Urban ideals and rural realities: Physiotherapists navigating paradox in overlapping roles

Abstract

Objectives: Rural practitioners who develop a sense of belonging in their community tend to stay; however, belonging means neighbours become patients and non-clinical encounters with patients become unavoidable. Rural clinical experiences expose students to overlapping personal and professional relationships, but students cannot be duly prepared to navigate them because ethical practice standards primarily reflect urban, and not rural, contexts. To inform such educational activities, this study examines rural physiotherapists' strategies for navigating overlapping relationships.Methods: Constructivist grounded theory guided iterative recruitment of 22 physiotherapists (PTs) living and practising in rural, northern or remote (RNR) communities in British Columbia, Canada, and analysis of their experiences navigating overlapping relationships.Results: PTs routinely navigate overlapping relationships while mindful of practice standards, neighbourly and community expectations, personal well-being and patient welfare. While off-duty, they balance opposing expectations and manage various responsibilities to achieve contradictory goals such as being a professional who protects patient confidentiality while being an active and cordial community member. While on-duty, they face ethical dilemmas where deciding not to treat acquaintances potentially denies access to care but allows for clearer personal-professional boundaries and deciding to treat contravenes (urban) practice standards but could allow for customised patient care based on knowledge gained through both clinical and social interactions. Conclusion:Overlapping relationships are a rural norm. Urban ethical practice standards imposed on rural contexts put RNR practitioners in a paradoxical situation where clinical and social interactions must be but cannot be partitioned. Examining the identified strategies through the lens of paradox theory shows sophisticated cognitive framing of the conflicting and interrelated aims inherent to living and practising in RNR communities. Consequently, introducing a paradox mindset in educational activities could be explored as a way to prepare students for the ethically complex overlapping relationships that they will need to navigate during RNR clinical experiences.

An Ecological Account of Clinical Reasoning

“…The concept of regionalized effectivities may provide a means to identify strengths and advantages of rural practice that avoid the “metrocentric” normativity in standardized training. 82,83…”

The Ethics of Overlapping Relationships in Rural and Remote Healthcare. A Narrative Review

“…While cautioning against a generic approach (Gonyea et al 2014), there is likely to be a tangible benefit in assisting practitioners to navigate situations such as whether to treat a friend (Zur 2005), play sport with a patient (Anderson, Pierce, and Crowden 2011), respond to an invitation to join a longstanding patient for dinner (Vig and Foglia 2014), negotiate the social fabric of a small town (Ringstad 2008), or to be able to contextualize their conduct to a regulatory body unfamiliar with the exigencies of practice in a particular location or setting (Scopelliti et al 2004). The paradox faced by rural clinicians in having to impossibly partition their clinical and social worlds within a community (Gingerich et al 2021) arguably provides a contextually informed rural ethics the opportunity to both support practitioners while more broadly making visible what is already a ethical reality (Simpson and McDonald 2017).…”

“…However, in recent decades the view that a treating practitioner must only have a singular relationship with their patient has been challenged as urban-centric in its ethical approach (Simpson and McDonald 2017) and in its ignorance of the realities of rural clinical practice (Gingerich et al 2021). It has been posited that professional boundaries and their management in a rural context may be recast in a manner that recognizes their pervasiveness (Thomas, Boxall, .and et al 2014).…”

Urban ideals and rural realities: Physiotherapists navigating paradox in overlapping roles

“…Gingerich et al argue, in their article entitled Urban ideals and rural realities, that overlapping personal and professional worlds in the rural context can lead to 'private' information being gathered as a part of social connectedness, with consequent violations of urban practice ideals to do with the separation of practice and person. 1 Their point is, however, that this information is then judiciously used for the patients' best outcome. My agreement with their argument lies in the thesis that genuine expertise lies in the judicious and wise use of information for best patient outcomes, which stands in contrast to the ethics taught to urban medical students under the rubric of 'confidentiality'.…”

“…Gingerich et al argue, in their article entitled Urban ideals and rural realities , that overlapping personal and professional worlds in the rural context can lead to ‘private’ information being gathered as a part of social connectedness, with consequent violations of urban practice ideals to do with the separation of practice and person 1 . Their point is, however, that this information is then judiciously used for the patients' best outcome.…”