What can physiotherapy learn by looking more closely at ‘how’ research insights come about? The role of reflexivity and representation

ABSTRACT

In this paper, we draw on an example of heuristic inquiry – (Re)imagining becoming a physiotherapist: a phenomenological approach – to illustrate the role that reflexivity and representation can play in physiotherapy research outcomes and the meaning they might have for moving the profession forward. Qualitative research in physiotherapy tends to acknowledge reflexivity as a route to objectivity by making researcher biases overt, yet the debate about data representation (a researcher’s decision-making about how data are represented in a text) barely feature. This contrasts with qualitative research in other fields, including other health professions, where matters of representation (i.e., how knowledge is conveyed) are routinely debated and contested. Reflexivity, in fact, is much more than being transparent. Together with representation, reflexivity helps to position both the voices of participants and researchers within the research. The heuristic inquiry described in this paper offers new insights about learning to be a physiotherapist; it challenged assumptions about care in physiotherapy practice and it changed the first researcher’s identity and practice. These insights were generated through the synergies between reflexivity and representation, and we argue that physiotherapy research has an opportunity to be more expansive by taking a commitment to reflexivity and representation more seriously.

KEYWORDS:

• Reflexivity
• heuristic inquiry
• physiotherapy
• representation

Introduction

Sarah’s doctoral thesis (Tai was one of her supervisors) explored how physiotherapy practice is experienced through physiotherapy education. It was an argument for a renewed physiotherapy profession and a different kind of educational preparation for its graduates. Broadly situated within a phenomenological tradition, specifically heuristic inquiry (Moustakas, 1990), the research was framed using transactional curriculum inquiry involving students, recent graduates and qualified physiotherapists. While the study contributed fresh insight about what it means to learn and become a physiotherapist, it also suggested that something was missing among its students, graduates, and practitioners: an orientation toward a sense of care in, and for, the profession’s future wellbeing (Barradell, 2021). These are profound observations about physiotherapy because they challenge the profession to move beyond providing services to clients, toward creating opportunities for learning from and with others – including people who have not been traditional partners of physiotherapy – and to devote time to reflecting on the profession’s strengths and weaknesses. The findings remind us to attend to important but under-represented voices in physiotherapy and that it is everyone’s responsibility – students, clinicians, educators – to think and practice in ways that are attuned to an obligation to shape the future of the profession. Furthermore, the findings were significant for Sarah – a physiotherapist now academic: they changed her professional identity and practice, which were outcomes that she did not anticipate.

In this paper, we ask a simple question: what can be learned by looking more closely at “how” these insights came about? While the researcher-researched relationship lent itself to a type of phenomenology (heuristic inquiry) in which Sarah’s experiences as a researcher, physiotherapy practitioner and teacher were integral to the sense making process, specific aspects of heuristic inquiry created opportunities to create new knowledge. Those aspects include: (i) a demand for a more complex understanding of reflexivity and (ii) an openness to reimagining data representation. We begin by broadly discussing reflexivity and representation in research: conceptions, challenges and what can be created in research spaces when these practices collide. We then move on to describing heuristic inquiry (Moustakas, 1990) – a form of phenomenology that is both inherently reflexive and attentive to different forms of data generation – which Sarah adopted in her doctorate to respond to the struggles, questions, doubts and conflicts she was facing professionally. We hone in on the final phase of heuristic inquiry – called creative synthesis – because of its crucial role in integrating and communicating the new knowledge generated by the research. To demonstrate this more clearly, we present the findings of Sarah’s creative synthesis, which took the form of a crossword. We include it because it demonstrates an example of how reflexivity and representation unfolded as part of the creative synthesis process. And throughout the paper, we offer various extracts from Sarah’s field notes (appearing herein in italics) – moments of introspection – as they act “as a springboard for interpretations and more general insight. In this sense, the researcher moves beyond ‘benign introspection’ (Woolgar, 1989) to become more explicit about the link between knowledge claims, personal experiences of both participant and researcher, and the social context” (Finlay, 2002). We conclude by offering an argument about paying attention to an expanding approach to reflexivity, and opening up the question of data representation in health education research more broadly so that critical questions can be asked about the assumptions that drive practice, education, and research, alongside the types of inquiry and ways of thinking that are employed to explore those areas. This paper is intended to be of interest to clinicians, educators and researchers, with an appeal to recognize that our research choices are consequential to the ways that physiotherapy is depicted, enacted and studied.

Reflexivity and representation: expanding horizons

Reflexivity

Reflexivity in physiotherapy research can often feel like a “positivist nod” to legitimization, without much consideration as to why and how to be reflexive. In studies where complex questions of methodology, ontology and epistemology are hidden from view (e.g., a mixed methods study with a large randomized control trial and a smaller survey), decisions about the philosophical perspectives in which the research is located are rarely represented and likely assumed. Because of that, reflexivity is not always defined and sometimes seems an add-on or is conflated and/or confused with reflection. Reflexive description tends to be included within accounts of the method with the goal of helping the reader to develop confidence and trust in the research approach and findings (Darawsheh, 2014). The purpose and value of reflexivity can be lost in a “land where the randomized controlled trial (RCT) is considered the apex of the methodological food chain” (Eakin, 2016). While reflexivity seems confined to the realm of qualitative research, there are arguments for it to feature in quantitative research studies as well because reflexivity fundamentally demands that researchers consider how their thoughts, actions, and values are influencing the research process (Jamieson, Govaart, and Pownall, 2023). Consequently, reflexivity has the potential to be so much more interesting and impactful for physiotherapy research. There is a nascent conversation: examples of physiotherapists who are engaged these practices resulting in important understandings such as how to rethink care, manage distress, and who are advocating practice in more socially just ways and in the best interests of clients (i.e., Heywood et al., 2024; Mescouto et al., 2024; Setchell and Dalziel, 2019; Trede, 2012).

The methodological literature in other fields is flooded with explanations about why reflexivity is fundamental to qualitative research. Reflexivity might be considered a form of thinking whereby a researcher’s (inter)subjectivity and presence within research is explained and analyzed (Doyle, 2013) and “alive in the moment-to-moment interactions between researchers and research participants” (ibid). Here, reflexivity involves being both responsive and intentional.

Yet knowing why to be reflexive does not easily answer the question of how to be reflexive (Finlay, 2002) or whether reflexivity is ever truly possible (Pillow, 2003). Knowing why or even how to be reflexive does not mean that researchers can anticipate with any confidence what might emerge from reflexive practices, how transformative that analysis might be, and what or whom those processes might change. In the broader conversation about forms of qualitative and post-qualitative inquiry, reflexivity is not at all straightforward and the debates about it are still live – even today – but in physiotherapy research, reflexivity appears to be largely unproblematic. It often presents in the form of a checklist to provide the researcher with confidence that reflexivity has been adequately addressed.

More fundamentally, the ways reflexivity is understood strongly influence why it is used, how it is enacted, and what it claims and accomplishes about the legitimacy of research. Reflexive practices are not a one size fits all but are shaped by the research question and its underpinning epistemology, ontology and axiology (Finlay, 2002; Trede and Higgs, 2009). For example, Finlay’s typology of reflexive variants (Finlay, 2002) encourages researchers to think about the aims and purpose of the research (e.g., introspection, inter-subjective reflection, mutual collaboration, social critique or discursive deconstruction), which in turn should relate to the philosophical traditions of the research methodology. Enosh and Ben-Ari (2016) on the other hand focus on those involved in the research process and what reflexivity might look like from their different subjective positions. Reflexivity might be an attribute of the researcher (noticing and reflecting on incongruities and contradictions and their meaning); an attribute of the participant (whereby at times a participant reflects on own experiences and assumes an observer’s position to consider own motivations); or the space where insider and outsider perspectives knock against each other and contribute to new knowledge. Wilkinson’s (1988) account of reflexivity is based in feminist studies and grounded in particular social, cultural and historical contexts. It recognizes that knowledge is socially situated and mediated by power. She describes three forms of reflexivity: personal (how researchers’ values shape the research), functional (how the methods and the design shape the knowledge produced) and disciplinary (how disciplines influence knowledge production and signal what matters). And there is Pillow (2003) who describes four related reflexive strategies commonly represented in qualitative research: knowing oneself as researcher; the recognition of participants (i.e., others); seeking legitimacy and trustworthiness; and achieving clarity by going beyond subjectivities. She also proposes a fifth strategy: a critical form of reflexivity that seeks to interrogate and disrupt the familiar toward the uncomfortable and messy (for example, she argues that reflexivity to legitimize is comfortable and limiting). Pillow is interested in the impact of reflexivity on what research produces, stating that “[t]o be reflexive, then, not only contributes to producing knowledge that aids in understanding and gaining insight into the workings of our social world but also provides insight on how this knowledge is produced” (Pillow, 2003).

These are a selection of the many accounts of reflexivity that researchers wrestle with. What is useful about these different conceptualizations – and the debates about reflexivity – is how the different framings prompt researchers to take up reflexivity in ways that go beyond transparency (i.e., enhancing research rigor). When prompted to be reflexive in ways not limited by concepts of trustworthiness, there is renewed potential for qualitative research to both yield and depict novel and meaningful insights that serve to disrupt taken for granted and unintended assumptions of physiotherapy practice.

Representation

We have been unable to locate any physiotherapy literature that explicitly discusses data representation. However, this is a lively and long debate in other disciplines, and it is not new (Byrne, 2017). Representation refers to conveying knowledge into a form that others can understand, usually, in a public form (Eisner, 1997). The process of representation makes, rather than finds, knowledge (Cousin, 2013); it makes meaning (Byrne, 2017). The representation of data (the how) signifies as much understanding about the research phenomenon and the epistemological and ontological underpinnings of the research approach, as the substance of the findings (the what) do (Cheek, 1996; Eisner, 1997; Mantzoukas, 2004). For example, text in the form of a report is a conventional mode of research representation in the scientific paradigm taking its cue from a particular view of what counts as research. The form is conventional in many health professions which have historical ties to biomedicine: “ … texts are not simply conveyors of reality or research, they actually work to create, at least to some extent, our very understandings of that reality or research … ” (Cheek, 1996).

While researchers might claim to be removed from their research, this is arguably completely impossible because research is always framed within a particular theory and philosophy with knowledge curated and selected by the researchers (albeit sometimes unconsciously). As Cousin (2013) puts it: “ … the self is the research tool in the inquiry rather than a threat to its objectivity.” Researchers create a particular view of research outcomes – about and/or with participants – and readers bring their own understanding to that view. The representation is always a negotiation between the contextual conventions of the field, the researcher, participants and readers (Cheek, 1996). And as Mantzoukas (2004) writes: “ … matters of representation in qualitative inquiry become not only volitional philosophical contentions of the researcher but also a central feature of the research inquiry, against which the validity and reliability of the whole research endeavor are judged and which the researcher is required to explicate and integrate within the study.” Representation in qualitative research requires explicit attention during the research process and explicit explanation during dissemination. Even then, the question of the possibility of “explicitness” is also a matter for debate.

Some qualitative forms of research refute the premise of a single reality or an absolute truth; instead, they assume that there are multiple ways of knowing. And if there are multiple ways of knowing, it stands to reason that there are multiple ways to represent, read, view and understand. Different forms of representation can help to show multiple perspectives and moral ambiguity. Researchers need to wrestle with tensions such as: knowing the rules and challenging assumptions; being creative and maintaining rigor; and honoring content and exploring form (Brearley, 2008). An aim of paying attention to representation is “to encourage the recognition on the part of both authors and readers of texts about health research, that reality is composed of a number of possible viewing positions … .Understanding of textual representations of qualitative health research is enhanced if it is informed by multiple viewing positions and even contradictory notions of reality that reverse the often unspoken rules of relevance that frame such representations” (Cheek, 1996). It is when these positions collide – the sticky, messy, complex, inter-subjective spaces – that research expands to advance knowledge, provide novel insights, solve problems, and change society.

“ … having incorporated myself into this work, there is a parallel and paradoxical task now of how to make that self less intrusive.” (Clough, 1999)

Reflexivity and representation enhance each other. Together reflexivity and representation are attempts to balance (and sometimes, struggle with) the experiences of both participants and researcher; to make sure that both “voices” are included as best as is possible given that the depiction of participants’ experiences is an interpreted translation (St. Pierre, 1997). Together, they pay attention to the relationship between researcher and researched in a way that “makes space for multiple voices, layers of stories and multiple interpretations” (Byrne, 2017). How the reader responds to the representation of that relationship, adds yet another voice and another layer of story.

Decisions about representation require reflexivity and researchers should aim to explain their choices, including how knowledge was formed and why (Byrne, 2017; Pillow, 2003). Reflexivity is often criticized for being overly indulgent, narcissistic and never-ending (Olmos-Vega, Stalmeijer, Varpio, and Kahlke, 2022) but working with representation demands that researchers think about how others (i.e., participants) feature in the final outcome/s of the research. It is a commitment that goes some way to countering some of the criticisms of reflexivity.

The next section of the paper draws on an example from Sarah’s PhD study to demonstrate the role of reflexivity and representation in her research, and the outcomes that resulted. It foregrounds the researcher decisions Sarah took in working and tussling with the complexities of reflexivity and representation as part of the “creative synthesis” – the final element of heuristic inquiry.

A researcher working with reflexivity and representation: Sarah’s approach

New research terrain

My early reflections allowed me to see that it would be hard to research the profession and physiotherapy education from a neutral position. And, if I was to try to do so, the research would likely be lacking in rigour and contribution to the field.

I identified several ways to tackle the research. I wanted to develop my understanding by talking to people involved in physiotherapy education and listening to what they had to say about their experiences of physiotherapy. Many people are involved in physiotherapy education, yet academics and professional bodies have been historically and disproportionately represented in those conversations in both the literature and professional contexts. It was important for me to invite new people to the dialogue and to highlight and learn from their experiences. I wanted to think about knowledge in different ways than I was accustomed to as a physiotherapist. I found it helpful to think about knowledge in relational ways, which fit with my educational practice where I featured as part of the educational encounter with the student. At the same time, I was seeking to understand how others experienced physiotherapy education in relation to an awareness of my experiences. I needed to carefully consider my stance as researcher.

To research physiotherapy practice and the educational formation of its practitioners, it made sense to me that it should be collaborative endeavour that include the people involved in physiotherapy. The profile of physiotherapy is diverse making it practically difficult to canvas all the areas that the profession engages in. And while physiotherapy practice is often thought about in terms of patient presentations and the speciality clinical streams and settings in which physiotherapists work, exploring practice in these ways seemed to overlook a contemporary understanding of practices: what it involves and how people act and relate in those practices. Instead, I chose to think about the people that comprise the physiotherapy profession and looked across the lifespan of the physiotherapy membership. Everyone enters the profession from the position of student. No matter the point at which physiotherapists are in their professional careers, being a learner and learning is a stage that everyone has experienced (and some many times over). Everyone within the profession is also involved in doing. This includes students who practise within supervised learning environments to reach the point of registering as an independent practitioner. And once qualified, there comes a time for most practitioners when, in addition to their clinical role, they begin to supervise and/or teach students during placements.

As a teacher and researcher, and with past experiences as student and clinician, I could potentially take up various and multiple positions in this inquiry. However, it was my development as a teacher and wanting to understand and help my students differently that prompted this research. While the roles of teacher and researcher demand a degree of separation at times (e.g., to be present in listening to another’s experience), I was the researcher I was because of the motivations and doubts I had as a teacher. I reasoned that knowledge of how students’ experience and understand practice would offer a unique insight from which to explore the future of physiotherapy and entry-level education. I selected a particular form of phenomenology that enabled me to explore different aspects of students’ experiences, and which viewed my own sense-making as an opportunity to enrich, rather than detract from, the research process. A second phase of the research involved clinicians and provided them with an opportunity to react to, expand upon, and add to what was learned from students.

Playing in heuristic inquiry

“The internal search to discover, with an encompassing puzzlement, a passionate desire to know, a devotion and commitment to pursue a question that is strongly connected to one’s own identity and selfhood.” (Moustakas, 1990)

Heuristic inquiry is a specific form of phenomenology. Not only does it set out to understand people’s experiences, it is also a “process of internal search through which one discovers the nature and meaning of experience” (Moustakas, 1990). Heuristic inquiry is concerned with “that which is, as it is” (Douglass and Moustakas, 1985), rather than what should or could be. It is a way of knowing about, and understanding, a particular phenomenon that has both autobiographical and social/universal significance (Moustakas, 1990).

Douglass and Moustakas (1985) describe heuristic inquiry as “an attitude with which to approach research.” There is no one method. Rather, heuristic inquiry is distinctive to the phenomenon being studied and the people (participants and researcher) who take part. Moustakas (1990) refers to certain attitudes or forms of engagement as the concepts and processes of heuristic research. These comprise: (i) identifying with the focus of inquiry; (ii) self-dialogue; (iii) tacit knowing; (iv) intuition; (v) indwelling; (vi) focusing; and (vii) the internal frame of reference. Together, these seven concepts prepare the researcher to find and reveal significant understanding and meaning. Significantly, the concepts and processes of heuristic inquiry constitute a reflexive research approach. The methods are also unique as there is no specific roadmap to follow, although there are certain phases: (i) methods of preparation; (ii) methods of collecting data; and (iii) methods of organizing and synthesizing data (Moustakas, 1990). The methods of preparation comprise the recruitment of participants and the ways in which data will be collected so as to most effectively and authentically gain a sense of participants’ experiences. Interviews are the most common method of collecting data although anything that offers meaning and/or depth to understanding the phenomenon might also be included. The methods of organising and synthesising data refer to how data is analyzed to form understanding of the phenomenon, the participants’ experiences of the phenomenon, and then how that understanding is represented as findings.

A large part of heuristic inquiry involves writing and reflexive thinking is an essential part of that writing. Writing acts to bring together the “substance” of the experience, the meaning given to it and the language used to describe it, and then to tease those things out into the open. It serves two broad purposes: to show and to offer more. van Manen (1990) describes writing thus: “Writing involves a textual reflection in the sense of separating and confronting ourselves with what we know, distancing ourselves from the lifeworld, decontextualizing our thoughtful preoccupations from immediate action, abstracting and objectifying our lived understandings from our concrete involvement … ., and all this for the sake of now reuniting us with what we know, drawing us more closely to living relations and situations of the lifeworld, turning thought to a more tactful praxis, and concretizing and subjectifying our deepened understanding in practical action.”

Heuristic inquiry opens up the understanding of a phenomenon and its “findings” are constituted in four different modes of representation: individual depictions, composite depictions, exemplary individual portraits and a creative synthesis (Moustakas, 1990). Each mode moves further away from the original data and involves added interpretation by the researcher. Individual depictions are the form of data representation that is closest to the original raw data (often an interview transcript). They focus on an individual’s story without extrapolation and are least influenced by the researcher’s own sense-making. The individual depictions inform the development of the composite depiction that represents the totality of participants’ collective experiences. The development of select exemplary portraits follows. Like the individual depictions, while these exemplary portraits focus on individuals, the portraits are developed for a smaller number of participants; those whose experience is considered characteristic of the whole group. As a result, the exemplary portraits illustrate both the person and phenomenon.

The individual depictions of Sarah’s research are first person narratives – the perspective of each participant (Barradell, 2020). They are Sarah’s account of key moments in each participant’s experience. The composite depiction represents six themes that typified the experiences shared by all participants; an interpretation of the ways the students saw the practice of physiotherapy (Barradell, Peseta, and Barrie, 2018). And four exemplary portraits highlight the relationship between the student and what they were learning about their profession (Barradell, 2023).

The fourth and final form of data representation in heuristic inquiry is the creative synthesis, an original and integrative form of representation that includes the most explicit interpretations of the researcher’s own knowledge and personal experience. The researcher analyses and interprets the participants’ experiences in a new way through a sense-making process that connects with his/her own experiences.

Within heuristic inquiry, the creative synthesis is “an original integration of material that reflects the researcher’s intuition, imagination, and personal knowledge of meanings and essences of the experience. The creative synthesis may take the form of a lyric poem, a song, a narrative description, a story, or a metaphoric tale. In this way the experience as a whole is presented, and, unlike most studies the individual persons remain intact” (Moustakas, 1990).

It is the culmination of the heuristic inquiry process. Moustakas (1990) describes it thus: “It invites a recognition of tacit-intuitive awarenesses of the researcher, knowledge that has been incubating over months through processes of immersion, illumination, and explication of the phenomenon investigated … .The researcher taps into imaginative and contemplative sources of knowledge and insight in synthesizing the experience, in presenting the discovery of essences – peaks and valleys, highlights and horizons. In the creative synthesis, there is a free reign of thought and feeling that supports the researcher’s knowledge, passion, and presence; this infuses the work with a personal, professional and literary value that can be expressed through a narrative, story, poem, work of art, metaphor, analogy, or tale.”

This next section of this paper offers a description of the creative synthesis in Sarah’s doctoral work: what it shows and how it came to be. We begin again with part of Sarah’s field notes to show how she reconciled the need to insert even more of herself in the research, while not overlooking the voices of her participants.

An approach to creative synthesis

The creative synthesis aims to show how I made sense of the students’ experiences and how crucial it is to remain authentic to their experience and not simply what I hoped they had encountered. They spoke with wonder about the body’s anatomy and physiology – but the wonder for me leaned more towards being human than form and function. In my mind, the physiotherapy profession was, and is, more complex than their descriptions of it. Additionally, I struggled to connect with the students’ positive view of physiotherapy and their overall confidence in the physiotherapy profession. I wrestled for a long time with this, becoming more and more frustrated. At some point in the analysis process, I shifted my thinking and started to look beyond substance to style, to the way that I represented the creative synthesis. I had been focused on the student experiences in a literal kind of way but started to think about the underlying assumptions of their experiences – and the assumptions that I had questioned when I began the research. This was an important breakthrough as it enabled me to think about how I could “add” my dissonant experiences to the findings; that I could usefully represent the tensions of my experience and problematize my interpretations as well as the students’ experience. Thinking about the form of the creative synthesis allowed me to connect the insider and outsider, participant and researcher perspectives that I had been struggling to reconcile. With this in mind, I decided to represent the creative synthesis as a crossword about physiotherapy.

The process of doing the crossword brings the reader into the analysis. Working out the clues requires the reader to think and this might be challenging and provocative. Another layer of experience emerges. Doing the crossword adds another level of interpretation to the study, one I hadn’t thought about before. I wonder now what people’s responses to (doing) the crossword are.

In Sarah’s study, the creative synthesis reflects the students’ experiences but it does so through the lens of her own experience. The creative synthesis is represented in the form of a crossword about physiotherapy and visually depicts her understanding of her participants’ (e.g., at that stage of the research, students and recent graduates) experiences of physiotherapy practice. The decision to craft the creative synthesis in this way was the result of a layered analysis of the three preceding forms of data representation (i.e., individual depictions, composite depictions and exemplary portraits). Both the form of the synthesis (i.e., the decision to use a crossword) and its components (i.e., the clues) are informed by Sarah’s analysis and interpretation.

The crossword (Figure 1)

The creative synthesis comprises three specific design elements. First, a crossword puzzle represents a set of problems to solve; second, the form of a structured puzzle contains clues; and third, the puzzle is presented within a silhouette of a person’s head. These three elements represent features that consistently stood out in the interview transcripts and subsequent representations of the students’ experience: problem solving, cognition and the body. The representation of these three elements ensures each participant’s experience is reflected within the creative synthesis. Every student interview featured discussion of the body. Usually the body – in an anatomical sense – was one of the first things students mentioned. For each student, an aspect of the body (usually its structure and/or function) was their primary connection to physiotherapy and a strong defining feature of physiotherapy for all participants. Students also described cognition and knowledge in powerful ways that underpinned other behaviors. Knowledge provided answers to clinical problems and contributed to the credibility of the profession. Cognitive processes – particularly systematic, logical analysis – tended to overshadow accounts of artistry and emotional concerns. Problem solving was described as central to the “doing” elements of physiotherapy and involved looking for clues and evidence. Patients’ presenting problems were described as puzzles to solve. Intervention was directed at finding solutions to those problems. Searching for evidence was part of a problem-solving process as it provided the knowledge – some of the answers – that were needed. In many respects these three elements were interconnected in the students’ experiences.

Figure 1. The crossword.

The clues

The inspiration for each clue and/or respective answers began with the composite depiction and its six thematic ways of thinking and practicing (WTP) (i.e., participant experiences) (Barradell, Peseta, and Barrie, 2018). The themes acted to both corroborate and provoke thinking. Sarah used the crossword clues to subtly gesture toward these tensions.

Areas of the students’ experience reflected longstanding and influential ideas of physiotherapy: for example, valuable knowledge (2 across), patient as body-as-object (13 across) and the structure of the profession (16 across). Uncovering these ideas within the student experiences reinforced, in an empirical way, Sarah’s reflections about the profession.

Although students’ experiences provided a rich and complex view about physiotherapy, Sarah’s inability to relate to some of their sentiments – in particular their optimism and confidence – reinforced that theirs was an understandably neophyte and incomplete view of practice. For some clues, especially those connected to identity (e.g., 17 across), Sarah drew on her own experiences to signal some of the limitations evident in the students’ experiences. Taken together, the clues reflect a range of physiotherapy knowledge, skills and dispositions. Table 1 lists each crossword clue and summarizes how each clue was derived.

Table 1. The creative synthesis’ crossword clues.

DOWN CLUES	ANSWER AND RATIONALE
1 The act of finding information in a thorough way	SEARCH Relates to the scientific approach that has been a mainstay of physiotherapy.
3 A skill that helps to juggle the demands of clinical work	PRIORITISING Reflects the need to respond to competing needs. Applies to caseload management but also physiotherapy’s origins in deciding its strengths and focus.
4 A balanced view of positivity and expectation	REALISTIC HOPE Possibilities but hints at limitations. Relates to physiotherapy at multiple levels (e.g. patient care, professional future).
5 Delineates the scope of practice	BOUNDARIES Defines what is and is not physiotherapy now and moving forward.
8 An unwavering certainty	TRUST A nod to students’ largely unquestioned confidence in the profession.
9 One of the attractions for those thinking about a career in physiotherapy	VARIETY Health settings and patient presentations were seen as different areas of practice.
10 Advancing from a rotational position to a specialty	CAREER PATH Missing from the students’ experiences as their focus seemed to be more on becoming than being.
12 A feature of independent practice	AUTONOMOUS A hallmark of becoming a physiotherapist.
13 Physiotherapists are seen to concern themselves with this aspect of health	PHYSICAL Physiotherapy’s orientation towards the body and movement but the wording of the clue signals tensions associated with restricted views of people and their health and wellness.
15 The feeling of satisfaction with one’s achievements	PROUD Tied to students’ aspirations, ambitions, sense of worth and confidence in the profession.
ACROSS CLUES	ANSWER AND RATIONALE
2 Knowledge approach valued by the profession (acronym)	EBP Represents a dominant idea about physiotherapy knowledge/knowing.
6 A naive picture of reality	IDEALISTIC A partial view of physiotherapy based on certain contexts.
7 The kind of influence that physiotherapists want to have	POSITIVE Tied to ideas of fixing and helping but also a reference to the students’ optimism.
10 A goal orientated process involving several stakeholders	COLLABORATION Collaboration was regularly mentioned although there were limits to how students understood teamwork.
11 To adapt to individual needs	TAILOR Reflects ideas about person-centredness but alludes to a need for the physiotherapy profession to adapt too.
13 The target of clinical physiotherapy	PATIENTS Represents dominant ideas around body-as-object.
14 Associated with a desire to learn	CURIOSITY A driver – for helping, knowing, discovering.
16 A focused and specialized clinical area	STREAM A way of structuring practice and education.
17 Respected and held in high regard	WORTHY Entwined with identity – of self and the profession.
18 Clinical reasoning involves solving this	PUZZLE Problem solving was described as central to what physiotherapists do, connecting thinking with practice.
19 To influence rather than empower	CONTROL Actual practice can be at odds with what is espoused.
20 A mainstay of physiotherapy intervention	EXERCISE A visible part of physiotherapy practice and linked to the profession’s ideas of the body

Outcomes

Heuristic inquiry, and its particular methodology, allowed Sarah to interrogate her profession and its practices in a unique way, revealing new, layered understandings about physiotherapy:

1. stories of individual physiotherapy students (individual depictions);

2. the shared ways that the sample student cohort saw physiotherapy thinking and practicing (composite depiction);

3. the fusion of individual stories and physiotherapy thinking and practicing to create portraits of becoming a health professional (exemplar portraits); and

4. Sarah’s empirically-derived and reflexively-oriented commentary of the totality of the student experience (creative synthesis).

The research revealed that caring for, and about patients, is what participants experienced physiotherapy practice and education to largely be about and directed toward. Graduates were failing to learn about the profession in ways that would equip them to unsettle, revive and progress what physiotherapy is about and for. Caring for the future of the profession was missing. Sarah thus made an argument that physiotherapy could benefit from adopting broader ways of thinking about, and enacting, care (Barradell, 2021). Broader conceptualizations of care would shift how physiotherapists practice, how they were brought into the profession and the types of capabilities were nurtured in learners. This would necessitate new, creative and more critical conversation within the physiotherapy profession about the assumptions on which the profession is based and the implications for the educational preparation of its graduates. These conversations would be aided by people outside the physiotherapy profession, and most suited to critical methodologies that many physiotherapists are unfamiliar with and skeptical about – although there are signs that pockets of the profession have already begun this kind of work. Sarah’s findings, made possible by thinking about overlooked voices and their connection to her own experiences, have implications for how universities and the profession provide ways to think about physiotherapy practice, and in particular, how all parties might contribute to the enculturation of students into the profession. The findings act to “expose the difficult and often uncomfortable task of leaving what is unfamiliar, unfamiliar” (Pillow, 2003).

Final thoughts and professional implications

One outcome of this research is that I do not identify with physiotherapy in the same ways I once did. I have changed as an outcome of this research. As a result, I have come to see part of my role as an educator as being a catalyst for change in learners and the profession they join. I want students to learn about the profession they have chosen, and to have some grasp of why it is looks like it does, and to speculate on what it could be. I want them to question what they are learning instead of replicating ideas they think I want to hear. I want them to believe they can contribute to the future of the profession.

The burden of being seen as someone capable of making change has sat uncomfortably with me at times. At many points during this research, I have not always felt positively towards physiotherapy and so while I was technically an insider, I did not necessarily feel the sense of belonging that might typically be associated with this subject position. It is a distance that has helped me to conduct a critical inquiry of physiotherapy because I have been able to question what I have long taken-for-granted about the profession. But I also needed to ensure that I was not arguing for change for change’s sake and that my claims are supported by findings either from existing literature or this research. I have been very cognizant of my position, my feelings and their potential influence on the research outcome. My field notes are littered with impressions and observations that are intended to reflexively attend to challenges and tensions as they arose.

By engaging in reflexivity and representation, Sarah’s research revealed that caring for, and about, patients is what people experienced physiotherapy practice and education to largely be about. These concerns are chiefly oriented toward what a physiotherapist does with clients today or the next day, and what graduates are likely to be equipped for on their first day of practice. Doing good work and garnering respect are undeniably part of the physiotherapy profession, and the way it is practiced and taught. And they should be. Being a caring professional is a crucial part of physiotherapy that graduates will need to participate in and engage with. However, when the clinical role of a physiotherapist is the focus, the historical passage, evolution, and forward direction of the profession is at risk of being ignored. Sarah’s analysis suggested that it is missing in physiotherapy. An outcome of her research was that physiotherapy would benefit from adopting broader ways of thinking about, and enacting, care, in the form of stewardship (Barradell, 2021). In an educational sense, the research supported the idea that preparation for practice should aim to involve students in diverse learning experiences (some of which do not receive sufficient attention in traditional curricula), including exposure to people with a variety of outlooks and approaches to life’s problems. The research also suggested that learning at university followed by a work-based apprenticeship model does not effectively equip graduates to be the change advocates that they will need to be. It demonstrated that physiotherapy students, even with limited formal practice exposure, can offer meaningful insights and that the value of student contributions is far from being fully realized. One interesting strategy is to incorporate student-staff partnerships directed at curriculum design in physiotherapy (Mercer-Mapstone et al., 2017) in order to help the physiotherapy profession to examine its assumptions, values and beliefs.

More generally, reflexivity and representation of knowledge demand that physiotherapy examines itself: the assumptions, beliefs and values underpinning established clinical practices, professional formation and ways of thinking. Insider research is not without its challenges and attention to reflexivity and representation is essential to navigating these challenges in ways that do justice to the perspectives of both participants and researcher/s (Hiller and Vears, 2015; Toy-Cronin, 2019). There are pockets of physiotherapy research that are critically examining the profession in such ways. Some scholarship highlights, for example, that physiotherapy’s motivating approach can actually have detrimental effects in certain rehabilitation settings (Heywood et al., 2024; Setchell and Dalziel, 2019). Literature suggests that discourses and structures exist in physiotherapy services globally, impacting the profession’s culture of equity, diversity and inclusion (Matthews et al., 2021; Rusinga, Setchell, Jang, and Costa, 2024). Physiotherapists report feeling they lack the capabilities they require to fully adopt biopsychosocial approaches to healthcare (Cormack, Stilwell, Coninx, and Gibson, 2022; Daluiso-King and Hebron, 2022; Mescouto, Olson, Hodges, and Setchell, 2022). Physiotherapy needs a level of criticality in the areas of practice, education and research to reinvigorate and transform the profession (Barradell, 2021). Graduates need the time and opportunity to question taken for granted practices – or “make strange” – and educators need the drive and skills to facilitate such learning (Yeung et al., 2021). Clinicians would benefit from time and space to think about what is right versus what matters (Setchell and Dalziel, 2019). Theoretically informed and theoretically driven research needs to be recognized, supported, funded and published to enable more quality work to happen in this space and to lead to change in physiotherapy practice (Setchell, Nicholls, Wilson, and Gibson, 2018).

Conclusion

Using the example of an heuristic inquiry project, and particularly its commitment to creative synthesis, this paper has illustrated the outcomes that emerge when researchers pay attention to the dynamic between reflexivity and representation. We have aimed to show how new knowledge arises from the tensions between participant experiences and researcher interpretations, and offer an example of how findings might be powerfully (and differently) represented. The outcomes of this study have led to scholarly contributions in the fields of higher education, health professional education and physiotherapy practice and education. And, as important, is the personal transformation of the researcher and its addition to practice.

The commitment to generating, analyzing, evaluating, reflecting on and representing knowledge remains an ongoing conversation among qualitative researchers. As our understandings of the contexts and audiences of, and for, knowledge production become more complex and political, it seems natural for researchers, including from physiotherapy, to search for ways that expand how to communicate their research differently. Attention to both reflexivity and representation gives researchers conceptual tools to expand (rather than abandon) their commitment to “trustworthy telling” – toward something truly new and surprising.

Acknowledgments

Parts of this paper are taken from areas of Sarah’s unpublished doctoral thesis. While her thesis was supported by publication, it also included other text to, for example, establish the problem and context, explain methodology and connect the publications. Some text included in this paper is drawn from those areas of the thesis and has not been published elsewhere.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.