International Journal of Osteopathic Medicine (2014) 17, 146e159

www.elsevier.com/ijos

RESEARCH REPORT

Osteopaths’ professional views, identitiesand conceptions e A qualitative groundedtheory study

Oliver P. Thomson a,b,c,*, Nicola J. Petty b, Ann P. Moore b

aResearch Centre, The British School of Osteopathy, 275 Borough High Street, London,United KingdombClinical Research Centre for Health Professions, School of Health Professions,University of Brighton, Darley Road, Eastbourne, United KingdomcResearch Department, The British College of Osteopathic Medicine, Lief House,Finchley Road, London, United Kingdom

Received 27 October 2013; revised 11 December 2013; accepted 18 December 2013

KEYWORDSOsteopathy;Osteopathic medicine;Knowledge;Decision-making;Clinical reasoning;Professionalisation;Professional identity;Grounded theory

* Corresponding author. Research Ceþ44 020 70895332.

E-mail address: o.thomson@bso.ac

1746-0689/$ - see front matter ª 201http://dx.doi.org/10.1016/j.ijosm.20

Abstract Background: The professional status of osteopathy calls for the criticalevaluation of the beliefs, knowledge and conceptions which underlie practitioners’clinical practice.Objectives: To explore experienced osteopaths’ professional identities, views andoverall conceptions of osteopathy in the UK.Methods: This qualitative study employed constructivist grounded theory set in theinterpretive research paradigm. The constant comparative method of analysis wasused to analyse and code interview data. A total of seventeen semi-structured in-terviews were conducted with twelve UK registered osteopaths. Data collectionmethods involved semi-structured interviews with participants and observationand video-recording of clinical appointments, which were followed by video-prompted reflective interviews.Results: There was diversity in how osteopaths viewed different aspects of theirprofessional practice. Views were constructed into the major categories of: profes-sional identity, traditional osteopathic theories and principles, health and diseaseand practice skills. Together these views formed three qualitatively different overallconceptions of osteopathy, termed: practitioner-centred osteopathy, collaborativeosteopathy, and osteopathy as empowerment.

ntre, The British School of Osteopathy, 275 Borough High Street, London, United Kingdom. Tel.:

.uk (O.P. Thomson).

3 Elsevier Ltd. All rights reserved.13.12.002

Osteopaths’ professional views, identities and conceptions 147

Implications for practice

� As professionals, osteopatcritically examine the vconceptions that underlie

� There is diversity in the rexperienced osteopaths hcore aspects of their pract

� How an individual practitinature of osteopathy and iprofession may influencdecision-making and the cthey take with their patien

� As knowledge and practichanging, practitionersreflect on their own persoosteopathy and how theclinical decision-making an

Conclusions: Osteopaths in this study held differing views, identities and concep-tions in relation to their practise of osteopathy. This diversity in professional identi-ties and conceptions may help to explain the variation of individual osteopaths’clinical decision-making and clinical approaches, thereby contributing to an episte-mology of osteopathy. These findings may be helpful to educators when planningcurricula and clinically tutoring osteopathy students. Further research is requiredto explore how these views and conceptions develop and evolve during undergradu-ate education and on-going professional development.ª 2013 Elsevier Ltd. All rights reserved.

hs are required toiews, beliefs andtheir clinical work.ange of views thatold in relation toice.oner conceives thedentifies with theire their clinicallinical approachests.ce are constantlyshould criticallynal conceptions ofse relate to theird practice.

Introduction

In many countries, osteopathy has undergone aprocess of ‘professionalisation’, which Cant andShamar define as a “type of occupational changeand formation that involves unification, stand-ardisation, and the acquisition of externallegitimacy”.1,p.197 There is evidence of the pro-fessionalisation of osteopathy in several corners ofthe world and different countries are at varyingstages of the process. For example, in the USA theformal process of professionalisation of osteopathyfirst began in the early 1960s, and has resulted inthe establishment of an osteopathic ‘medical’profession which enjoys the full range of clinicalpractices and procedures employed by the ortho-dox medical profession, in addition to osteopathicmanipulative therapy.2 In comparison, osteopathyin the UK and the antipodes is considered to be anemerging manual therapy profession3e5 whereprofessionalisation has taken place since the early1990s. Examples of strategies taken to facilitatethe process of professionalisation of osteopathy in

the UK and antipodes include3e5: 1) the formationof a single statutory register of osteopaths; 2) aregulatory body which sets standards of practiceand training; 3) structured and externally inspec-ted educational programmes; 4) legally protectedprofessional title of ‘Osteopath’; and 5) measuresin place to discredit those practitioners who do notpractice to agreed standards. All of these strategieshave provided osteopathy with unity, exclusivityand social closure which are considered to becharacteristics of a profession.1

The professional status of osteopathy carrieswith it the requirement to be critically reflective,and to constantly self-evaluate and self-questionin order to develop the knowledge base whichunderpins clinical practice and also to understandhow osteopaths know, what they know (an epis-temology of practice).6 Although a challengingprocess, identifying an epistemology of osteopathythrough critical enquiry and research is crucial tothe continued development of the osteopathicprofession. A number of other healthcare pro-fessions have discussed the importance of devel-oping an epistemology of practice, including thephysiotherapy7e10 and nursing professions.11,12

Although osteopaths’ professional knowledge,values and beliefs has been discussed theoreti-cally,13,14 and investigated in relation to specificaspects of clinical practice (e.g. prescriptionrights15 and chronic musculoskeletal pain16), thereis little research-based knowledge of how practi-tioners conceive osteopathic practice and how thisinfluences their clinical work. Developing an epis-temology of osteopathy through research wouldallow for the identification of the tacit or non-propositional knowledge used by practitioners, asthey work through the complex problems of dailypractice. Research of this kind would help to un-derstand what motivates individual practitioners’actions and decision-making when working clini-cally with patients. Furthermore, research whichdevelops knowledge of what steers osteopaths’clinical actions and behaviour would facilitate

148 O.P. Thomson et al.

clinical educators when working alongside stu-dents and also provide an understanding of therange of professional identities which could beembedded within osteopathic curricular.17 Ourrecent research suggests that how osteopathsconceive the nature of their practice (practiceontology) influences their clinical work and theirviews on knowledge (epistemology of practiceknowledge), decision-making and technical skillsand may help to explain the variation in clinicalapproaches (e.g. during treatment and manage-ment) that each osteopath takes with their pa-tients.18,19 How an individual practitioner’spersonal conception of practice develops andchanges during the course of their professional lifeis thought to be related to how they identify withtheir profession, their professional values and isultimately tied to their interactions with patientswhich take place during the clinical milieu.19e21

The physiotherapy literature suggests that practi-tioners’ professional values and identities developduring their interaction and socialisation withpeers during their undergraduate education andcontinues throughout their professional careerswhen interacting with professional colleagues.22

The nature of osteopaths’ professional values,conceptions and identities is yet to be investi-gated, and how these relate to their views on thetreatment and management of patients iscurrently unknown.

This paper explores experienced osteopaths’professional identities, views and overall concep-tions of osteopathy, and the findings from thisstudy form part of a broader theory of osteopaths’clinical decision-making and therapeutic ap-proaches reported elsewhere.18,19,23

Methods

Study design

This qualitative study followed a constructivistgrounded theory approach, with the primaryresearcher (OT) iterating between data collectionand data analysis.24 In accordance with interpre-tive research,25 throughout this study, OT assumed“multiple realities; indeterminacy; facts andvalues as linked; truth as provisional; and sociallife as processual”.24,p.126 In practice this meantthat during data collection the researcherexplored the social worlds of participants and co-constructed knowledge and meaning through asocially interactive process.25,26 The constantcomparative method of analysis was used to code

and analyse data.24 This involved OT reading andre-reading the transcripts, whilst looking for pat-terns in the data (such as differences and com-monalities across the data and between and withinparticipants) and allocating segments of data acode based on an interpretation. Memos werewritten throughout the course of the study andfacilitated OT’s reflexivity by explicating a prioribiases, assumptions and presuppositions whichcould be checked out and tested with the data,thereby contributing to the credibility of theresearch.27 Memo-writing also facilitated dataanalysis and theory development by criticallyquestioning data and forming hypotheses whichwere generated by the constant comparativemethod of analysis.24

Initially, experienced osteopaths with a mini-mum of five years in clinical practice and who wereinvolved in clinical education, were sampled pur-posefully as it was thought that these individualswould be ‘good informants’ and able to effectivelycommunicate and verbalise their professionalviews.28 In the latter stages of the study, theo-retical sampling, informed by data analysis, led tospecific participants and individuals not involved inclinical education to be sampled.24 For example,participants 1 and 10 were theoretically sampledand re-interviewed as they each appeared toconceive osteopathy in quite different and distinctways. This theory-led approach to sampling aimedto generate data that would help develop cate-gories and their properties and move the study’sfindings towards theoretical sufficiency.24

Data collection methods involved semi-structured interviews and non-participant obser-vation of practitioners during a patient appoint-ment, which was video-recorded and followed by avideo-prompted reflective interview.29 A total ofseventeen semi-structured interviews were con-ducted, three of which occurred immediately aftera patient appointment and were prompted by thevideo-recording of the session.29 The decision toincorporate video-recording and video-promptedreflective interviews as a method of data collec-tion was theory-led and constituted part of theo-retical sampling.24 It provided further specific dataabout how participants acted-out their views,conceptions and identities, in the context of theirclinical work with patients. All interviews wereaudio-recorded and transcribed verbatim. Themethods of data collection and analysis used inthis study have been presented in detail else-where.18,23,30 A number of strategies were used toenhance the trustworthiness of this study,31 andare summarised in Table 1.

Table 1 Strategies used to enhance and evaluate the trustworthiness of this grounded theory study.30

Description31 Strategies

Credibility Confidence that the research hasobtained an accurateinterpretation of the meaning ofthe data which reflects theexperience of participants.

- Prolonged immersion in the data (3years).

- ‘Insider’ position as an osteopathprovided opportunities to informallyverify, test and check the theory as itwas constructed during the analysis.

- Member checking e Participants wereasked to read through the interviewtranscript to confirm or refute that itrepresented an accurate account ofwhat was said, and were encouragedto add any further comments thatthey felt necessary.

- Peer debriefing in the form of feed-back from the peer review processfollowing the submission of sectionsof study to research journals andconferences.

- A well-developed researcher-participant relationship so thatparticipants had trust in disclosingpersonal details of their clinicalpractice.

- A reflexive diary was kept to discloseassumptions, biases and beliefs, andhow they have shaped the researchfindings.

Transferability Transferability is the extent towhich the ideas generated may beapplied to other populations orsituations, and may be consideredthe theoretical generalisability ofthe findings

- During interviews, the goal was toobtain “thick descriptions”, i.e. thosewhich were “deep, dense, detailedaccounts.”32,p.83

- Ideas and theories were discussedwith osteopathic colleagues notinvolved in the study.

Dependability andconfirmability

The degree to which the researchercan demonstrate that the findingsrelate to the data. Whether thefindings of the study offer adependable and realisticinterpretation of the view held bythe participants.

- An audit trail in the form of memos,reflexive diary and interview tran-scripts so that the reader can followthe research process.

- The word allowance of this paperlimits this, a fuller account can befound elsewhere.18,19,23,30

Osteopaths’ professional views, identities and conceptions 149

Participants

A total of twelve UK registered osteopaths tookpart in this study. Participants’ were recruitedfrom adverts placed in the national osteopathicpress and in osteopathic educational institutions(OEI). Participants’ biographical information isprovided in Table 2. Approval was granted by theFaculty of Health and Social Science ResearchEthics and Governance Committee at the Univer-sity of Brighton and the Ethics Committee of theBritish College of Osteopathic Medicine.

Findings

Participants expressed a range of views and per-ceptions in relation to many different aspects ofosteopathy. These professional views are dividedinto five major categories:

� professional identity� traditional osteopathic theories and principles� health and disease� practice skills� conception of osteopathy.

Table 2 Biographical information of studyparticipants.

Mean age (years) 43.5 (range 30e56)Mean years in clinicalpractice

15 (range 6e25)

Gender 10 males2 females

Work setting All worked in privateclinical practice10 held additionalroles as clinicaltutors or lecturersat an osteopathiceducationalinstitution

Education All had undergraduatequalification inosteopathy (BSc, DO)4 held additionalpostgraduatedegrees (MSc)

BSc e Bachelor of Science; DO e Diploma in osteopathy; MSce Master of Science.

150 O.P. Thomson et al.

The categories are discussed in turn and sup-ported with participants’ quotations from inter-view data which serve as evidence forthe theoretical claims made in this paper. Table 3and Fig. 1 summarise the five major categories.

Table 3 Summary of participants’ professional views.

Professional identityStrong and well defined: Osteopathy’s whole system [of twhat we are feeling passively. (P12)

Undefined; ambivalent: I don’t think that osteopaths do an

Traditional osteopathic principles and theoriesDefensive stance; principles and theories inform practicethose people are what I’ve always gone back to. I’ve alw

Critical stance; towards theories and principles: I don’t beosteopathy, or things like movement dysfunction, or pos

They [the osteopathic principles] were just musings of an ofrom the late eighteenth century rather than directives

Health and diseaseTowards a biomedical view: If you don’t have the basics lthe right decision. If you know your basics you can get t

Towards a biopsychosocial view: I like to see the other fapatient] experience their problem.it gives you a much

Practice skillsEmphasis on hands-on skills: Usually my treatments will stsoft tissue techniques with 95% of my patients.to loosemobilising [the joints] once you’ve softened the tissues.

Emphasis on communication skills: I like to spend time juit’s impacting them.(P7)

Emphasis on educational skills: I really believe in this noresponsible for themselves.and. if they can work out wit, it gives them back their control. (P6)

Professional identity

There was variation in how participants viewedthemselves as osteopaths in the context of theirprofessional work, and how they viewed osteopathyin relation to other healthcare professions, whichtogether constituted their professional identity.Five participants (P1,4,5,11,12) considered that asosteopaths, they were particularly different fromother healthcare professionals, and that osteop-athy was defined by distinct osteopathic values,skills and knowledge. These participants looked todefend osteopathy, and frequently drew compari-sons with other similar health professions to high-light professional differences:

Chiropractors and physios don’t have thattruly holistic approach that we [osteopaths]have. (P5)

Osteopaths look at the whole person morethan the average doctor. [and] that’s why Iwanted to become an osteopath and not a GP.(P4)

These participants tended to value approachesto osteopathy based on long-established traditionsand some felt strongly that the specific skills and

reatment] is based upon what we see structurally and

ything which is particularly unique, to be honest. (P6)

: The philosophical thoughts of Andrew Taylor Still andays read the old osteopathic stuff (P1)lieve that we should be obsessed with the principles ofitional lesions, I’ve thrown them out the window. (P3)ld man. [and] they’re just observations of physiology. (P6)

ike anatomy and physiology you are never going to geto the right decision very quickly. (P12)ctors that would be influencing the way that they [therounder picture of the person you’re treating. (P6)

art with quite a lot of palpation and soft tissue e I usen the tissues and developing into joint work, HVTs,(P5)

st talking to the person about what’s going on and how

tion of patient autonomy and I think patients arehy it’s there and what they can do to stop it or control

Osteopaths’ professional views, identities and conceptions 151

theories which they possessed were central totheir practise of osteopathy:

Osteopathically it’s our philosophical idea that iscentral to osteopathy. (P1)

Palpation is essential to the osteopath. If youdon’t know what’s underneath your fingers thendon’t touch the body. It’s as simple as that. (P12)

In contrast, several other participants(P2,3,6,9,10) did not consider osteopathy as beinga distinct discipline different from other health-care professions and had less-defined professionalidentities. These participants tended to highlightthe similarities of osteopathy compared to otherprofessions:

If you go with shoulder pain to a physio, a chiro-practor, and osteopath, it’s the samething.we’re all dealing with the same things. Soover the years it’s getting to the point where allprofessions look at things similarly. (P2)

Osteopaths don’t do anything new. chiropractorshave been doing it for a while; physios, massagetherapists [and] rolfers do the same. (P3)

Other professions do exactly the same asus.certainly the ones that I’ve worked with. (P10)

Participants that were ambivalent and who heldless-defined professional identities consideredthat their clinical practice entailed more than justthe application of osteopathic skills, theories andknowledge, and they appeared self-assured intheir own personal style and approach to practice:

Rather than just being an osteopath who doesosteopathy, I see myself as a person who willactually help facilitate patients’ recovery. (P7)

I’m not concerned about being called an ‘osteo-path’, it’s just a title that allowsme to do what I dowith my patients.[so] the word ‘osteopath’ isn’timportant tome, theword ‘clinician’ is better. (P3)

Overall, there were some participants that hadwell-defined professional identities and defendedthe distinctiveness of osteopathy by emphasisingwhat they considered to be the strengthscompared to other healthcare professions. Theyconsidered that specific osteopathic skills, knowl-edge and theories separated them from otherprofessions and shaped their professional identity.There were other participants who were

ambivalent and did not emphasise inter-professional differences and had less-defined pro-fessional identities.

Traditional osteopathic theories andprinciples

Participants expressed a wide range of views ontraditional osteopathic theories and principles (forexample33,34). Several participants (P1,2,8,11,12)valued particular time-honoured osteopathic the-ories and principles and considered that theseformed specialised osteopathic knowledge whichguided their clinical work:

The osteopathic concept that the body is its ownmedicine chest is one that I very much believe.[and] that’s where I think my approach becomesosteopathic. (P12)

There’s only one osteopathic principle, which iswhat A.T Still discovered, that you could treat anysymptom by working on the body. (P2)

The principles of osteopathy are instinctive to meand make me do what I do. (P1)

These participants perceived that osteopathyincorporated unique concepts of health, illnessand diagnosis and defended the importance ofthese for clinical practice. They tended toconsider that long-established osteopathic princi-ples should remain unchanged over time, and thatthe original ideas and theories derived fromimportant individuals within the osteopathic pro-fession were valuable to inform their decision-making and clinical work:

You have to think osteopathically, ‘What are thefluid mechanics like? What’s happening? Are thetissues being bathed?’ (P8)

You need to keep pure to the osteopathic philo-sophical idea.[and] I still operate from an oldschool point of view, where I use palpation to tellme what to do.[because] the principle ofremoving obstacles from the patient’s body, froman osteopathic point of view, is very important tome. (P1)

However, views varied as suggested by thefollowing comments from participants; some par-ticipants appeared ambivalent (P4,5,9) as illus-trated by the first comment; while otherparticipants (P3,6,7,10) were especially critical of

152 O.P. Thomson et al.

traditional osteopathic theories and principles.Some of these participants believed that adheringto such time-honoured customs was detrimental tothe osteopathic profession, as illustrated by thesecond and third comments:

I’m not so convinced on the A.T. Still stuff.I’mnot sure that I’m following the principles. (P5)

Certain osteopathic institutions teach treatmentalgorithms that come from the sacred books ofosteopathy.they’re traditionalists that have anold-fashioned, paternalistic approach topatients.[which] I don’t think is doing the pro-fession much good at all. (P6)

A.T. Still had a good idea at the time, but for us tostill remain by his book, like he’s some form ofdeity, is absurd [so] there’s a danger that someosteopaths will adhere to dogma (P3)

Overall, the variation in views suggests thatthere were participants who embraced traditionalosteopathic theories and concepts, and appliedthese to their practice. Other participantsappeared more critical of specific osteopathicprinciples and theories suggesting that they playeda less important role in their clinical work. Theseparticipants appeared to be more comfortabledeveloping their own clinical approaches andidentities.

Health and disease

Views about health and disease differed amongststudy participants. Almost half the participants(P1,2,5,8,11,12) expressed views that emphasisedthe physical, biological and physiological aspectsof the patient’s problem. These participantsappeared to place less emphasis on the emotionaland psychological experiences of the patient, andwhen talking about their views and practise ofosteopathy they focused strongly on the patient’sbody, physical structure and biomechanics. Thissuggests that they viewed patients’ problemthrough a predominantly biomedical lens:

If you know that the problem in the knee is causedby excessive rotation of the pelvis, then the [knee]ligament will be overloaded. So my work is to treatthe compensations of the patient’s body. (P1)

These participants tended to place high impor-tance on their technical expertise and hands-on

skills to assess and treat the patient, and inparticular the identification of dysfunctional re-gions in the patient’s body and tissues. Partici-pants that emphasised biomedical and physicalaspects of pain and disability (P1,2,5,8,12) tendedto view patients’ problem as separate from theirsocial and emotional circumstances. These par-ticipants appeared to separate out patients’physical and mechanical problem from their livedexperience and social circumstances:

I try and find the tissues causing symptoms, firstand foremost; then I can satisfy myself that this isa simple facet lock [or] strain. (P2)

If I can find the exact action that produces painthen I can have an idea of what tissue is involvedand start to think about treatment. (P5)

A view of health and disease which emphasisedthe biomedical aspects of the patients problem,resulted in several participants (P1,2,5,8,12)emphasising their technical expertise and directedtheir skills in clinical examination towards discov-ering and separating out an ‘objective dysfunc-tional entity’:

If the patient has pins-and-needles in their legs, Ineed to establish exactly where the pins-and-needles are. (P12)

My goal is to identify the local problems withinthe knee and clear the symptoms with treatment.(P5)

In contrast, other participants (P3,4,6,7,9,10)considered patients’ problem in the context oftheir lives and their illness experience, suggestinga broader psychosocial view of health and disease,as illustrated by the two comments:

My [clinical] examination is a patient-specificfunctional assessment [to get] an overall pictureof their pain and coping, in order to get a pictureof what we’re dealing with and how the person isdealing with it. (P9)

I always consider the physiological and psycho-logical aspects of the patient and how those areasrelate. that’s what I consider holistic. (P7)

Overall, participants viewed health disease indifferent ways. Some appeared to separate outpatients’ physical and mechanical problem fromtheir lived experience and social circumstancesand held views of health and disease which leant

Osteopaths’ professional views, identities and conceptions 153

towards a biomedical view. Several other partici-pants saw the patient’s pain and dysfunction aspart of ‘them’ and their everyday lives, activitiesand experiences and held views which emphasisedthe psychosocial aspects of health and disease.

Practice skills

There was diversity in the type of skills that par-ticipants emphasised in their practice. Although,all participants employed hands-on skills in theirclinical work; there was wide variation in theimportance that manual techniques played in ex-amination and treatment. Several participants(P1,2,5,8,12) emphasised the importance ofhands-on skills and technical expertise often withthe aim to try and discover and resolve the pa-tient’s physical impairment:

In my book the only reason why the patient hascome to your practice is because they have lostthe ability to move in a certain direction. (P1)

..the sense of touch and the sense of restriction,palpation helps you to identify tissue lesions orrestrictions.it’s about feeling and identifyingareas of cold, stiff, tense muscles. (P5)

It’s about my fingers giving me the informationthat I need, telling me about those tissues, thequality of them, what are they doing? Are theydoing what they’re supposed to be doing? What dothey feel like? (P8)

I’ve got to feel [palpate] the rotation of eachsegment of his spine, of each segment in the flesh.(P 12)

In contrast other participants (P3,4,6,7,9,10)placed less significance on hands-on skills andmanual therapy techniques directed to the pa-tients’ body. Three of these participants (P3,4,7)emphasised their communication skills and inter/intrapersonal skills in addition to hands-on skillsalone:

The physical examination is something that I’d beexpected to do. but the value of the actual in-formation is not critically important for me; Iknow how inaccurate the physical examination canbe. (P10)

I can perform the hands-on stuff in the back-ground which leaves me the capacity to talk to thepatient.because I concentrate more on devel-oping a relationship with the person. (P7)

While other participants that did not emphasisehands-on skills in their practice (P6,9,10) tendedto accentuate education and self-managementstrategies in addition to manual therapy treat-ment. These participants emphasised working withpatients to help them develop the skills to self-manage their health problem:

Lots of what we see is brought upon by patients’bad habits or lack of knowledge [and] so witheducation it’s all potentially preventable or self-manageable. (P6)

Three participants (P3,6,10) that emphasisededucational and communication skills in theirpractice appeared very critical of some of thehands-on aspects of osteopathy, for example:

To say that there’s a movable skull that we canpalpate, is ridiculous.[and] I’m happy toappraise the evidence and question it. (P3)

The osteopathic concept that your hands are themost important tools and you should rely on yourhands because they never lie is fallacious. (P6)

Most of the hands-on stuff is nonsense. It justhelps to loosen the patient off and make themfeel a bit better and more relaxed. (P10)

Overall, there was variation in the type of skillsthat participants emphasised in their practice.Some participants focused their clinical work ontheir hands-on skills and technical expertise, whileothers focused on the patient as a person andemphasised their communication, interpersonaland educational skills during their clinical prac-tice. Participants’ views on their professionalidentity, traditional osteopathic theories andprinciples, health and disease and practice skillsare summarised in Table 3.

Conception of osteopathy

Participants’ views on their professional identity,traditional osteopathic theories and principles,health and disease and practice skills formed anoverall conception of the nature of osteopathy,resulting in three qualitatively different ‘concep-tions of osteopathy’, which were termed: practi-tioner-centred, collaborative, and empowerment.This is not to suggest that all participants fitteddistinctly in each conceptual category, rather itoffers a crude differentiation of the diverse viewsthat participants’ held, allowing for theoreticalcomparison. These are illustrated in Fig. 1 and

•I don’t need patients to dictate what I do. I didn’t spend all this time training for a patient, who doesn’t understand osteopathy, to tell me how they want me to treat and manipulate their joints. (P1)

•I spend lots of time discussing and explaining what the options are with patients. I'll say, “this is what I can do to treat this with osteopathy and this is what you can do". (P7)

•By giving patients choice it treats them as an adult and gives them autonomy...so they are in control. (P6)

Conception of osteopathy

Practitioner-centred

Identity strong/distinct, defends

traditional theories/principles, biomedical

view, emphasises hands-on skills

Collaborative Identity less defined, critical of traditional theories/principles,

biopsychosocial view, emphasises communication

skills

Empowerment Identity less

defined, critical of theories/principles,

biopsychosocial view, emphasises educational skills

Fig. 1 Summary of participants’ overall conception of osteopathy.

154 O.P. Thomson et al.

discussed below with illustrative commentsprovided.

Practitioner-centred osteopathyFor half of the participants (P1,2,5,8,11,12) acentral feature of their conception of osteopathywas their application of specific osteopathic the-ories, hands-on skills and technical expertise.These participants emphasised their knowledgeand their technical skills, suggesting a conceptionof osteopathy which was practitioner-centred:

I need to know what I’m treating. [and] I’ve gotto know what the diagnosis is, so that I can getbehind the reason for it and I can treat it. (P12)

Participants with a practitioner-centredconception of osteopathy emphasised applyingtheir knowledge of osteopathic theories in combi-nation with their hands-on skills to discover andtreat patients’ physical dysfunction. Theypossessed a view of health and disease whichtended to focus on patients’ biomedical impair-ment. These participants possessed a strong oste-opathic identity which was characterised by theirspecific osteopathic hands-on skills, knowledgeand theories which they considered distinctivefrom other health professions.

Collaborative osteopathyA collaborative conception of osteopathy resultedin participants placing significant value on workingwith patients so that decisions could be madetogether. These participants (P3,4,8) emphasisedcollaboration and partnership with the patient,respecting them as an equal:

Having the patient onside and working with mefacilitates a better relationship that I have withthem. (P3)

Participants who conceived osteopathy ascollaboration were ambivalent in regards to theimportance of traditional osteopathic theories andprinciples in their clinical work; for them, usingtheir interpersonal and communication skills todevelop a therapeutic partnership with the personwas central to their practise of osteopathy. Theseparticipants did not consider themselves asdistinct osteopathic professionals; they sawthemselves as individual healthcare therapistsworking alongside other healthcare professionals.They endeavoured to understand the patient’spain and physical dysfunction in the context oftheir lived experience and social situation, andcommunication was an important part of devel-oping this understanding. In this regard they

Osteopaths’ professional views, identities and conceptions 155

possessed a view of health and disease whichconsidered the psychological and social aspects ofthe patient and their problem.

Osteopathy as empowermentParticipants in this group conceived osteopathy asa means by which they could facilitate patientempowerment. These participants (P6,9,10) didnot distinguish facilitating patient empowermentfrom their practise of osteopathy, and enablingpatient learning was the basis of their treatmentand management strategies. These participantsconsidered their educational skills as central totheir practice, which enabled them to supportpatient empowerment and self-management:

Osteopathic care is about helping to educate pa-tients; it’s about empowering patients to be ableto look after themselves and make the most oftheir life. (P6)

Participants that conceived osteopathy asempowerment emphasised educating patientsthrough sharing knowledge and valued the patient’sown knowledge of their pain and disability. Theyembraced a psychosocial view of health and in doingso they considered the patient’s problem in thecontext of their daily life and how it impacted theirday-to-day functioning. These participants tendedto be critical of long-held beliefs, traditional oste-opathic principles, theories and customs and feltthat hands-on skills alone were insufficient to helpthe patient self-manage their problem.

Discussion

This study is the first of its kind to explore theprofessional views, identities and conceptions ofosteopathy of practitioners in the UK. The findingsfrom this study suggest that osteopaths holddifferent views and perceptions of their profes-sional identity, traditional osteopathic theoriesand principles, health and disease and practiceskills, which together help shape their overallconception of osteopathy. The diversity of viewsand identities amongst the practitioners in thisstudy is consistent with research investigatingphysiotherapists’ professional identities andvalues.21,22,35 Previous research suggests that howthese identities, views and conceptions are enac-ted during actual practice will influence osteo-paths’ clinical decision-making and ultimately theclinical approaches they take with their pa-tients.18,19 Importantly, research suggests that theattitudes and beliefs of manual therapy practi-tioners (physiotherapists, chiropractors and

osteopaths) in relation to common clinical condi-tions such as low back pain may influence theirclinical decision-making and behaviour when car-ing for patients.36,37

In this study, individuals that conceived oste-opathy as practitioner-centred emphasised theirrole as a distinct osteopathic professional thatpossessed the knowledge, skills and technicalexpertise to discover and treat the patient’sproblem. This finding is consistent with someosteopathic literature which proclaims that animportant goal of the osteopath is the ability tofind disturbances and abnormal segments withinpatients’ bodies by skilfully employing hands-onexamination and palpation procedures.38 Thisfinding also echoes a mechanistic view of thefounder of osteopathy, A.T. Still, who considered“man as an engine and the osteopath as a humanengineer”.39,p.374 Practitioner-patient interactionwhich overly emphasises patients’ bodies (such astheir movement and physical/structural charac-teristics) may limit practitioners’ understanding tothat of the objective reality of patients’ anatom-ical, physiological and biomechanical dysfunc-tions.40 This view could be considered narrow andtherefore fail to connect the physical impairmentwith patients’ social world and lived experiences,which is necessary for a deeper understandingwhich is embodied and relational.41 Although someresearch suggests that practitioner-centred clin-ical practice is a characteristic of novice practi-tioners,42,43 in this current study there did notappear to be a qualitative association betweenpractitioners’ years of clinical experience andtheir conception of professional practice, and thisfinding is in agreement with others.44,45

Practitioners that conceived osteopathy ascollaboration centred their practice on the thera-peutic relationship and the sharing of knowledgeand decision-making with the individual person.These practitioners emphasised talking andlistening with patients above both providing hands-on treatment and facilitating patient empower-ment. This finding echoes the concept of the‘therapeutic use of self’ discussed in the psycho-therapy,46 occupational therapy47 and nursingliterature.48 It is maintained that the use of per-sonal attributes as part of the therapeutic processoffers alternative insights and perspectives,thereby facilitating professional judgement anddeveloping a therapeutic relationship.46

Finally, practitioners that conceived osteopathyas empowerment focused their practice oneducating patients, eliciting their personal pref-erences and their learning needs, and providingchoice. Facilitating patient empowerment so that

156 O.P. Thomson et al.

they can be involved in decision-making abouttheir treatment and management involves situ-ating the patient at the centre of their care.49 Theliterature argues that in practice, enabling patientempowerment requires placing the patient asprofessionals in their own right and experts of theirown care, bodies, symptoms and situations.50 Thisechoes with the finding in this study, in that thosepractitioners that conceived osteopathy asempowerment sought to generate meaningful,patient-specific cues, pertaining to the impactthat patients’ pain and dysfunction has on theirdaily lives and activities. The literature suggeststhat interacting and communicating in this wayfacilitates a patient-centred approach to educa-tion and self-management of patients, particularlythose with chronic conditions.50,51

The findings from this study suggest that someparticipants held practitioner-centred conceptionsof osteopathy resulted in them focussing theirclinical work on identifying the manifestations ofphysical (‘somatic’) dysfunctions within the pa-tient’s body regions. Such a focus on the physical‘osteopathic’ impairment may overlook the pa-tient as a person and their individual illnessexperience. Throughout the history of osteopathy,numerous theories and practice models have beenespoused often from prominent individuals fromspecific corners of the osteopathic profession (forexample52e54). Many of these theories tend toplace the patient’s body and the practitioner’sknowledge and skills at the centre of practice, andoffer ways in which the practitioner can correctand remove dysfunction and disability from thepatient. Such practitioner-centred approachesmay advocate inequality, promote patientpassivity and facilitate practitioner paternalism.As the osteopathic profession matures, it shouldcritically review such models and be confident inletting go of those theories and models whichpromote dualistic thinking, patient passivity andpaternalistic care. This process of critical reflec-tion may be made more challenging by resistancefrom practitioners who consider such practitioner-centred approaches to be ‘traditionally osteo-pathic’ and form part of their ‘unique sellingpoint’ within the competitive market of privatemanual therapy practice. If the profession fails todo so it risks being excluded from mainstreamhealthcare, policy and decision-making.

The physical and manual therapy professions arecontinuing to grow and are becoming increasinglycompetitive in the provision of musculoskeletalcare.55,56 The increasing range of literature andCPD courses currently available, provide opportu-nities to cross-pollinate knowledge and skills

between different healthcare professions. Thismay be particularly significant in relation to thoseprofessions where there are significant similarities,as is the case of the major manual therapy pro-fessions: osteopathy, physiotherapy and chiro-practic. In response to such influences, it is possiblethat some members of the osteopathic profession,in an attempt to remain ‘pure’ and appear distinct,may uncritically adhere to osteopathic theories,models and traditions which overly emphasise thebody, and its specific parts and segments (forexample53,57). Many of these models are over fiftyyears old, and their positivist and biomedical slantreflects the period in which they were conceived.Uncritically accepting and rigidly applying dualistictheories, in light of the widespread acknowledge-ment of the social, psychological and behaviouralfactors of health, pain and disability58,59 mayjeopardise the osteopathic professions’ develop-ment and perhaps most importantly, fail to provideoptimal patient care. Furthermore, a practitioner-centred approach to practice appears to conflictwith the Standards of Osteopathic Practice set outby the osteopathic regulator in the UK, which areexplicit in stating that practitioners should “work inpartnership with patients to help find the besttreatment for them”.60,p.8 Future CPD coursescould be directed towards helping practitioners tofoster critically reflective practice and promotepatient collaboration and inter-professional co-operation in line with practice standards andessential for modern professional practice.

This study explored the views, identities andconceptions of osteopathy from the perspective ofexperienced practitioners, and how such concep-tions are experienced and perceived by patientsrequires further research. Future studies couldexplore how these views, identities and concep-tions of osteopathy develop though undergraduateeducation and evolve during professional life.20,35

Such knowledge would be useful to osteopathiceducators and curriculum planners to help preparestudents to develop a professional identity. Theliterature suggests that during professional edu-cation, practitioners begin to develop their ownvalues, beliefs and philosophy of practice, whichare considered to be some of the most influentialforms of professional socialisation.20,61 It may bethe case that undergraduate osteopathic educa-tion would have enabled groups of individual stu-dents to develop shared perspectives, commonvalues and assumptions.62 Once qualified, practi-tioners may have also developed new perspectivesand values based on the day-to-day social inter-action in the workplace with other colleagues.22

Symbolic Interactionism Theory63 proposes that

Osteopaths’ professional views, identities and conceptions 157

an individual’s behaviour is influenced by theculture and context in which the social interactionis situated. This means that student osteopathslearning together may develop common ‘taken-for-granted’ assumptions of their professional roleand identity,22 such as emphasising the impor-tance of anatomy and a shared interest inbiomechanics. Due to the long history of many ofthe OEIs in the UK, (with some dating back almost100 years), each institution is considered to havedeveloped its own ‘flavour’ with their teachingand learning emphasising different aspects andinterpretations of osteopathy. However, the find-ings from this study suggest no qualitative rela-tionship between participants’ conception ofosteopathy and the OEI that they graduated fromor which they worked.

Finally, further research could investigate theinfluences that the professional views, identitiesand conceptions have on clinical outcomes, andhow they relate to clinical guidelines on commonand professionally relevant conditions, such aschronic low back pain.37 The attitudes and beliefsheld by practitioners regarding specific compo-nents of patient care, such as effective reassur-ance, self-management, return to work, and theprovision of hands-on treatment in the short term,may all impact on patients’ health outcomes withchronic musculoskeletal pain.37,64,65 These com-ponents could be investigated in relation to thedifferent professional views, identities and con-ceptions developed from this study, with the po-tential to enhance the clinical effectiveness ofosteopathic care.

There are several limitations to this study whichshould be highlighted. The limited number ofpractitioners which took part in this study meansthat transferability of the findings to the widerosteopathic and manual therapy professions needsto be established through further research.Furthermore, this research did not include osteo-paths working within the public setting (NHS).Although these practitioners represent a relativelysmall proportion of the UK profession,66 it’spossible that as a result of working within such alarge, complex and multidisciplinary organisationas the NHS, such practitioners would have adoptedquite different models of practice and helddifferent professional views and warrants furtherresearch.67

Conclusion

Osteopaths in this study held a range of views inrelation to their professional practice, and were

characterised by the major categories of: profes-sional identity, traditional osteopathic theoriesand principles, health and disease and practiceskills. Individually, these views contributed topractitioners’ overall conception of osteopathy,which was characterised as either practitioner-centred, collaborative or empowerment. This di-versity in professional identities and conceptionsmay help to explain the variation of individualosteopaths’ clinical decision-making and clinicalapproaches, thereby contributing to an episte-mology of osteopathy. Further research is requiredto explore how these views and conceptionsimpact on patient care as well as how they developand evolve during undergraduate education andon-going professional development.

Acknowledgements

Thanks to the British College of Osteopathic Med-icine, the British Naturopathic and OsteopathicAssociation and the Osteopathic EducationalFoundation for helping to fund this doctoralresearch.

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