A Reorientation of Belief: Considerations for Increasing the Recruitment of Black Students Into Canadian Physiotherapy Programs
By Paulina Wegrzyn, MScPT, Celina Evans, MScPT, Gina Janczyn, MScPT, Jasline Judge, MScPT, Remi Lu, MScPT, Rahim Manji, MScPT, Julia Gray, PhD, Meredith Smith, MScPT, and Stephanie A. Nixon, PhD
Racism, and anti-Black racism in particular, are structures in society that are infused within institutions, including higher education and healthcare. One result of these systemic forces is the underrepresentation of Black students in clinical training programs, including physiotherapy (PT) in Canada. Having a healthcare workforce whose diversity reflects that of the population is essential for mitigating health inequities. Guided by the work of cultural theorist Sara Ahmed, and critical race scholar Camara Phyllis Jones, we explore the perspectives of various experts regarding barriers to and opportunities for increasing the recruitment of Black students into PT programs in Canada. We conducted this qualitative study using semi-structured interviews. Participants included seven Black physiotherapists, one Black PT student, and two university staff members responsible for recruiting Black students into clinical training programs. Data were analyzed using the DEPICT framework and engaging the theories of Ahmed and Jones. Participants discussed how the field of physiotherapy is oriented around whiteness, which serves to exclude people who are Black. Three themes spoke to this interrelationship: PT as a white space; the white orientation of PT limits Black people; and co-creating an inclusive PT profession. We close by inviting those in the field of PT, including in higher education, to unlearn inherited processes, and engage with humility, reflexivity, and vulnerability, in order to fuel material change. We suggest how the field might reorient itself to actively resist structural racism and ensure more equitable physiotherapy education and care.
There is growing recognition that structural racism, and anti-Black racism in particular, infuse societal institutions in North America, including higher education and healthcare.1-3 The impact of these systems of inequality is evidenced in a number of ways, including the underrepresentation of Black students and the overrepresentation of white students in clinical training programs. Scholarship analyzing racism is at a nascent stage in the rehabilitation sciences,4-6 and in physiotherapy (PT) in particular.7,8 In contrast, there is increasing scholarship in cultural studies and critical race studies that attends to the ways that structures of power, including institutional structures in higher education, serve to reproduce existing inequities.9-11 The intention of this article is to draw upon critical scholarship from these fields to consider the underrepresentation of Black students in PT programs in Canada.
We are an interdisciplinary research team, including six recent physiotherapy graduates who identify as East Asian (RL), South Asian (JJ), Indo-Canadian (RM), multi-racial (CE), and white (GJ, PW); and three advisors: one Black physiotherapy clinician educator (MS); one white critical physiotherapy researcher (SN); and one white health humanities and performance studies scholar (JG). We come from a range of geographical locations across Canada, including urban and rural settings, and identify with a range of communities of difference.
We recognize that the ideas discussed in this article may be self-evident to some Black, Indigenous, and other racialized readers. Our aim is not to harbor long-known experiences of racialized readers, nor to suggest we have discovered anew such experiences within PT, which have been researched and discussed at length in other fields within higher education.12-15 Rather, our aim is to contribute to a growing body of critical scholarship on racism in the context of PT, which is woefully needed. As such, while our long-term aim as interdisciplinary researchers and scholars is to open up discussions within a multi-racial readership, with this particular article we assume a PT audience that is disproportionately composed of people who are white.
In this article, we share the results of a qualitative research study that illuminates ways that the field of physiotherapy ‘orients’ itself as white, which excludes Black and other racialized practitioners.9 Our paper unfolds thus:
First, we explicate our conceptual framework rooted in cultural studies and critical race theory, with particular focus on the scholarship of Sara Ahmed9 and Camara Jones.16,17
Next, we provide a summation of literature related to structural racism in social institutions—including healthcare, rehabilitation, and higher education—and describe our study design. Following this, we analyze how the field of physiotherapy is currently oriented to and around whiteness, and how Black people, including Black students, are routinely made to feel different because of their race, or are not included at all.
This work is organized into three themes: (1) PT as a white space; (2) white orientation of PT limits how Black people enter and move within the field; and (3) co-creating an inclusive PT profession. Building on these insights, we suggest how the field might ‘reorient’ itself to actively resist structural racism and ensure more equitable physiotherapy education and care. We close by inviting those working in the field of PT, including in higher education, to unlearn inherited processes and ways of doing that have informed current structures of the field of PT, and to engage with humility, reflexivity, and vulnerability, in order to fuel material change.
Our Conceptual Framework
Race is a social construct that was created historically to justify the subordination of people defined as non-white in order to advance social and economic interests of people defined as white, including enslavement and colonization.10,11,18 There is no biological basis for race.16,19 Over time, the structure of racism has become deeply entrenched and normalized throughout societal institutions, including education and healthcare. Anti-Black racism is a form of racism that targets people who are Black, and which includes a history of slavery in Canada, forced resettlements, immigration practices, violence at the hands of police, and specific laws that have led to a lack of equitable access, opportunities, and outcomes for Black people.20 The presence of racism (and anti-Black racism) can seem invisible to some because people are socialized to view it as normal—particularly, those who benefit from this structure.9,21 In this study, we use the term racialized to emphasize that race is a socially-constructed concept created to define positions of superiority and inferiority. Furthermore, we draw on the work of cultural theorist Sara Ahmed and critical race scholar and public-health physician Camara Jones to understand racism as institutionalized and personally mediated.9,16,17
Institutionalized racism occurs at a structural level and can be understood as “differential access [of individuals] to the goods, services, and opportunities of society by race,”16(p1212) which often manifests as an inherited disadvantage. Ahmed’s thinking around the interrelationship between individual bodies and broader social spaces is useful here.9 According to Ahmed, the social world must be agreed upon and structured by people who inhabit it. People within particular social spaces must be “oriented” or in line with each other, in order to have access to things within the space. Extending this to race and Blackness, Ahmed discusses how reaching for particular “things” (eg, goods, services, and opportunities) can be “stopped” (eg, through exclusion) for Black people within “white spaces.”9(p111) A “white [social] world” is ready for only certain kinds of bodies and this world is “inherited,”9(p111) so that “to inhabit a white world with a Black body” holds the potential to be “disorienting” (eg, unwelcoming within the dominant orientation).9(p129) Formal institutions, such as universities, are oriented toward whiteness, which might seem invisible or normal to white people; however, racialized individuals might feel “uncomfortable and feel exposed, visible, and different.”9(p133) This institutionalized racism, where spaces are structured in particular ways to ensure certain (white) people can access goods, services, and opportunities while hindering other (racialized, Black) people, additionally makes prejudice and discrimination seem normal.
Personally mediated racism can be understood as both prejudice, meaning “differential assumptions about the abilities, motives, and intentions of others according to their race” and discrimination, meaning “differential actions toward others according to their race [emphasis added].”16(p1212-1213) This form of racism is often understood as what “racism” is, focused only on interactions between people. Ahmed’s concept of “the White gaze” helps illustrate how implicit ways of thinking about race lead to discriminatory actions.9 These experiences of personally-mediated racism might initially be disorienting for a racialized person, but may become “normal” when repeated over time. These interrelated levels of racism, informed by Ahmed’s work on the interrelationship among bodies and spaces, directly impact individuals’ lived experiences, including the possibility of accessing and entering the PT profession.
Structural racism operates through societal institutions, including healthcare, rehabilitation, and higher education, to limit opportunities among Black, Indigenous, and other racialized people in Canada.20,22-25 James et al highlight how rehabilitation science unwittingly reflects and reproduces structural racism by “absenting the role and impact of racialization” within the field.4 Grenier draws on critical race theory to illuminate how anti-Blackness, anti-Indigenous colonial relations, and Orientalism have and continue to influence the ways occupational therapy is taught and practiced in Canada.5 Martin and Kipling found that the experiences of Indigenous students at two Canadian nursing schools were shaped by racism from individuals, groups, and institutions.26 Beagan reported that racialized students in a medical school in Canada experienced marginalization through segregation, struggled to respond to racist jokes and comments from patients and staff, and were less likely to identify the advantages enjoyed by white students (eg, being granted student-doctor status).27 In 2017, Anderson DeCoteau et al used Jones’s framework to report experiences of institutional, personally-mediated, and internalized racism among medical students at a Canadian medical school.28
Research on racism within the field of physiotherapy in Canada is beginning to develop. In 2016, Gasparelli et al called for anti-racism education in PT in response to the report of the Truth and Reconciliation Commission of Canada.29 In 2017, Canada’s national professional magazine, Physiotherapy Practice, produced a special issue focused on issues of diversity and equity.30 In 2019, Vazir et al used Jones’s framework to illuminate institutional and personally-mediated racism experienced by racialized physiotherapists in Canada.31 Their findings aligned with reports among PT students in the UK of feeling like an outsider and being forced to navigate marginalizing behaviors by people who are white.32 Both studies call for changes to institutional structures and practices that produce these forms of exclusion.
Long-Term Effects of Racism in Health Professions
The long-term effects of institutionalized racism impact Black students’ possibilities in many health professions. A Canadian study found multiple barriers for entry into nursing programs for Black students, including gaps in academic preparation that impacted students’ ability to meet program entry requirements, lack of awareness about the profession, limited financial resources, and geographical distances.33 Similar barriers were identified for racialized students entering American physiotherapy programs.34,35 Racialized students in the UK were found to be twice as likely to have limited knowledge of physiotherapy than of medicine or nursing.36 Studies have begun to identify factors that support racialized students to enter physiotherapy programs in the US, including a racially-diverse faculty and student body,35,37 early exposure to the profession,34,35 and family influences.34
Strategies for Increasing Racial Diversity in Health Professions
Although there are no known studies investigating the recruitment of Black students into Canadian PT programs, a number of studies have explored recruitment strategies for increasing racial diversity in other healthcare programs in Canada and the US. Common efforts among these programs include changes to student admissions, curriculum development, faculty recruitment, support services, and community engagement.33,38,39 While these types of changes may be necessary, Cox et al described the need for a transformational shift within the profession in terms of understanding and dismantling its colonial underpinnings as a prerequisite for increasing the number of Indigenous students entering Canadian physiotherapy programs.40 In this inquiry, we turned our attention to the underrepresentation of Black physiotherapists in Canada. Specifically, we explored experts’ perspectives regarding the barriers to and opportunities for increasing the recruitment of Black students into Canadian PT programs.
Study Design, Participants, and Recruitment
This critical qualitative study explored considerations for increasing the recruitment of Black students into Canadian PT programs.41,42 Participants were sought purposively for their ability to inform these considerations, and included: (1) students currently enrolled in Canadian PT programs who self-identify as Black; (2) physiotherapists in Canada who self-identify as Black and who attended a Canadian PT program; and (3) university staff involved in the recruitment of Black students into PT and/or other health professional programs. We recruited through the research team’s professional networks across Canada, and email recruitment notices through national professional organizations. This study received approval from the University of Toronto’s Health Science Research Ethics Board.
Data Collection and Analysis. One-on-one semi-structured interviews lasting 30 to 70 minutes were conducted at a location convenient to both the participant and interviewer (either in-person, via Skype, or via phone). Interviews were transcribed verbatim, checked for accuracy, and uploaded to NVivo. All student researchers conducted interviews, supported by an interview guide and training from two of the advisors. Data collection and analysis occurred concurrently to allow new information to inform subsequent interviews. Our analysis was guided by the DEPICT model, a multi-stage collaborative process designed to ensure rigor while being inclusive of novice researchers (see Table 1).43 Throughout the analysis process, we engaged with Ahmed’s and Jones’s ideas about race and racialization to help mediate and understand the participants’ narratives.9,16
We met with 10 participants as part of this study: 7 Black physiotherapists, one Black PT student, and 2 university staff members whose longstanding role has been to promote recruitment of Black students into health professions programs. Overwhelmingly, study participants discussed the ways the field of physiotherapy is currently oriented to and around whiteness, and that Black people, including Black students, are routinely made to feel different because of their race, or are not included at all. We identified 3 themes that speak to the interrelationship between the whiteness of the field of PT in Canada and the ways Black people are limited in their movement within that field, or are not able to enter at all.
Theme 1: PT as a white space, articulates how the field of physiotherapy is oriented toward and around whiteness by the ways that white people have constructed the profession, including professional training programs.
Theme 2: The white orientation of PT limits Black people, focuses on the ways Black people are limited to enter or move within PT as a field due to its whiteness.
Theme 3: Co-creating an inclusive PT profession, is an articulation of the ways the field needs to reshape itself to include diverse ways of being and doing, including Blackness, in order to increase recruitment of Black students.
PT as a White Space
Participants discussed ways that the field of physiotherapy is oriented to and around whiteness, which has negative implications for their entry and movement as Black people within this white space. The student participant discusses how whiteness is reflected in the dominant image associated with physiotherapists:
I just think that PT is not something that Black people have been…it’s not something that has penetrated aspects of different Black cultures…I mean…a stereotypical image of a physical therapist… I think it’s very Caucasian. At least that’s the image that I’ve kind of—that comes into my mind. And I think that image isn’t conducive to Black people wanting to get into PT. —(PT Student)
The student describes how a Black person may not identify with or imagine themselves in the PT profession due to its whiteness, which is shaped by the people who inhabit it as predominantly white. As Ahmed reminds us, the institution, including professional training programs, is “an effect of the repetition of decisions made over time [by people within it], which shapes the surface of institutional spaces.”9(p133) Here, the student participant notes:
We [Black individuals in the physiotherapy space] just kind of take it for granted, kind of take it as a colorless experience. But it is an experience that—it’s very much shaped by the majority of people who are in that program. —(PT Student)
While the whiteness of the PT space is apparent or visible to Black people, participants discussed how this whiteness may not be apparent to those whose identities align with the orientation of the space (ie, those who are white). One student participant describes this invisibility as follows:
…[T]here’s a culture in place that is in a sense almost invisible to the people who are comfortable within and the people who are the majority within that culture. —(PT Student)
As Ahmed discusses: “whiteness is only invisible for those who inhabit it.”9(p133) The lack of awareness of the white orientation of PT for white people creates an atmosphere for institutionalized racism, meaning structures are in place to support whiteness, including resultant limited access for Black people. The whiteness is “around” and is “assumed to be given.”9(p133) For Black people, this both limits entry into white spaces and limits movement within the space, as discussed in the next theme.
The White Orientation of PT Limits Black People
The orientation of the physiotherapy space around whiteness limits the ways Black people come to enter and move within it. Participants discussed the ways personally-mediated racism, ie, assumptions about race that lead to discriminatory (inter)actions, was a significant way they were made to feel different or reminded of their Blackness within the white PT space. This exposure of difference within a white space was significant in terms of the ways Black participants felt they could move into or within the PT space.
As an example, this physiotherapist participant described an experience where they were “made [B]lack” through an interaction with a colleague. As this participant discusses, up to that point, communication with their white PT colleague had only taken place over the phone. Here, the participant discusses what happened when the two met for the first time in person:
[She said] “You know, I had no idea you were Black.” I’m like, “Well, you probably
wouldn’t, though, because you hadn’t met me…” And she said, “No, no, no,
but you speak so clearly and you…” […] She couldn’t even think that what
she was saying was really pretty rude, you know. But those kind of things,
you deal with that… And she knew me as white. Some of that pre-judgment of how you’re supposed to speak. —(Physiotherapist)
Although this interaction occurred in a professional context, not in school, this participant’s experience is relevant to the ways personally-mediated racism has implications for the movement of Black people within the broader field of PT. This example highlights the ways this individual was “exposed” as Black upon being seen by a white physiotherapist in-person.9(p133) The white colleague is aligned with and can easily move within the white PT space already, and makes bare the participant’s race through her comments, thereby making or “exposing” them as Black. In this way, this colleague embodied white ignorance, in that she was largely unaware that it was her comments that made the participant different and not their skin color. Africana philosopher Amir Jaima,44(p217) citing Mills,45 discusses white ignorance as the ways that white people are unable to understand the world that they have made. This lack of awareness, which in this case resulted in a personally-mediated racist interaction, sustains institutional racism in that it discourages Black people from entering and moving within white spaces.
Study participants discussed how this exposure of Black as different limited entry into professional training programs. As an example, a physiotherapist participant discusses a Black colleague who decided to reject his offer to a PT program after learning more about the racial construct of the profession as white:
…[He] interviewed, got in, talked to a student, uh, another… Black student who was there, and… that [ie, the whiteness of PT as a profession] heavily influenced his decision in fact to… turn down the spot when it was offered for him. —(Physiotherapist)
Here, this participant’s colleague was “stopped” from entering the white PT space as a Black individual.9(p139) Those who are white access and move into this white space without extensive consideration because whiteness aligns with the profession. In contrast, a Black individual either must “check” their Blackness within a space, or they are stopped from entering it in the first place.9(p139) Being “stopped,” then, can cause that individual to choose a different path, rather than if the “motility” had been afforded to them akin to white individuals within the PT space.9(p139)
This whiteness of the PT space also has implications for the ways Black people move within it, including the ways experiences and opportunities might be restricted. As an example, this physiotherapist participant recounted an experience that occurred during their PT training program:
Everything I wrote [as part of my physiotherapy training program] for, like, the next 2 years, I never got higher than a 76%… Until the last assignment… it’s anonymous, so you’re not allowed to use your own name at any point through this document…So… I get 98.5%. —(Physiotherapist)
As this Black participant discussed in another part of their interview, they had previously received high grades for academic writing throughout their undergraduate academic career. When they entered the white PT space for professional training, they were unable to attain high grades when their individual identity was “exposed,” or made visible or different, as Black.9(p139) When their Blackness was made invisible through the anonymizing process in that particular assignment, higher grades became attainable.
Participants indicated that a dramatic restructuring, or reorientation, of the PT profession is required in order for people who are Black to no longer be limited by the whiteness of the PT space. We explore this idea in the next theme.
Co-Creating an Inclusive PT Profession
As part of reorienting the field of PT, participants discussed specific ways the profession needed to be more inclusive, including re-creating PT as diverse and built upon authentic relationships and community needs. This authentic relationship-building can take many forms, but ultimately the aim is to create a diverse field where Black students and practitioners belong, and a range of life experiences, cultural perspectives, and ways of being and doing are valued. As an example, participants discussed the ways that, as part of recruitment into university programs, particular kinds of preparatory work tend to be valued over others. In the quote below, the university staff participant highlights how those already working within white PT spaces are biased in assessing recruitment criteria toward experiences that are upheld and valued by whiteness:
If you have folks… who’ve had the resource[s] at their disposable to go off and do, like, non-profit work…and you have students who…had to work part-time at [a restaurant] … . there’s still subjectivity and unconscious bias that creeps in…. So that’s why it’s important to have greater representation in terms of the folks that are making the decisions when they, when they look at it. —(University staff)
This participant highlights how “even bodies that might not appear white still have to inhabit ‘whiteness’ if they are to get ‘in.’”9(p134) Through the recruitment process, this unconscious bias that the participant mentions aligns with Ahmed’s discussions of institutional recruitment and the ways it “functions as a technology for the reproduction of whiteness.”9(p133) Recruitment indicates a particular “direction” and allows the higher education program, as well as the profession more broadly, to “renew and restore.” 9(p133) In this way, recruitment is a structure to accept certain kinds of people while keeping others out, with the potential to uphold institutional racism. To “get in” or “inhabit” the institution (and by extension, the profession of PT), applicants must enact particular values through the kinds of work they do before entering, such as non-profit work, which is vital to be included yet unevenly available to prospective students. The participant’s suggestion of more diverse recruitment officials is one important way to address this issue.
Participants also suggested the importance of having Black faculty leaders, teachers, and staff within Canadian PT programs. A physiotherapist participant discussed the importance of this:
Once you get out into the working world, you’re going to have to deal with people from different backgrounds… And I don’t think that that same level of diversity is really represented within any of the university programs, whether it’s from a faculty perspective or the instructors that come in to do, like, clinical skills or are TAs for some of the courses. — Physiotherapist
This physiotherapist discusses the importance of diverse faculty and instructors as a way to prepare students to be able to better serve racially-diverse Canadian populations. We argue that this diversity is also important as part of reorienting the space of PT more broadly. Following Ahmed’s statement that “white bodies do not have to face their whiteness” because it is a “given” and not an “obstacle,” and that the field of PT in Canada has been constructed as white, including more diverse faculty leaders and other instructors expands perspectives and possibilities for what comes into reach for students.9(p132) If “institutions provide collective or public spaces,” and white bodies gather, shape, and extend those institutions in certain directions, then it follows that the inclusion of Black faculty and instructors helps to reoccupy spaces so they become not “given” as white.9(p132) This includes the ways all students are educated to care for a diversity of people in the clinical world, as well as the potential for the institution’s whiteness to be disrupted and reoriented.
Participants also discussed the importance of authentic and inclusive community-building with diverse partners and communities. As an example, participants discussed the importance of outreach with racialized young people, such as earlier exposure to PT through career fairs at elementary and high schools, summer mentorship programs, and partnerships with Black student organizations. Throughout this process, Black physiotherapists and leaders would engage with youth, as discussed by this participant:
Getting people of color in those professions in front of people, of students of color, [helps them] to be, like, “This is an option for you, like, this is a real thing that could happen.” — Physiotherapist
Developing this kind of community outreach holds the potential for Black youth to imagine their own futures within PT, as well as the ongoing disruption and reorientation of the PT profession.
Additionally, as part of community-building, one university staff participant suggested:
If you want to have an equitable outcome, you need to have an inclusive process that includes all stakeholders there… so, like, the community at the table, community members being external to the university. We have students at the table as well, all giving their… their input in terms of the design. —(University staff)
This participant highlights the important relationship between equitable and authentic processes and outcomes. If administrators and faculty members want to achieve diverse program outcomes (by which we mean diversity in the profession, and that Black physiotherapists belong and practice as Canadian-trained professionals without barriers), then program processes themselves must be diverse, meaningful, and enacted such that Black people are centered and belong. In this way, it is not only for white people already within the profession to make space, or include Black people, since this implies that current spaces are adequate for Black people to be included.
Rather, as this participant suggests, for a new design of PT programs, Black people must belong to a process that legitimately meets community needs and values, and upholds a range of experiences and perspectives beyond whiteness. Recognizing that these inherited white processes and spaces could be otherwise, and that they currently limit what Black people can do, is essential for their disruption and reorientation—thus allowing new possibilities to come into reach.9(p130) This participant suggests more racially diverse community members need to be at the table as part of the process; however, as we argue in the following Discussion, this also requires a dismantling of unjust structures and discriminatory ways of seeing and doing that keep Black people out.
We begin by considering the relevance of the phrase having a seat at the table, as discussed by one of our participants, by following Ahmed’s recognition that “to take up space is to be given an object, which allows the body to be occupied in a certain way,” or “to feel at home.”9(p138) In different ways, study participants discussed the relationship between Black people and the white space of the PT profession in Canada. Based on their discussions, we suggest that institutions are not neutral, but are “orientation devices, which take the shape of ‘what’ resides within them.”9(p132) The “what” referred to here is whiteness, shaped historically and contemporarily by white people, which is assumed to be “around,” like water for fish. Movement is not easy for Black people who do not align with this whiteness, and many are often stopped from entering the PT space in the first place. As Ahmed reminds us, recruitment into institutions, including PT training programs, “functions as a technology for the reproduction of whiteness” and “creates… what [the institution] imagines as the ideal.”9(p133-134)
The participants’ narratives also illustrated the interrelatedness of institutional racism and personally-mediated racism.16 Personally-mediated racist interactions—as assumptions about race that lead to discriminatory (inter)action—have upheld institutional structures that stop Black people from moving within the PT space or from entering at all. By supporting or upholding whiteness, institutional structures make Black people different, and create the context for personally-mediated racism based on white ignorance.44,45 Allowing for the movement of Black people into the field of PT in Canada requires more than opening the door, or making space at the table; it requires whiteness to be made different.
It follows then, in taking this statement of having a seat at the table seriously, that it is insufficient to suggest that Black people simply pull up a chair. As our participants discuss, when Black people enter white spaces, they are exposed as different and “stopped.” Ahmed might describe this as a dis-orientation; it is disorienting for the Black person experiencing the “stop,” but it also holds the potential to disorient the white space. “When [Black] bodies ‘arrive’ that don’t extend the lines already extended by [white] spaces, then those [white] spaces might even appear slantwise or oblique.”9(p.135)
These insights have direct implications for action if the goal is to increase the recruitment of Black students into PT programs. We must not insist that Black people “pass through” whiteness, or relish in “the presence of minorities and racialized others as an ‘eccentric’ effect.”9(p135),46(p26) As a profession, we must not force alignment with a space that will never fit. Rather, we advocate that this disorientation provides an opportunity to consider what is exposed about whiteness. How might the field of PT make ourselves different, and see the whiteness as something that is non-neutral as opposed to something taken as given? Rather than seeking to make space, how might we dismantle the table itself and jointly reconstruct it so there is no option but to have multiple people and perspectives at it? To quote one of our study participants, what is required is “a reorientation of what you believe the profession is.”
Two Future Directions
By suggesting those working within the field of PT in Canada attend to the disruption as an opportunity, we point to the possibility of capitalizing on the loss of orientation as potentially productive.47 We offer two directions that hold the potential to contribute to this reorientation: (1) advancing critical race theory in PT, and (2) enacting anti-racist education and practice.
Advancing Critical Race Theory in PT. First, we align ourselves with James et al, who deftly call out the under-recognition of the impact and role of racialization and racism in rehabilitation science research and clinical practice.4 The small body of scholarship about racism in the context of PT in Canada is limited both in quantity and in engagement with critical race theory. Critical race theory takes the starting point that race is socially constructed and that racialization has structured society, which results in racism being positioned as ordinary and expected throughout societal institutions as opposed to something that is aberrational.1,10 Critical race theory embraces an intersectional approach, which understands the unearned advantage and disadvantage produced by racism to be shaped in complex and powerful ways by other historic systems of inequality (eg, colonization, ableism, heterosexism).11
This approach centers “storytelling” and “counter-storytelling” as key tools for unlearning harmful beliefs that are understood to be true.42 Importantly, this approach is emancipatory in its orientation, such that scholarship is part of the praxis toward liberation. Critical race theory was borne in legal studies and has flourished in other fields (eg, education48 and social work49), but is at a nascent stage in PT and the rehabilitation sciences broadly, with several notable exceptions.4-6
Enacting Anti-Racist Education and Practice. Second, we advocate for members of the PT profession in Canada, and especially those in positions of leadership, to enact anti-racist education and practice. Here we invite an embrace of Jaima’s call to address white ignorance, which results in reproducing exclusivity and hierarchies of knowledge, and advocate for a centering of Black and other racialized perspectives as part of reorienting the field of PT more broadly.44 We advocate Nixon’s framing of “practicing critical allyship” as an orientation for people who find themselves in a position of unearned advantage in relation to systems of inequality.21,50 In the case of racism, this call for practicing critical allyship applies to people who are white, and for anti-Black racism in particular, the orientation applies to anyone who is not Black.51
This anti-oppression approach calls for action that is in solidarity with people who are historically oppressed to resist and dismantle these social structures that are harmful for all. This is in contrast to the dominant orientation that positions people “on the top of the coin” (ie, in a position of unearned advantage, or privilege) to operate from a motivation of altruism or helping.21 This approach invites white people to anticipate and resist the emotions (eg, shame, denial, guilt) and behaviors (eg, shutting down, making claims to good intent) that sabotage unlearning and progress toward racial justice.52 Further, in line with critical race theory, this approach sees learning and unlearning not as an end, but as the means to the end of concrete social change.1,10
The challenge for PT is to reflect and act on what “practicing critical allyship” will look like in education and practice. How might we center the expertise, perspectives, and bodies of Black people in all aspects of the profession? How might we embrace and advance widespread learning on structural racism, especially for people who are not Black, and use new insights to fuel concrete action? How might we embrace anti-colonial and anti-racist pedagogy in our teaching? PT leaders producing statements of solidarity with Black communities can be seen as an important step, but how might these rhetorical commitments be translated into action?53,54
Last year saw the creation of the Black Medical Student Association of Canada, followed several months later with public calls to action for all medical schools in the country to, among other goals, improve representation of Black students in medical schools.55 How might we invite and make room for the wisdom and experiential expertise of our Black and other racialized PT students to help drive the evolution of the profession? A crucial step in this movement is support for the emerging Black Physiotherapists Association of Canada, which stands to be a source of mentorship and wisdom as we move toward co-creating a more inclusive profession.
This analysis draws on the narratives of 10 individuals. While our data support this initial analysis, further research is needed with larger and more diverse samples to more comprehensively understand this issue. For instance, we do not engage with the vast heterogeneity among Black people and populations, nor do we explore the intersections of racism with other systems of inequality, which can produce complex forms of disadvantage. Furthermore, this analysis focuses on whiteness and Blackness, and does not explore the role of non-Black racialized people in terms of experiencing racism and also potentially upholding anti-Black racism. A key limitation of this study is the identification of all members of the research team except for one as non-Black. We have taken steps to deepen our insight regarding the influence of each of our positionalities on the analysis, and we have sought guidance from Black colleagues with expertise in critical race theory; however, we recognize that this analysis may be impoverished due to the lack of experiential expertise and formal training in critical race theory held by our team.
Queer and cultural theorist Jack Halberstam writes of the importance of unlearning as part of recognizing certain inherited processes and ways of doing that are assumed to be more legitimate or valuable than others.47 This requires engaging with a vulnerability, humility, and even a foolishness, meaning a willingness to risk being wrong, but to try with openness and curiosity anyway.56,57 This not knowing seems to fly in the face of everything the academy, including PT programs, aims to perform: certainty, objectivity, and seriousness.58 Yet, it is this capacity for humility and re-learning that is required to reorient the profession. Our analysis offers an introduction to imagining PT differently, which we hope will be embraced with curiosity and an appetite for greater anti-racist learning and action.
This research was completed in partial fulfillment of the requirements for a MScPT degree at the University of Toronto. We thank our participants for their time and wisdom; the Ontario Physiotherapy Association Central Toronto District, and Dr. Barbara Gibson (Department of Physical Therapy, University of Toronto) for their funding contributions; and Nancy Salbach and Kelly O’Brien for their guidance. We also thank Stephanie Lurch for her helpful comments on an earlier draft of this article.
1. Bonilla-Silva E. Rethinking racism: toward a structural interpretation. Am Soc Rev. 1997;62(3):465-480.
2. McGibbon EA, Etowa JB. Anti-racist health care practice. Int J Fem App Bioeth. 2011;4(2):164.
3. Henry F, Dua E, James CE, Kobayashi A, Li P, Ramos H, Smith M. The Equity Myth: Racialization and Indigeneity at Canadian Universities. Vancouver: UBC Press; 2017.
4. James LL, Abudiab S, Said Omar S. Racialization and racism: uncovering the implicit in rehabilitation sciences and research. RehabINK. 2019;7. Available at: https://rehabinkmag.com/previous-issues/rehabink-summer-2019-volume-1-issue-7/racialization-and-racism-uncovering-the-implicit-in-rehabilitation-sciences-and-research/
5. Grenier M-L. Cultural competency and the reproduction of white supremacy in occupational therapy education. Health Edu J. 2020;79(6). https://journals.sagepub.com/doi/10.1177/0017896920902515
6. Omar S, James L, Colantonio A, Nixon S. Integrated care pathways for Black persons with traumatic brain injury: a protocol for a critical transdisciplinary scoping review. Sys Rev. 2020;9:124.
7. Vazir S, Newman K, Kispal L, et al. Perspectives of racialized physiotherapists in Canada on their experiences with racism in the physiotherapy profession. Physio Can. 2019:1-10. doi:10.3138/ptc-2018-39.
8. Hammond J, Marshall-Lucette S, Davies N, Ross F, Harris R. Spotlight on equality of employment opportunities: a qualitative study of job seeking experiences of graduating nurses and physiotherapists from black and minority ethnic backgrounds. Int J Nurs Stud. 2017;74:172-180.
9. Ahmed S. Queer phenomenology: orientations, objects, others. Duke UP. 2006. Available at: http://gateway.proquest.com/openurl?ctx_ver=Z39.88-2003&xri:pqil:res_ver=0.2&res_id=xri:ilcs-us&rft_id=xri:ilcs:rec:abell:R04034814.
10. Delgado R, Stefancic J. Critical Race Theory: An Introduction. 2nd ed. New York University Press; 2012.
11. Crenshaw K et al. Critical Race Theory: The Key Writings That Formed the Movement. The New York Press; 1995.
12. Moore WL. Reproducing Racism: White Space, Elite Law Schools, And Racial Inequality. Rowman & Littlefield Publishers; 2017.
13. Gutiérrez y Muhs G, Niemann YF, González CG, Harris AP. Presumed Incompetent: The Intersections of Race and Class for Women in Academia. Utah State University Press; 2012.
14. Bryzzheva L. “Two jobs”: On experiences and duties of faculty of color at a predominantly white institution. J Understand Dismant Priv. 2016;6(1).
15. Beeman A. Teaching to convince, teaching to empower: reflections on student resistance and self-defeat at predominantly white vs. racially diverse campuses. J Understand Dismant Priv, 2015;5(1):13-33.
16. Jones C. Allegories on Race and Racism.
(2019). Available at: https://www.youtube.com/watch?v=GNhcY6fTyBM&t=230s. Accessed 25 Jul. 2019.
17. Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Pub Health. 2000;90(8):1212–1215. Available at: http://doi.org/10.2105/AJPH.90.8.1212.
18. Harris CI. Whiteness as property. Harv Law Rev. 1993;106(8):1707-1791.
19. Boyd RW, Lindo EG, Weeks LD, McLemore MR. On racism: a new standard for publishing on racial health inequities. Health Affairs Blog. July 2, 2020. Available at: https://www.healthaffairs.org/do/10.1377/hblog20200630.939347/full/.
20. Maynard R. Policing Black Lives: State Violence in Canada From Slavery to the Present. Halifax: Fernwood Publishing; 2017.
21. Nixon SA. The coin model of privilege and critical allyship: implications for health. BMC Pub Health. 2019;19:1637. https://doi.org/10.1186/s12889-019-7884-9.
22. Lux MK. Separate Beds: a History of Indian Hospitals in Canada, 1920s-1980s. Toronto: University of Toronto Press; 2016.
23. Allan B, Smylie J. First Peoples, Second Class Treatment: The Role of Racism in the Health and Well-being of Indigenous Peoples in Canada. Toronto, ON: The Wellesley Institute; 2015.
24. National Collaborating Centre for Determinants of Health. Let’s Talk: Racism and Health Equity (Rev. ed.). Antigonish, NS: National Collaborating Centre for Determinants of Health, St. Francis Xavier University; 2018.
25. Nestel C. Colour Coded Health Care: The Impact Of Race and Racism On Canadians’ Health. Toronto: The Wellesley Institute; 2012.
26. Martin DE, Kipling A. Factors shaping Aboriginal nursing students’ experiences. Nurse Educ Pract. 2006;6(6):380–388.
27. Beagan BL. ‘Is this worth getting into a big fuss over?’ Everyday racism in medical school. Med Educ. 2003;37(10):852-860.
28. Anderson DeCoteau M, Woods A, Lavallee B, Cook C. Unsafe learning environments: Indigenous medical students’ experiences of racism. LIME Good Prac Case Stud. 2017. http://www.limenetwork.net.au/wp-content/uploads/2017/10/Anderson-DeCoteau.M-Woods.A-Lavellee.B-Cook.C-GPCS-V4.pdf
29. Gasparelli K, Crowley H, Fricke M, McKenzie B, Oosman S, Nixon SA. Mobilizing reconciliation: implications of the Truth and Reconciliation Commission Report for Physiotherapy in Canada. Phys Can. ;68(3):211-212.
30. The diversity issue: equal quality of treatment for all Canadians. Phys Prac. 2017;7(2):1-44. Available from: https://physiotherapy.ca/publications-practice
31. Vazir S, Newman K, Kispal L, et al. Perspectives of racialized physiotherapists in Canada on their experiences with racism in the physiotherapy profession. Phys Can. 2019: :1-10. doi: 10.3138/ptc-2018-39.
32. Hammond JA, Williams A, Walker S, et al. Working hard to belong: a qualitative study exploring students from Black, Asian and minority ethnic backgrounds’ experiences of pre-registration physiotherapy education. BMC Med Educ. 2019;19:372. https://doi.org/10.1186/s12909-019-1821-6
33. Etowa JB, Foster S, Vukic AR, Wittstock L, Youden S. Recruitment and retention of minority students: diversity in nursing education. Int J Nurs Educ Schol. 2005;2(1):13.
34. Wiggs JS, Elam CL. Recruitment and retention: the development of an action plan for African-American health professions students. J Nat Med Assoc. 2000;92(3):125-130.
35. Wise D, Dominguez J, Kapasi Z, et al. Defining underrepresented minorities and promoting holistic review admission strategies in physical therapist education. J Phys Ther Educ. 2017;31(4):8-13.
36. Greenwood N, Bithell C. Perceptions of physiotherapy compared with nursing and medicine amongst minority ethnic and white UK students: implications for recruitment. Physiotherapy. 2005;91(2):69-78.
37. Nuciforo MA. Minority applicants to physical therapist education programs 2010-2012. Phys Ther. 2015;95(1):39-50.
38. Simone K, Ahmed RA, Konkin J, Campbell S, Hartling L, Oswald AE. What are the features of targeted or system-wide initiatives that affect diversity in health professions trainees? A BEME systematic review: BEME Guide No. 50. Med. Teach. 2018;40(8):762-780.
39. Haskins AR, Kirk-Sanchez N. Recruitment and retention of students from minority groups. Phys Ther. 2006;86(1):19-29.
40. Cox J, Kapil V, McHugh A, Sam J, Gasparelli K, Nixon SA. Build insight, change thinking, inform action: Considerations for increasing the number of indigenous students in Canadian physical therapy programmes. Phys Can. 2019; 1-9. doi: 10.3138/ptc.2018-14.e.
41. Eakin J, Robertson A, Poland B, Coburn D, Edwards R. Towards a critical social science perspective on health promotion research. Health Prom Int.;11(2):157-165.
42. Solόrzano DG, Yosso TJ. Critical race methodology: counter-storytelling as an analytical framework for education research. Qual Inq. 2002;8(1):23–44.
43. Flicker S, Nixon SA. The DEPICT model for participatory qualitative health promotion research analysis piloted in Canada, Zambia and South Africa. Health Prom Int. 2014;30(3):616-624.
44. Jaima A. On the discursive orientation toward whiteness. J Intercult Stud. 2019;40(2):210-224.
45. Mills CW. White ignorance. In: Sullivan S, Tuana N, eds. Race and Epistemologies of Ignorance. Albany: State University of New York Press; 2007: 11–38;.
46. Puwar, N. Space Invaders: Race, Gender and Bodies Out of Place. Oxford: Berg Publishers; 2004.
47. Halberstam J. The Queer Art of Failure. Duke University Press; 2011.
48. Dei GJS. Knowledge and politics of social change: the implication of anti-racism. Brit J Soc Educ. 1999;20(3)
49. Dumbrill GC, Yee JY. Anti-Oppressive Social Work: Ways of Knowing, Talking, and Doing. Oxford Press; 2019.
50. Nixon S. What Every Health Researcher Needs To Know About Health Equity: Privilege, Oppression and Allyship. 2017. Video available at: https://www.youtube.com/watch?v=APdNxzsqnz4.
51. Paradkar S. Dear brown people: I’m about to wash some dirty linen in public. Toronto Star. June 28, 2020. Available at: https://www.thestar.com/opinion/star-columnists/2020/06/28/dear-brown-people-im-about-to-wash-some-dirty-linen-in-public-consider-this-an-overdue-act-of-tough-love.html.
52. DiAngelo R. White Fragility: Why It’s So Hard for White People to Talk about Racism. Boston, MA: Beacon Press; 2018.
53. University of Toronto Department of Physical Therapy. Department of Physical Therapy Statement of Solidarity with Black Communities. 2020. Available at: https://www.physicaltherapy.utoronto.ca/news-events/department-of-physical-therapy-statement-of-solidarity-with-black-communities/.
54. Black Lives Matter. Frontline: The Physiotherapy Magazine for CSP Members. July 1, 2020. https://www.csp.org.uk/frontline/article/black-lives-matter
55. Black Medical Students Association of Canada. Recommendations to Canadian Faculties of Medicine. 2020. https://drive.google.com/file/d/12Gdf4_IejRWMiJAQ3PXwt_3pUqKRIWrx/view?fbclid=IwAR3l1ilZyKHf7Rn_42D2vthI3uba3kZ5OQ3cGwNeH4DnsiFJGenE55-qGKE
56. Gray J. Working within an aesthetic of relationality: theoretical considerations of embodiment, imagination and foolishness as part of theatre making about dementia. Res Drama Educ: J App Theatre Perf. 2019;24(1):6-22.
57. Salverson J. Taking liberties: a theatre class of foolish witnesses. Res Drama Educ: J App Theatre Perf. 2008;13(2):245-255.
58. Gray J, Donnelly H, Gibson BE. Seriously foolish and foolishly serious: the art and practice of clowning in children’s rehabilitation. J Med Human, 2021: 42, 453-469.