in the early stages of my observations I did believe that I would

make huge progress in learning Hindi, which later would show to be a difficult task. I always wanted

to learn as many Hindi and Marathi phrases as possible because I thought it was my obligation when

conducting this kind of field work. Indians response for me trying to speak the local language was

always received with most happiness; laughter and encouragement.

But it was still very hard to learn new phrases as all my mental energy was focused on writing down

my observations and I was almost all the time flooded with different impressions and feelings, which

made it hard to squeeze in more information. A situation where I did ask for a translation for the word

“Exigoo” explains the dilemma:

Erik: What does that mean?

PT: Do it again or properly

Erik: Exigoo, do I pronounce it right?

PT: No, Exigoo

Erik: Exigoo

After some tries he starts to giggle his head as all Indians do when they have received a

situation/shown their acceptance/ their interest. It is always hard to learn new phrases; the whole

experience of my work here at the hospital is in itself extremely intense. To learn all the new

phrases I would need a clone that was solely focusing on this. (Field Journal 24/11)

At the end of my observations I could notice that I started to write some phrases in Marathi

instead of English or Swedish automatically. My subjective reflection was that I got much

better at understanding given conversations. I conducted an experiment when placed at the

rural healthcare center to see how much I could interpenetrate of a situation when a patient

entered the treatment room and got down on a chair in front of the interns desk:

The patient points to his arm, and I realize that this patient suffers from some sort of radiation.

Intern says “OK/Tekee” and looks at the patient. The patient starts thereafter to give his story

regarding his case. While he does so the intern writes the journal, asks question to get a picture of

the case, the patient continues to give history, the interns comes with a following question which

patient answers “No” on. Intern **** “Does it hurt/Dukta?”. The patient continues his story. I get

that the Intern asks if he has received any PT treatment before. The Patient answers hesitatingly:

Emmm.. Nooo. *** Massage?

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Intern says No, and starts to give a small explanation about the cornerstones of physiotherapy: She

mentions “pain/Dukta” for the movement generating organs, after surgery, she mentions

something about dentists which she speaks pretty long about.

After this situation when the patient had left I asked if my interpenetration was correct by reading

my field note for her. She conquered and explained that the reason she mentioned dentists was that

physiotherapy has not existed that long in India and she gave an example by saying that dentists

once upon a time was a part of the medical doctors profession. It was the same with PT’s as we

were a part of orthopedists. (Field journal 21/12)

Discussion

The analysis process resulted in 5 themes: Reflecting on the structure of the physiotherapy

context, reflecting on the physiotherapy work, Reflection on patient’s in physiotherapy work,

Being in the field and Being a student with minor experience and knowledge.

Findings discussion

Reflecting on hierarchal systems and time disposal

When first observing the clinics drop in systems and usage of time at some of the ICUs I did

reflect upon them as unfamiliar and ineffective. It emerged big gaps in the working schedule

where the staff could just sit and chat and relax for long periods where I felt that they wasted

their working time with an ethnocentric outlook. In later stages in my research, it struck me

after reflection that Indians time arrangement is maybe not the problem; it could as well be

the Swedish/western arrangement where we constantly keep working and just get burned out

syndromes (Felton, 1998). Research has shown that levels of experienced burned-out

syndromes can vary between cultures (Etzion & Pines, 1986). The long lunch breaks were

partly used for the personal to discuss patient cases to share and gain knowledge as I

interpenetrated these situations. Deeper reflection and reasoning regarding these issues can be

seen as a step to develop physiotherapy practice (Higgs et al., 2008).

I found it difficult to call master students who were not that much older than me Mr. or

Mrs. and to see that the higher ranked persons in the clinic was treated with much more

respect than from my experience in Sweden, Cushner & Brislin (1996, p. 312) supports that it

can be hard to initially comprehend a new working cultures characteristics. By just staying at

the rural setting for 3 weeks I could see the teaching hospitals hierarchy´s pyramid from top to

bottom; Student-Masterstudent-Lecturer-Principal. On the contrary I have not been able

identify the pyramids linage at my Swedish University in 3 years. The differences in the

working organizations are explained as power/distance (Hofstede, 2001). Where working

cultures that has high level of power/distance has more manifest readable hierarchal working

29

structures, and structures with a low level supports equality and hierarchy’s are rejected and

therefore unclear (ibid). With time I learned to accept these differences when remembering

that Swedish working places had the same working place hierarchy just a few decades back in

time (Lindgren, 1992). Evaluating one’s own ethnocentrism, personal values and beliefs

(Black & Purnell, 2002) is an important step towards cultural competence and helped me to

increase my own cultural understanding in this matter.

Reflecting on my changing understanding of physiotherapy work

When observing many treatment situations, I gained cross-cultural clinical knowledge in how

Indians PT’s received and treated their patients that will be useful for me along my future

career. The treatment characteristics had a lot in common with how we conduct clinical work

in Sweden as the physiotherapy profession is closely aligned with the biomedical framework

globally (Norris & Allotey, 2008). In the early stages of my fieldwork I did feel unpleasant

towards situations where patients could lose face. But after experiencing a couple of these

situations at different clinics and looking at affected patients in the situations, I did realize that

they did not seem to mind being out watched and exposed. I started to understand that only

because it would be embarrassing for a patient to experience this kind situation in Sweden

must not automatically mean that it should be the same way in India. I reasoned in the same

way regarding the usage of cellphones as I did not see any patients seem to mind the usage.

One must learn to try appreciate and respect diversity (Tesoriero, 2006; Black & Purnell,

2002). I realized that I needed to try to change my own cultural outlook on things even though

it was hard, as a voluntary physiotherapist placed in a developing country putted it:

“Acknowledging that, at the end of the day, I´m a foreigner, and people in Tanzania do things

differently to the way I would do it, and it´s me that need to change” (Humphreys &

Carpentener, 2010, p.154). With change I do not mean that I tried to erase my own values or

beliefs for the Indians way of doing things, which is called assimilation (Leavitt, 2010, p.52-

53). This new perspectives was rather adapted like an extra tool to my cultural outlook

(Tesoriero, 2006).

One of the hardest cultural dilemmas for me to accept in the clinical settings was the

extended usage of passive treatment. In the Swedish curriculum we are thought that the

patient should take an active role in the rehabilitation, and by scientific articles that the

evidence grade for passive modalities as thermal and electrotherapy are moderate and low for

example long-lasting pain and neck pain (Gross et al., 2008; The Swedish council on

technology assessment in health cares, 2006). Initially I did react emotionally with frustration

30

and an ethnocentric feeling that the Swedish curriculum was superior to the Indians on this

point. I although remembered that when tension arises in a cross cultural meeting, this can be

a sign that your own cultural values are being challenged (cf. Taylor, 1998).

Over time after many discussions with Indian PT’s and Students I slowly realized that the

matter was more complex due to patient’s expectations to receive passive treatment and their

lacking motivation for exercises. It seemed that the patient’s expectations or cultural belief of

what physiotherapy should consist of, was a factor that affects their compliance. PT’s

delivering of exercises programs to strengthen patient’s individual participation in

rehabilitation can seem unfamiliar in many cultures (Black & Purnell, 2006).

I gained a cultural understanding for the complexity in this matter and learned to emotionally

tolerate it. But to appreciate and value the difference according to the third step in Black &

Purnell’s model (2002), I did not. Discussions regarding these topics were always giving to

both me and Indians as it led to that we had to reflect on the differences we have had between

our cultures and ask ourselves why it was in that manner. It led me and hopefully Indian PT’s

and students to get new perspectives about physiotherapy and helped us to “learn from one

another and grow” (Black & Purnell, 2006, p. 95). Wickford (2010) reflects on her own

experiences:

“As Afghan and expatriate physiotherapists work together, they will impact each other´s views on

what it means to be a physiotherapist, but also their interactions will impact the view of the own

culture and context, and they will participate in these in a new way”. (p. 25)

When first entering the field I got impressed of the students self-confidence and knowledge

base, PT’s fancy clothing wear, PT’s and students being able to perform surgical

intertubations and use stethoscopes. But as my field work progressed, I started to reflect on

why I was so impressed of them, and wanted to find a logical explanation to why I

experienced the student’s self-confidence and knowledge base superior to mine. To enhance

my cultural understanding for this matter I started to ask questions and have discussions with

students and PT’s regarding these queries. Wickford (2010) also described that discussions

with the local therapists were invaluable to get a further understanding.

The reason to why I found that Indians had a better self-confidence, could be that they are

more used to act in front of many people due that India is a highly populated country and

wherever you are, you are always surrounded by people. My experience of their bigger

knowledgebase could be found in that their curriculum is 1 year longer than the Swedish one

(Indian association of physiotherapists, 2010), and that they seem to have more teachers led

31

lesson per week. I did feel that students had a bigger theoretical glossary memory than me, as

for example for anatomy insertions which could be due to: either my individual skills were

less, Indian students study harder than Swedish ones due to a higher study discipline or are

having more for follow ups from teachers, different emphasis in the countries theoretical

curriculums or above mentioned reasons affects. My admiring of Indian PT’s surgical

intertubations and usage of stethoscope could be due to my lacking experience from Swedish

ICUs.

When reflecting on this I feel that I moved towards reversed ethnocentrism by critically

questioning my own beliefs and understandings of the Swedish physiotherapy curriculum.

Sandin et al. (2004) states that: “One´s own culture is a frame of reference for comparing and

explaining differences in experience” (p.226).

My preparations for the Indian travel

I did experience sensations of cultural shock and ethnocentrism, but not in such a big degree

that I had expected before travelling. The theoretical knowledge base regarding culture,

ethnocentrism, culture shock etc. I collected before traveling prepared me for the coming

experiences in some degree. For example I reflected upon my own sensations of

ethnocentrism in my field notes. I do think my preparations by gaining theoretical knowledge

of what to expect for the trip acted as a “airbag” when I “crashed” into India, gaining

theoretical knowledge regarding relevant cultural aspects when facing diversity is an step

towards cultural competence (Black & Purnell 2002). But all experiences are subjective. As

an example in a study where eight Swedish nursing students conducted an ethnographic study

individually in a hospital setting in Tanzania, there were different experiences of cultural

shock and feelings of lacking preparations for the trip, although the participants did get the

equal amount of preparations (Sandin et al., 2004).

Being a novice and communication difficulties

My experience of confusion of languages and misunderstandings are not unique, Humphreys

& Carpenter (2010) detected language barriers as a main difficulty to provide sufficient

assessment and treatments. A qualitative study by Lundberg et al. (2005) did find that the

biggest experienced problem among Swedish nursing students when treating culturally

diverse patients were language and communication. Difficulties’ with delivering clinical

sentences in English has been shown to be a problem as well for Asian physiotherapy

exchange students in Australia (Ladyshewsky, 1996). Ladyshewsky (1999) describes the

mental process for the student when translating a sentence:

32

“First the learner hears the question and translates it into his own language. Second, he thinks of

an answer in his own language. Third, he translates the answer to the host language. Fourth, he

has to think about how to structure the answer appropriately using correct conversational

grammar. Fifth, he has to articulate the response”. (p. 166-167)

My efforts to enhance communication by learning basic phrases of the local language are

supported as important tools in cross-cultural communication (Meadows, 1991; Leavitt. 2010,

p. 61). The appreciation I received when trying to learn the local language did Wickford

(2010, p.86) as well experience when conducting fieldwork in Afghanistan, she mentions that

it “can be an important assessment to show interest in the concerned people’s culture”.

Leavitt (2010) states a figure where between 60-90 % of communication is nonverbal, which

could be an explanation for my emphasis on the role the nonverbal language played for my

understanding of the communication given in treatments situations.

There was a connection between my difficulties to have a whole understanding of

treatment situations due to lacking clinical knowledge and my feelings of being misplaced.

Where the answer did not just lie within cultural aspects but in me being inexperienced

clinically or being a “novice” (Jensen, Gwyer, Hack & Shepard, 1999). As novices lack

clinical knowledge and experience they tend use a hypothetico-deductive process to solve

patient cases instead of expert’s pattern recognition (Higgs et al., 2008). I had no possibility to

conduct hypothetico-deductive processes to gain further clinical understanding due to my role

as an observer and had minor clinical knowledge and experience. which made it harder for me

to get a full understanding of situations especially in the ICU where I did not have any

experience from Sweden. In orthopedics departments I felt that I had more knowledge and

experience which led me to have some pattern recognition.

Methodological discussion

When conducting an AEG study it can be hard to separate analysis and interpretation because

the whole process is based on the author’s own subjective experience (Chang, 2008). My own

feelings and emotions had an effect on what I choose as important to analyze and interpret

from the data. Even though I used Black and Purnell’s model (2002) as a scientific frame for

the collecting of data, my role as an observing participant and the outlay of the cultural

context I participated in, had an impact on my arisen emotions and reactions which in its turn

shaped what I chose to observe and reflect upon in my field notes. Hammersley & Atkinson

33

(2007) argues that all ethnographers in the beginning of their fieldwork are novices and has to

face the fact to be an “acceptable incompetent” (p. 79).

The participant observer role the researcher possesses could send mixed signals as for

example when the students got a bit nervous of my impression or when a student called me

sir. This kind of reactions is natural due to as the individuals “Tries to locate the

ethnographer defined in the social landscape defined by their experiences” (Hammersley &

Atkinson, 2007, p. 63). This role led me to get access to many settings as many of the higher

ranked directors wanted me to experience as much as possible of the more positive sides of

Indian healthcare culture. The directors were open minded to me and gave me “their keys” to

access to all different settings where I wanted to conduct my research as they wanted to show

hospitality.

When conducting an ethnographic field work the researcher due to being a novice and the

burden different roles brings can get the researcher to experience feelings of: stress,

incompetence, fear, anger, frustration (Hammersley & Atkinson, 2007, p. 89) and loneliness

(Kaijser & Öhlander, 1999, p. 38). My role as a participant observer had an impact on my

research as my result shows above-mentioned reflections and feelings. My tendency to stick

with students and personal that I felt safe with when being in the field was an unconscious

coping strategy to avoid unfamiliar situations connected with my role as an observer and

student when meeting demanding questions from more experienced professionals. The

coping strategy had an impact on from which situations I collected data in, as I preferred

student based situations before situations where more experienced professionals acted.

Black and Purnell’s model (2002) aims to develop cultural competence for the health care

giver in the clinical encounter, but I used the model as an observation tool and not for its valid

aim when treating patients. Hammersley & Atkinson (2007, p. 81) mentions that preconceived

expectations for the fieldwork can give the researcher feelings of self-doubt and feeling of

betrayal when facing a different reality.

As one of Black and Purnell’s model (2002) aims is to value different explanatory models of

diseases and disabilities, I felt frustrated when the cultural context in India did not give me

that information. This in its turn made me experience even more of the above-mentioned

feelings which colored my results. My findings could have been different if I had prepared for

what it meant to be in an observer role, I could have been able to distance myself from

negative emotions as I would have understand the under laying mechanisms for them.

I switched between more working places and departments than I had planned for when

conducting the research. The switching was logical due to when as I was placed in one setting

34

for a too long period of time, I just felt that I had observed all interesting situations and

collected the information I needed, which made it hard for me to focus on observations. Too

Long placements got me distressed, bored and frustrated and the emotions I felt in settings

where I observed passive predictable treatments is a sign of this (Smith, 1996; Hammersley &

Atkinson, 2007, p. 90-91). This switching although affected my research as I had to face

being “the acceptable incompetent” and “the novice” every time I was placed in a new

setting which added my negative emotions in a vicious cycle. These emotions in its turn

affected my everyday working mood and my attitude towards my research which affected the

type of and total amount of data collected.

I got a broader experience by switching settings, but I never penetrated the depth of any of

them, I could have received a bigger understanding by staying in a setting for a longer period

of time (Hammersley & Atkinson, 2007, p. 31).

As I was placed at two hospitals of high standards, I did meet many English speaking and

well educated patients. My findings may have been different if I would as well have been

placed in the public sector where I could have been faced with more patients of lower socio

economic status, education level and where there were less employed physiotherapists,

lacking of treatment equipment etc.

My findings could have been different if I had travelled with a fellow student from Sweden

that I could reflect everyday observations with. Swedish nursing students placed in Tanzania

shared feelings and experiences with each other as coping strategy to endure the new culture

(Sandin et al., 2004). By traveling alone although I got new friends mostly from the clinical

settings which led me to embrace the Indian culture in faster pace, and I did find my adaption

useful when working in the field as I learned much of the local language and Indian values

and customs at the clinics from them. Travelling with someone could have led me to become

more introvert, Barron (2006) showed that many foreign and international students in

Australia tend not to work or socialize together.

The value of reflection and this experience

By critically reflect on and analyze my field notes I became much more aware of the explicit

meaning of them (Higgs et al., 2008; Gallé & Lingard, 2010; Tesoriero, 2006; Wickford,

2010, p.28). Reflective thinking regarding cultural critical incidents can be seen as a step

towards cultural competence (Odawara, 2009).

35

Murray-Garcia, Harrell, Garcia, Gizzi & Simms-Mackey (2005 p. 654) states that “Reflection

is cultivated when trainees are given opportunity to cognitively and emotionally process---to

reflect on---the social, cultural, and personal meanings of events and life experiences”.

Gallé & Lingard, (2010) emphasis the importance of reflection in AEG research: “The

learning that I gained from each of these experiences arose largely from the reflexive activity

I engaged through Autoethnography” (p. 731).

When conducting this fieldwork I was afraid that I would not have any progression in my

cultural understanding. But I now understand that by reflecting upon my field notes I gained a

understanding. As I have not used any measurement tools to see if I have developed my

cultural competence, I cannot say in what degree I have explored my cultural understanding

(cf. Leavitt, 2010, p. 43-47). When analyzing my field notes I had to look back and reflect

upon mostly happy but as well some negative experiences mostly connected to my role as an

observer. Why reading those I have questioned myself why I have this strong feeling that I

have to get out in the world again even though the experience was so full of hardships? It

seems like a contradiction. Cushner & Brislin (1996, p. 2-3) states that people look back at

these hardships as enriching and challenging parts of their lives and that they feel competent

that they can overcome new difficulties they will face. I got an answer to the question spot

on. When lived through this experience:

I feel that I have developed both personally, professionally by this journey.

I will start to emphasis cultural factors from Purnell’s model and other theoretical

knowledge gained by conducting this work when facing patients from different

cultures in the clinic domestic or when working abroad.

. The most valuable lesson I have been taught is the importance of leaving one´s own

culture and meet a new one to be able to understand what culture really is and to

understand the upsides that cross cultural exchange has upon the understanding of

one’s own.

I think the open subjectivity in this thesis can be an advantage as I hope it can function like

an open voice which leads to reflection within the Swedish and Indian physiotherapy

profession as I did experience positive and negative aspects in both of them. And I hope that

physiotherapists and healthcare givers worldwide will notice that auto ethnographic method is

unique by connecting the self with the whole in the multicultural world we live in which is

just getting smaller for each day.

36

Conclusion

Conducting an AEG work in a different healthcare culture lead me to reflect upon my

reactions and experiences when being in the Indian physiotherapy culture in relation to my

earlier experiences, which resulted in five themes: Reflecting on the structure of the

physiotherapy context, reflecting on the physiotherapy work, Reflection on patient’s in

physiotherapy work, Being in the field and Being a student with minor experience and

knowledge. .The experience of conducting this thesis in India and by analyzing and reflecting

upon my field notes led me to start questioning and reflect upon the Swedish physiotherapy

curriculum, advantages and disadvantages with the Swedish and Indian physiotherapy

profession, and I learned to respect the trying experience of being an AEG researcher in the

field. Facing a different culture on the other side of the world with lacking clinical and life

experience lead me to experience confusion of languages, fear of losing face, getting my

cultural beliefs questioned, misunderstandings and the feeling of being misplaced but as well

my progress to enhance communication. The whole process of conducting this thesis in a

different health care culture helped me gain further insight of the importance of cultural

factors and diversity in physiotherapy.

I hope this thesis can help Swedish physiotherapy curricula decision makers to start valuing

the importance of cultural aspects in the educational physiotherapy programs. Interesting

would be to hear Swedish PT’s and students experiences of treating patients that are cultural

diverse.

Further AEG research is needed where the researcher conducts clinical practice in a

different cultural context or domestic facing patients of cultural diverse origin over a longer

period of time, in fewer settings would be of value to explore physiotherapist’s path towards

cultural competency.

37

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