Hypothesis Paper“If you don't use or understand visceral osteopathy you're not a real osteopath”: Professional identity in Australian osteopathy through the lens of a single traditional technique
Introduction
Multidisciplinary healthcare describes a collaborative approach to assessment, treatment and management plans with the aim of providing comprehensive patient care.1,2 This approach continues to gather traction in recognition of the complexity of the healthcare needs of patients who increasingly present with co-morbidities and chronic health conditions.3 Working in multidisciplinary teams highlights to health professionals their scopes of practice and the professional boundaries within which they conduct their practices. These boundaries have evolved over time and delineate current conceptions of each profession and how it functions in the healthcare system.4 This paper discusses the professional identity of osteopaths in the context of their use of and attitudes towards a single technique in their practice.
The concept of professional identity has been described as the construction of a person's experience, qualities, beliefs and values that define their professional role. It emerges from both internal influences (e.g. personal values and expectations) and external ones (e.g. the public image of the profession, the opinions of other health professionals and professional entry education).5., 6., 7. Professional identities have been particularly important for professions that offer similar services. Manual therapies professions in Australia are one such example. Australian osteopaths, chiropractors and physiotherapists have considerable overlap in their scopes of practice,8., 9., 10. however only physiotherapists have the status of mainstream healthcare.11 As such, physiotherapists can work in the public hospital system and are the preferred recipient of medical referrals for manual therapies.12 Chiropractors and osteopaths, on the other hand, can find themselves defending their professional status and their inclusion in multidisciplinary healthcare teams.13,14 Consequently, there have been calls from some sections of these professions to differentiate their unique contributions to Australian healthcare.15 One study into the professional identity of chiropractic concluded that it ‘remains, at best, a work in progress and, at worst, a matter of considerable controversy’.16
Professions rely on exclusionary strategies like certification and credentialing processes to secure professional boundaries and to prevent other professions from claiming its knowledge base.17,18 The motivation for exclusionary strategies is the ongoing negotiation of social standing and the income and power associated with achieving a high status.19 Osteopaths have used both credentialing and licensing strategies in their professionalization. For example, in recent decades, the profession has achieved a high level of professional status through public university education and government licensing. In Australia, students can choose between three public universities to study osteopathy and be eligible to register with the Osteopathy Board of Australia (through the Australian Health Practitioner Regulation Agency) to practise and use the title ‘osteopath’. The curriculum at each university is accredited with the Australian Osteopathic Accreditation Council and is required to align with the Capabilities for Osteopathic Practice.8 Osteopathy Australia recently launched two clinical practice groups, with a further four due for release in 2020, with a view to identifying and claiming its specialist knowledge in these areas.20 Combined, this accreditation, credentialing and the legal framework within which osteopathy operates strengthens its scope of practice and the professional identity of osteopaths. However, this is an ongoing negotiation.21
The Australian Capabilities for Osteopathic Practice refer to a range of manual therapy techniques, including ‘short precise impulses, rhythmic mobilising and stretching techniques, joint positioning techniques and very gentle specifically applied pressures’ designed to ‘strengthen unstable joints and address areas of tissue strain, stress or dysfunction that may impede normal nerve function, circulation and biochemical mechanisms’.8 A range of visceral techniques, that is techniques designed to normalise mobility disturbances that can be palpated in abdominal viscera by palpation and treated by manipulation22 are also included in all osteopathic curricula in Australia. In fact, Benchmarks for Osteopathic Education published by the World Health Organization in 2010 included osteopathic visceral techniques23 and these techniques are reported to be routinely used in osteopathic practice.24,25 Although visceral techniques are used by osteopaths, research supporting their effectiveness is equivocal. Academics in osteopathy, as in other complementary medicine professions, have prioritised building the evidence to support their professions and are keen to align with allied health professions who have broad mainstream professional recognition.21 Consequently, evidence-based diagnostic and treatment approaches are prioritised. A systematic review published in 2018 found no quality research investigating the reliability or efficacy of visceral osteopathy.22 Consequently, techniques that lack strong supporting evidence, like visceral techniques, are likely to receive little attention in contemporary osteopathic curriculum.
Osteopaths’ use of and attitudes towards visceral techniques in their practices presents an opportunity to explore external and internal influences on the professional identities of osteopaths.17 In March 2020, there were 2627 registered osteopaths in Australia.26 The majority of osteopaths in Australia practise in privately owned clinical settings,27 with patients accessing these services privately. It is estimated that 10% of Australian osteopaths use visceral techniques in practice27 with up to 70% of their patients.28 The aim of our study was to understand the professional identities of osteopaths through the analysis of open-ended text responses collected in a survey of Australian practitioners about their use of visceral techniques.
Section snippets
Method
This study was approved by the Human Research Ethics Committee at Victoria University (Melbourne, Australia). This work reports on the analysis of the open text comments only with the quantitative data being analysed separately.
Results
A total of 143 osteopaths (14.4% of 992 invited osteopaths) accessed the survey; 137 provided complete responses and were included in analysis. Of these 98 (72%) reported using visceral techniques and 28% reported not using them in the preceding 6-month period. Three key themes emerged from analysis of open-ended responses of both groups (those reporting using visceral techniques in the preceding 6 months and those reporting not using them): (1) being an osteopath; (2) applying visceral
Discussion
The aim of our study was to analyse open-ended text responses collected in a survey of Australian practitioners about their use of visceral techniques from the perspective of professional identity. Responses suggested a range of osteopathic identities, reflecting the diversity within the profession in Australia today. The professional identities of all health practitioners are influenced by internal and external factors.5,7
Conclusion
This study explored the internal and external influences on the professional identity of osteopaths through the lens of a single traditional osteopathic technique – visceral. Professional identities of respondents aligned with their own world views and values (internal influences), including the inclusion or exclusion of visceral techniques as part of osteopathic care. Practitioners were either strongly committed to including visceral techniques as part of a holistic model of health care and as
Ethical approval
This study received ethical approval from the Victoria University Ethics Committee - #HRE19-044
Financial interests
None declared.
Declaration of Competing Interest
None declared.
Acknowledgment
The ORION project is funded by Osteopathy Australia. The funding source had no influence in the design of the study and collection, analysis, and interpretation of data and in writing the manuscript. The research reported in this paper is the sole responsibility of the authors and reflects the independent ideas and scholarship of the authors alone.
The authors would also like to thank Professor Jon Adams, Dr Amie Steel and Dr Wenbo Peng from the Australian Research Centre in Complementary and
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2022, International Journal of Osteopathic MedicineCitation Excerpt :Over the last 10 years, researchers have made a significant effort to understand the nature, processes and role of osteopathic clinical practice and decision-making. Research using qualitative and quantitative research methodologies is developing an increasing understanding of different aspects of osteopathy including osteopaths' professional identity [1,2], their clinical reasoning [3,4], their attitudes and skills in relation to evidence-based practice [5,6] and how osteopaths conceptualise and implement the biopsychosocial model [7,8]. Despite this increasing understanding of osteopathic practice, the therapeutic approaches adopted by an osteopath for individual patient care continue to be defined by their application of specific manual therapy techniques.
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2021, International Journal of Osteopathic MedicineCitation Excerpt :We are not sure why these differences exist, we would need a more detailed breakdown of the data to compare, for example, the geographical setting, gender and age of those working alone and with others. We also know from research done in Australia that the characteristics of osteopaths who prefer to use the more gentle light touch techniques are wrapped up in a complex identity association [25]. The legal status of recognition and regulation of osteopathy may also impact on education standards, service delivery and/or private health insurance re-imbursement for the cost of care.