This study traces distress through an advanced practice physiotherapy-led clinic delivering chronic pain care in a tertiary hospital. It explores how historical, political, and economic forces guide the clinic’s development, spatial structure, everyday functioning, and how this influences distress within the clinic.
The study employed two qualitative data collection methods: 1) ethnographic observations of physiotherapy clinical interactions; and 2) participatory dialogues. In ethnographic observations (n=15), a trained observer wrote fieldnotes of clinical interactions. Across 6, two-hour participatory dialogues, discussions with physiotherapists investigated the factors that influenced their experiences of distress, in chronic low back pain care. Data analysis was conducted iteratively with 1) researchers in team analysis meetings, 2) clinicians in participatory dialogues, and 3) in patient panels. Informed by these collaborative analysis processes, the core research team then progressed the analysis, using Sara Ahmed’s theorisation of ‘use’, to analyse the political and economic forces shaping care and distress within the clinic. Two key ideas from this theoretical approach were utilised: the metaphor of ‘well-used’ paths and requirements for ‘use’ and to be ‘useful’.
Distress was traced back through pathways and metrics within the clinic. The metaphor of the ‘well-used’ path shows how histories of ‘use’ and ‘overuse’, shaped by political and economic forces, influence practices and pathways within the clinic. Such practices and pathways were observed to unintentionally become routine and overlooked, producing distress and directing care along the ‘well-used’ narrow biomedical pathway. Such ‘overuse’ can restrict possibilities and limit capacities to imagine broader approaches to care. Overuse is entangled with requirements to be ‘useful’, illuminating the political, governing and evaluating structures within the clinic. The desire to be ‘useful’ tended to mean that economic factors (such as cost-effectiveness, clinic activity, and waitlist management) and quantifiable metrics were prioritised, limiting more-than-biomedical understandings of clinical outcomes (such as the appropriateness of care, or patient and clinician experiences) and producing distress.
This study makes the familiar strange within the clinic, illuminating how political and economic forces can shape the structure and functioning of the clinic, unintentionally producing distress and constraining care.
This study highlights the need for more attention to the people – patients, carers, clinicians – entangled within healthcare systems. Findings suggest that political and institutional level change is required to enable broader approaches to care. This may be facilitated by shifting the focus beyond quantified evaluation and economic outcomes to better incorporate the human aspects of care, along with the emotional elements of service users’ and clinicians’ experiences.
Political and economic factors
Distress
