Physiotherapy Theory and Practice

An International Journal of Physical Therapy

ISSN: 0959-3985 (Print) 1532-5040 (Online) Journal homepage: https://www.tandfonline.com/loi/iptp20

Moving forth: Imagining physiotherapy education

differently

Sarah Barradell

To cite this article: Sarah Barradell (2017) Moving forth: Imagining physiotherapy
education differently, Physiotherapy Theory and Practice, 33:6, 439-447, DOI:
10.1080/09593985.2017.1323361

To link to this article: https://doi.org/10.1080/09593985.2017.1323361

Published online: 16 May 2017.

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PHYSIOTHERAPY THEORY AND PRACTICE
2017, VOL. 33, NO. 6, 439–447
https://doi.org/10.1080/09593985.2017.1323361

PROFESSIONAL THEORETICAL ARTICLE

Moving forth: Imagining physiotherapy education differently

Sarah Barradell, BPT, MSca,b
a
College of Science, Health and Engineering, La Trobe University, Bundoora, Victoria, Australia; bSchool of Education and Social Work, The
University of Sydney, Sydney, New South Wales, Australia

ABSTRACT ARTICLE HISTORY

Contemporary and future physiotherapists are, and will be, presented with challenges different to Received 8 November 2015
their forebears. Yet, physiotherapy tends to remain tied to historical ways of seeing the world: Revised 18 May 2016
these are passed down to generations of physiotherapy graduates. These historical perspectives Accepted 28 May 2016
privilege particular knowledge and skills so that students gain competency for graduation. KEYWORDS
However, contemporary practice is inherently more complex than the focus on knowledge and Curriculum; physiotherapy;
skills would have us believe. Professional life requires students to develop the capability to deal practice-based education;
with uncertain and diverse futures. This paper argues that physiotherapy needs to think differ- threshold concepts; ways of
ently about entry-level education; the focus on knowledge and competencies that has been the thinking and practicing
mainstay in physiotherapy education must now be understood in the context of an education
that embraces knowing, doing, being. Two educational frameworks are offered in support of this
argument – threshold concepts and ways of thinking and practicing (WTP). Taken together, these
ideas can assist physiotherapy to think in fresh ways about disciplinary learning. Threshold
concepts and WTP help to understand the nature of a discipline: its behaviors, culture, discourses,
and methods. By interrogating the discursive aspects of the discipline, physiotherapy educators
will be better placed to provide more relevant preparation for practice.

Introduction responded to consumer interest and demand. As a

result, programs have needed to think differently
Entry-level physiotherapy education is at a crossroad.
about course pathway options and prior learning
Firstly, there are challenges from within and linked to
experiences of prospective applicants. Resources (i.e.
universities. The role and nature of universities – and
finances and placement opportunities) that are already
the possibilities that lie ahead for them – are shifting
stretched are put under more strain. As knowledge
and contested. Four dominant ideas of the university
grows and changes, universities need to think carefully
have been analyzed (Barnett, 2011, 2015). Once a place
about what students need to be able to know, do and
of ideological inquiry, the idea of a university also now
value for graduation and beyond, as it is impossible to
spans research and the pursuit of knowledge, being a
teach and include everything that may be desired.
more entrepreneurial entity and becoming more busi-
The relationship between universities and society is
ness-like. The last idea (i.e. entrepreneurship/business)
also changing. There is an increasing expectation that
is arguably the one that is currently overtaking univer-
contemporary universities produce work ready gradu-
sities. Institutions each have their own strategic plans
ates (Hager and Holland, 2006; McAllister and
and agendas that degree programs must observe (e.g.
Nagarajan, 2015; Walker et al., 2013); individuals who
who they market to and the educational principles they
not only think and practice in the ways of their chosen
choose to adopt) which can place additional pressure
field and discipline but who also have the capability to
on programs in doing so. For physiotherapy specifi-
develop beyond those defined abilities. There is evi-
cally, the number and type of entry-level programs
dence that universities will need to help prepare grad-
continues to grow: currently at least 92 countries offer
uates for different practice needs (e.g. more emphasis
such programs (World Confederation for Physical
on chronic conditions and longer term illness, as well
Therapy, 2016). This creates more choice for student
as prevention through maximizing health and wellness)
consumers, and with it comes competition. New degree
and a broader skill set (e.g. new roles, greater inter-
structures, such as graduate entry Masters programs,
professional working and skills in digital technologies)
are one example of the way that universities have
(McAllister and Nagarajan, 2015). A re-imagination of

CONTACT Sarah Barradell s.barradell@latrobe.edu.au Physiotherapy, School of Allied Health, College of Science, Health and Engineering, La Trobe
University, Kingsbury Drive, Bundoora, Victoria 3086, Australia.
© 2017 Taylor & Francis
440 S. BARRADELL
physiotherapy education is required to most effectively
address these expectations and meet workforce
demands.
There are also challenges that are driven by profes-
sional needs. The role and context for physiotherapy
are changing on a scale, and at a speed that is unpre-
cedented (Grant and McMeeken, 2009; Pynt, Larsen,
Nicholls, and Higgs, 2009; Webb et al., 2009).
Globalization and advances in information and com-
munication technology have changed the world as well
as the interventions used to promote health and well-
being. The current demands on physiotherapists are
different to those that were faced when physiotherapy
first became recognized as a profession in the 1800s.
Yet, contemporary physiotherapy tends to remain reso-
lutely tied to historical and often unspoken ways of
seeing the world. These dominant ways are then passed
onto generations of graduates through entry-level phy-
siotherapy education that continues to impart these
perspectives to learners. For example, biomedically
oriented subjects typically provide a strong foundation
to programs (Webb et al., 2009), biomechanical dis-
courses remain prevalent (Nicholls and Gibson, 2010)
and evidence-based physiotherapy tends to emphasize
the use of empirical research (Herbert, Jamtvedt,
Hagen, and Mead, 2011). It is a history that reifies an
educational experience focused on knowledge and
skills, and that is driven by competency for graduation
rather than the agency students need to navigate uncer-
tain and changing futures.
It is true that physiotherapy education has changed
alongside and in response to the evolving nature of the
profession. Graduates are now typically educated in
tertiary institutions rather than within hospitals
(Bithell, 2007; McMeeken, 2007; Skinner, 2007). New
educational strategies, such as problem-based learning
and simulation, are being adopted and evaluated
(Gunn, Hunter, and Haas, 2012; Mori, Carnahan, and
Herold, 2015). However, ongoing change is required. It
has now become necessary to think of entry-level edu-
cation as more than ‘preparation’ and competency for
practice. Learning does not stop at graduation and nor
do the challenges.
Working in professional practice is complex and chal-
lenging. Enormous tensions exist in the workplace; phy-
siotherapists (in fact healthcare professionals in general)
remain under pressure to produce better outcomes in
less time with less money and minimal resources. The
scope of practice is blurred; inter-disciplinary and inter-
professional ways of working are no longer the exception
but are rather, an expected part of day-to-day work. New
physiotherapy roles now incorporate extended clinical
responsibilities. Healthcare users are both informed and
misinformed more than ever due to the easy availability
and accessibility of information, and there is increasing
pressure to involve patients in their own healthcare in
new and diverse ways. It is important that students’
learning experiences are authentic enough to truly pre-
pare them for the uncertainties and ambiguities of
tomorrow and the future (Barnett, 2012). Practice-
based education, an educational approach whose overall
orientation is founded on and within a practice’s know-
ing, doing and being rather than simply including work-
based learning (Boud, 2012) has never been more neces-
sary. This approach is not new to health professional
education, however, this paper suggests additional ways
to understand practice and to translate this understand-
ing to entry-level curricula.
A report to the Australian Universities Teaching
Committee (McMeeken et al., 2005) noted the range
of challenges facing physiotherapy programs. The same
report declared a ‘need for ongoing educational
research in the field of physiotherapy so as to inform
curriculum change and support existing good practice
in physiotherapy education’. These challenges are unli-
kely to be unique to the Australian context. Education
demands the same scholarly attention as clinical prac-
tice (Chipchase, Dalton, Williams, and Scutter, 2004). A
reading of the very recent archives of Physiotherapy
Theory and Practice shows that this type of research is
slowly coming to light. Scholars are interested in help-
ing physiotherapy students to develop the capabilities
needed to practice in a rapidly changing world; how
students make sense of their role; and the professional
world they are joining. Furthermore, these scholars
prompt us to think about the sorts of curriculum that
might help our students to do so. For example, Patton,
Higgs, and Smith (2013) argued that a robust under-
standing of various theories of workplace learning
would likely enhance students’ learning during clinical
education experiences. Brazete Cruz, Caeiro, and
Pereira (2014) are concerned with helping students to
engage in different clinical reasoning strategies as a way
of assisting students to expand their views of phy-
siotherapy practice- to also pay attention to the patient
as a person with his or her unique story and experience,
rather than be focused on disease and impairments.
And recently Kurunsaari, Piirainen, and Tynjälä
(2015) explored physiotherapy students’ conceptions
of skill and discussed the curriculum implications of
these conceptions; what learning experiences might
need to be considered to help students to develop
individual agency while at the same time learning
about the ways of the discipline.
This paper adds to the concerns of these scholars
and seeks to extend the professions’ thinking about

entry-level education and learning to become a phy-
siotherapist. The main contention is that physiotherapy
would benefit from thinking about entry-level educa-
tion in broader, more expansive ways. It is suggested
that two higher education frameworks in particular: 1)
threshold concepts (Meyer and Land, 2003; Meyer and
Land, 2005) and 2) ways of thinking and practicing
(WTP) (McCune and Hounsell, 2005) are promising
ideas for shifting physiotherapy education (and with it,
the profession) in directions that recognize the ongoing
complexities of practice. These two educational ideas
are introduced in the next section. In the remainder of
the paper, three arguments are advanced. First, it is
suggested that the pressures of a volume-laden curricu-
lum can be alleviated by a shift in how curriculum is
conceived. Second, it is argued that an education
understood in the context of knowing, doing and
being helps students to develop the multiple capabilities
needed for the complexities of practice. Third, that all
curricula decisions are better informed by a socio-
cultural view of practice. How threshold concepts and
WTP could enrich physiotherapy education and in
turn, the profession is illustrated for each argument;
health science examples are provided due to the lack of
specific work in physiotherapy. Grounded in an
encounter between higher education research and phy-
siotherapy, these ideas have the potential to help the
community of physiotherapy practice (i.e. academics,
clinicians, students, and researchers) to interrogate the
discipline in order to effectively and sustainably pro-
gress educational and professional interests.
Threshold concepts and ways of thinking and
practicing
Threshold concepts and WTP are two educational ideas
that have generated enthusiasm and curiosity across the
higher education learning and teaching research com-
munity in a relatively short period of time (Meyer and
Land, 2003; McCune and Hounsell, 2005; Meyer and
Land, 2005). They each promote a mindfulness to dis-
ciplinary-based learning: different types of knowledge,
identity development, and belonging to communities of
practice.
Threshold concepts represent areas of learning
where students often get stuck due to the knowledge
being troublesome in some way; for example, it may be
counter-intuitive, alien or routine (Meyer and Land,
2003; Meyer and Land, 2005; Perkins, 2006). This trou-
blesomeness is one identifying feature of a threshold
concept. There are seven other characteristics: 1) trans-
formative; 2) integrative; 3) irreversible; 4) bounded; 5)
reconstitutive; 6) discursive; and 7) liminality (Meyer
PHYSIOTHERAPY THEORY AND PRACTICE 441
and Land, 2003; Land, 2011; Meyer and Land, 2005).
These eight characteristics distinguish threshold con-
cepts from more fundamental building blocks of
knowledge. By virtue of these identifying characteris-
tics, threshold concepts are overwhelmingly oriented
toward knowledge transformation: 1) the aspects of
knowledge which are cognitively challenging for stu-
dents; 2) the importance of learning these concepts in
order to establish a networked understanding of the
broader disciplinary perspective; and 3) learning about
oneself and developing a reworked personal and dis-
ciplinary identity in the process.
Ways of thinking and practicing is a framework that
might be considered to take a broader focus. The idea is
less concerned with knowledge, but rather putting
knowledge to work as part of the overall process of
socializing students into a discipline (Anderson
and Day, 2005; Hounsell and Anderson, 2009;
McCune and Hounsell, 2005). Ways of thinking and
practicing are:
not confined to knowledge and understanding, but
could also take in subject-specific skills and know-
how, an evolving familiarity with the values and con-
ventions governing scholarly communication within
the relevant disciplinary and professional community,
and even a nascent meta-understanding of how new
knowledge within the field was generated (McCune
and Hounsell, 2005; p.271).
The WTP framework acknowledges the complex
relationship between knowing-that and knowing-how,
and recognize the culture of creating, sharing, and
using new and different forms of knowledge. The fra-
mework is explicitly concerned with becoming part of
and joining a disciplinary community, and it provides
learners with a variety of multifaceted experiences from
which to grow. These are experiences that help to
welcome students into the real world; a perspective of
tertiary education that is encouraged by contemporary
scholars (Barnett, 2009; Barnett and Coate, 2005;
Dall’Alba and Barnacle, 2007).
To date, there has been no specific work on WTP in
either physiotherapy or health sciences. However,
threshold concepts has captured the imagination of
researchers across a range of medical and allied health
disciplines including: occupational therapy (Rodger and
Turpin, 2011; Tanner, 2011); dentistry (Kinchin, Cabot,
Kobus, and Woolford, 2011); social work (Foote, 2013);
and prosthetics and orthotics (Hill, 2012).
Physiotherapy is represented by only one study related
to the clinical placement experiences of physiotherapy
and occupational therapy students (Clouder, 2005).
There is every possibility that the body of threshold
concepts work will enrich and challenge critical
442 S. BARRADELL
thinking about physiotherapy (and the profession) even
further. In fact, there are already moves in this direc-
tion in at least four promising ways. First, a recent
synthesis of this work (Barradell and Peseta, 2017)
demonstrates that healthcare educationalists are very
concerned with the challenges posed by practice; both
from the professional perspective of being a health
practitioner but also from the perspective of educator
or scholar. Second, there is evidence that healthcare
related threshold concepts are oriented toward the
development of students’ dispositions toward knowl-
edge, and learning about one self rather than the typical
focus on declarative forms of knowledge. Third, scho-
lars have singled out the importance of investing time
in discussions about curriculum in order to help stu-
dents manage the invariably troublesome transitions of
personal and professional identity. Finally, while the
work to date has tended to involve a specific set of
disciplinary participants (i.e. notably academics) the
examination of the discipline would benefit from a
more inclusive approach if practice-based education is
to be accomplished.
Managing the quandary of an overcrowded
curriculum
Concerns have already been raised (in an Australian
context at least) about what is currently in physiother-
apy curriculum (McMeeken et al., 2005). These relate
to how decisions are made about what to teach and the
cognitive load that is associated with learning more
knowledge and techniques. These concerns represent
a particular focus on content – what knowledge and
skills to teach students when the body of work to
choose from is increasing rapidly. A curriculum that
is primarily driven by content or competencies is a
reductionist view of curriculum and education (Fraser
and Bosanquet, 2006). It is oriented to the now and not
the future, leaving little room for (individual) imagina-
tion, professional artistry and capability. A view of
curriculum as content does not reflect what physiother-
apy practice requires: for example to be visionary, to
connect in more fluid ways and across vast spaces, to
see beyond practice horizons and liberate the profes-
sion from long established work routines and defined
relationships with others, to foster a new criticality and
reflexivity and for its members to have a strong sense of
their own values, beliefs and assumptions and the
impact of these on practice.
This paper proposes that threshold concepts and
WTP can expand attitudes and beliefs about teaching
and learning in ways that help to go beyond this view of
curriculum as content. Threshold concepts and WTP
have the potential to help the profession, particularly
academics and clinical educators, to concentrate on the
critical and defining aspects of practice and profes-
sional citizenship: for example, developing a diverse
way of seeing and knowing about situations, cultivating
a sense of personal and professional self, and acting in
ways that draw on both of these capabilities. Threshold
concepts are said to represent the ‘jewels in the curri-
culum’ (Land, Cousin, Meyer, and Davies, 2006). By
helping to identify the crucially transformative and
troublesome areas for students when learning to master
the discipline, authentic and complex disciplinary
insights are more likely to be realized. Ways of thinking
and practicing help to integrate these conceptual land-
marks, supporting students to form a ‘worked’ and
holistic understanding of the discipline. In order to
address the problem of an overcrowded syllabus, deci-
sions about curricula content should attend to the
powerful and defining moments that help students
engage with what is meaningful in becoming a
physiotherapist.
Occupation and its relationship to health and well-
being has been suggested as the threshold concept for
the occupational therapy profession (Fortune and
Kennedy-Jones, 2014). The authors argue that this is a
concept that represents a unified disciplinary view and
one which sets occupational therapy apart from other
health disciplines: understanding occupation is what
makes occupational therapists ‘occupational therapists’.
The way this threshold concept is put to work and
understood by therapists informs their practice: how
therapists interact with clients and why their focus is on
participation rather than body structure and function
(Fortune and Kennedy-Jones, 2014). Occupation and
its relationship to health and wellbeing therefore pro-
vides a curriculum thread for entry-level occupational
therapy programs. Other concepts are understood in
relation to it: meaning, purpose, participation, identity,
time use and wellbeing for example (Fortune and
Kennedy-Jones, 2014). Decisions about what to include
in curriculum can then be based on this threshold
concept, how it is understood and what it means for
practice. A sense of a unifying paradigm is not as well
established within the physiotherapy profession
(Bithell, 2005; Gibson, Nixon, and Nicholls, 2010;
Kerry, Maddocks, and Mumford, 2008; Nicholls and
Gibson, 2010; Noronen and Wikström-Grotell, 1999;
Roskell, Hewison, and Wildman, 1998; Tyni-Lenné,
1989; Wikström-Grotell and Eriksson, 2012).
Threshold concepts and WTP may help the discipline
to frame future conversations about what a physiother-
apy paradigm might be, in order to determine the same
curriculum thread for physiotherapy programs.

Furthermore, the identification of these critical con-
cepts and practices can help to illuminate ‘the under-
lying game’ (Land, Cousin, Meyer, and Davies, 2006) or
hidden curriculum (O’Donnell, 2015); in other words,
the important tacit facets of the discipline such as
organizational systems, workplace cultures, power
dynamics and professional behaviors. These implicit
and often informal areas of learning contribute to the
sense of professional and personal self that learners
develop. They influence how physiotherapists, in fact
all health professionals, work and interact, but are not
necessarily acknowledged and sometimes may even
conflict with more formal learning. Professional prac-
tice requires physiotherapists to have an understanding
of these implicit aspects yet students are often left alone
to recognize them. This is challenging for students and
provides no guarantee they will make the necessary leap
(Balmer and Richards, 2015). Therefore, embedding a
commitment to threshold concepts and WTP in phy-
siotherapy curricula identifies and signals the range of
both formal and informal experiences (i.e. classroom-
based learning, fieldwork, extra-curricular activities,
reflection, interactions with various people in the
healthcare sector, contact with alumni) that are neces-
sary for students to become members of the physiother-
apy community. In short, a perspective of curriculum
as a process and student learning experience, rather
than only a focus on content, helps to move physiother-
apy education beyond a focus on transmission of
knowledge and acquisition of skills and competency
toward an approach that also embraces connections
between knowing, doing and being.
Developing multiple student capabilities
Knowledge is a valuable commodity to the physiotherapy
profession and physiotherapy education. Higgs and
Titchen’s (1995) model of professional knowledge, com-
prising propositional, professional craft and personal
knowledge, features prominently in literature on health
professional education (Edwards, Best, and Rose, 2005;
Higgs, 2009; Higgs, Jones, Loftus, and Christensen, 2008;
Higgs, Richardson, and Dahlgren, 2004; Higgs and
Titchen, 2001; Smith, Ajjawi, and Jones, 2009). This
model provides a neat way for physiotherapy, and in
fact many healthcare professions, to think about the dif-
ferent forms of knowledge required for practice.
While Higgs and Titchen (1995) have argued for more
meaningful understanding of these different forms of
knowledge amongst physiotherapists, indications are that
the profession has not committed to this agenda in any real
way. Physiotherapy (and physiotherapy education) tends
PHYSIOTHERAPY THEORY AND PRACTICE 443
to remain entrenched in its historical legacies. The profes-
sion’s inclination is to view hard knowledge (knowing-
that) as the most legitimate form of knowledge, demon-
strated in the weight given to evidence from large rando-
mized controlled trials or systematic reviews (Herbert,
Jamtvedt, Hagen, and Mead, 2011), and in keeping with
the profession’s historical links to medicine. Shifts from the
established biomechanical view of the body and biological
model of disease, to more contemporary perspectives, such
as postmodern views of the body as socially constructed,
are slow and not particularly pervasive (Nicholls and
Gibson, 2010). Knowledge, skills, and competencies still
dominate the educational agenda. In many ways, this is
unsurprising. These legacies served the profession well in
the past when it was establishing itself as a legitimate
enterprise more than a century ago, yet both the educa-
tional and professional landscapes are vastly different now,
and ever changing.
Threshold concepts and WTP encourage thinking
about practice-based knowledge in terms of: 1) proposi-
tional, professional craft, and personal knowledge; 2)
creating, acquiring, sharing, and disseminating knowl-
edge in both academic (research oriented) and/or practice
(individual or problem oriented) situations; 3) learning
about and participating in the disciplinary community
and locating one’s self within that community; and 4)
emphasizing capability and resilience rather than certain-
ties or competencies. These frameworks can help educa-
tors to create experiences for students that shift education
in directions such as Wenger (1998) describes:
Whereas training aims to create an inbound trajectory
targeted at competence in a specific practice, education
must strive to open new dimensions for the negotiation
of self. It places students on an outbound trajectory
toward a broad field of possible identities. Education is
not merely formative – it is transformative.
This view of education is a very relevant one for
physiotherapy practice. Educational experiences
informed by threshold concepts and WTP can help to
realize the development of personal and professional
agency that is critical in navigating the uncertainties
posed by practice. Clouder (2005) has described how
students’ exploration of critical incidents can help
change their perceptions of caring and their own pro-
fessional identities as health professionals. Foote (2013)
has written about how a nuanced understanding of the
complexities of critical reflection can help social work
students to identify the impact of their experiences,
values and beliefs on both their work practices and
help them to integrate various forms of knowledge.
Blackburn and Nestel (2014) described the emotional
aspects of healthcare learning, the impact of ‘cognitive
444 S. BARRADELL
scars’ and the need for supported reflection and discus-
sion to help learners move through such experiences
most positively.
However, universities are also places to stimulate,
inspire, innovate and discover. In these ways, universi-
ties offer a mechanism for disciplines and professions to
look beyond their usual horizons. Morgan (2012)
explained how social work might use threshold concepts
to interrogate the profession’s understanding of disabil-
ity as well as challenging student’s expectations of social
work practice and how it ‘helps’ others. Her argument
demands that the discipline explores both its historical
and contemporary practice to respond to questions
about the social justice commitments of the profession.
Attention to threshold concepts and WTP invites teasing
out of underlying assumptions, biases or preferences
that can shift persistent ways of thinking that are char-
acteristic forms of the discipline. Rejuvenating long-held
and taken for granted disciplinary conventions and
assumptions about knowledge (i.e. how it is formed
and what knowledge is important) is more conceivable.
Curricula decisions enriched by a sociocultural view
of practice
Contemporary physiotherapy in western society owes
much to its roots in massage, and the efforts of British
women in the late 1800s to legitimize touch (Nicholls
and Cheek, 2006; Nicholls and Holmes, 2012; Pynt,
Larsen, Nicholls, and Higgs, 2009). This step helped
to distinguish therapeutic massage from less respectable
practices as massage had come to be seen as tanta-
mount to prostitution. The profession’s origins lie in
these struggles for credibility. Physiotherapy was
founded on the importance of practice standards and
regulations, examination of competency, strong links to
the medical profession, and a scientific model of
enquiry. These strands remain strong as influences on
the profession and its educational practices today.
Literature about physiotherapy curriculum is scarce,
especially over the last decade or so (Chipchase,
Williams, and Robertson, 2008). Curriculum decisions
appear to be largely determined by aspects of clinical
practice, scientific disciplinary-based research/evidence,
and professional accreditation requirements
(Chipchase, Williams, and Robertson, 2007). In the
main, these decisions seem to have fallen to the indivi-
dual academic and the team that teaches the material,
reinforcing a role of expert. These approaches are
inconsistent with ideas about the social construction
of learning, and the socio-cultural nature of practices
that prevail in the higher education literature. Barnett
(1994) noted that a curriculum represents a ‘telling
commentary on the weight of influence of the different
interests’. Physiotherapy education might thus be con-
sidered vulnerable to the interest of two distinct parties:
on the one hand, what Boud and Brew (2012) have
called ‘provider-capture’ (e.g. accrediting bodies and
other professional factions) rather than the needs of
beneficiaries (e.g. students and patients); and on the
other hand, by the proclivities of academics working
in relative isolation.
Neither of these influences (on their own, or in
combination) is likely to achieve the most effective
educational experience that society demands of phy-
siotherapy and that the profession should expect of
itself. Rather, there is a need for the kind of model
that Parker (2002) advocates; courses in all disciplines
debating and engaging in all kinds of disciplinary prac-
tices not as a precursor to doing the work but as the
ongoing and inclusive job of forming, reflecting on and
establishing disciplinary understanding where the dis-
cipline is modeled not as a citadel of knowledge,
guarded by experts, but as a community of practi-
tioners. Here many voices are encouraged, an extensive
disciplinary discourse is explored, and a range of
knowledge, behaviors, and dispositions are valued.
There has never been a more opportune time to con-
sider innovative ways to prepare physiotherapy gradu-
ates for the rigors and complexities of the new
environments and circumstances that they will face.
Barnett (1994) maintained that curriculum reflects
its influences and stakeholders. As such, there is a
great benefit in physiotherapy education more expli-
citly addressing the requirements of the profession.
Curriculum should be responsive to professional
practice and workplace change, and it should also
stimulate and generate change. Professional practices
are a social phenomenon (Schatzki, 2001) inherently
complex and dynamic. And although practices reflect
a collective purpose (Green, 2009), they are not alto-
gether straightforward. Practices are often highly con-
tested and this is in part because they are contextually
located in place and time, and shaped by a fluid mix
of historical, political, moral, ethical, local and eco-
nomic influences. In spite of a shared code of con-
duct, not all physiotherapists practice in the same
way. Moreover, practice-based education requires
that physiotherapists are schooled in understanding
the multiplicity of knowledge forms. In addition to
knowing-that and knowing-how, there is also what
Barnett (2000) called knowing-in the-world. An
essential objective of practice-based education then
becomes helping learners to form the spirit, convic-
tion and capacity to manage these potentially daunt-
ing conditions.

Boud (2012) argued that it is necessary to explore the
nature of practice in more depth if curriculum is to move
from being practice-oriented to practice-based, and for the
impact on student learning to be most substantial.
Threshold concepts and WTP are ideas that can prompt
a richer, more holistic, more critical understanding of
practice. Understanding real world context was an impor-
tant theme of Tanner’s work (2011) to identify threshold
concepts in occupational therapy; that students often have
an idealistic view of practice and have difficulty coming to
grips with the reality of practice. An understanding of
things such as systems, politics and policies, and how
these impact the services provided to clients and the con-
straints placed on health professionals is suggested as help-
ing students to move beyond their naïve views. Nambiar-
Greenwood (2010) and Royeen, Jensen, Chapman, and
Ciccone (2010) also use threshold concepts to help gain
an understanding of the complexity of concepts in practice.
They explore the enactment of person-centeredness and
interprofessionality respectively and what might be
required for authentic learning of these two ideas.
Both the threshold concepts and WTP frameworks offer
occasions to be critical and scholarly about professional
and educational dimensions of practice. By adopting more
practice-based ways of conceptualizing curriculum and
learning, entry-level education can be reimagined.
Threshold concepts and WTP are frameworks that help
us to think in precisely these ways, and that encourage
curriculum conversations across and beyond the discipline
balancing the needs of a whole range of stakeholders
including students, teachers, clinical educators, practi-
tioners, healthcare users and other professional organiza-
tions. Threshold concepts and WTP have the potential to
help physiotherapy educators and other key stakeholders
interrogate the nature of the discipline and its professional
practices. They can help unlock what ‘counts’ or ‘matters’
in the discipline. They remind us to attend to who is
participating in disciplinary conversations and what their
purpose (and power) might be. As such, a curriculum
approach informed by threshold concepts and WTP can
provide more relevant preparation for the uncertainties of
practice and stimulate future growth of the discipline.
Conclusion
Physiotherapy’s overt emphasis on knowledge, skills,
and competency has tended to limit the ways its unique
practices have been recognized and valued. This narrow
view has also kept the profession and its educational
partners tied down to a dominant way of thinking. It is
not disputed that other discourses might exist but these
are neither immediately visible nor as well established.
PHYSIOTHERAPY THEORY AND PRACTICE 445
The fact remains that students and neophyte practi-
tioners will more likely learn the messages that are
strongly signaled to be the most ‘valuable’, unless
there is reason to do otherwise. The complex nature
of practice provides a reason to do just that.
If it is accepted that higher education’s purpose is to
prepare learners for the life that is ahead of them, then
curricula, teaching and learning must be sensitive to real
life demands. Because the curriculum offers a statement
about what is worth knowing and how to go about learning,
this paper has argued that physiotherapy’s ideas of curricu-
lum needs to be expanded to openly embrace a professional
education for knowing, doing and becoming. This involves
a shift toward a greater appreciation of the many ways
knowledge is formed, different ways of seeing the world
and nurturing self-awareness. Students need space to
understand how their own knowing and acting are posi-
tioned within a developing sense of personal and profes-
sional self. Providing students with learning experiences
that are authentic to the complexity of practice is a crucial
aspect of professional education. This entails consideration
of the nature of the profession’s knowledge base, its history,
values, attitudes and philosophy. Threshold concepts and
WTP are frameworks that can help physiotherapy think
about its ‘core business’ from multiple and perhaps less
familiar perspectives. When attention is given to threshold
concepts and WTP, educators are obliged to critically
examine the nature of the discipline; the what, how and
why of its behaviors, culture, discourses, methods, and
contexts, and thus are better positioned to think about
how best to inaugurate learners into a complex and chan-
ging community of practice.
Acknowledgments
I am enormously grateful to both Tai Peseta and Simon
Barrie and the discussions I’ve shared with them that have
helped me to find my argument. Thank you also to my
colleagues Delyse Leadbetter, Lester Jones and David
Nicholls who read early drafts of this paper and provided
invaluable feedback.
Declaration of interest
The author reports no conflict of interest. The author alone is
responsible for the content and writing of the article.
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