Background
This is the second article reporting on a study exploring accreditation standards and processes of chiropractic education. The role for the training of chiropractors is undertaken by Councils on Chiropractic Education (CCEs), which oversee the regulatory and educational standards for chiropractic education providers. These standards are outlined in their written documents. They are composed of a description of the competencies a student is expected to attain before graduation as well as a set of requirements for chiropractic programs, among others, curriculum content, facilities, and staff.
Previous studies have raised concerns in a number of areas of the accreditation processes conducted by CCEs [
1‐
5]. These have included variability in standards between accrediting agencies [
6], lack of an evidence-based (EB) approach [
2], inclusion of non-evidence-based philosophies such as
vitalism and
subluxation theory [
3]. Also, non-evidence-based beliefs have been identified in chiropractic students, who are resistant to the educative process [
7], as well as deficits in their understanding of non-indications for care [
5]. Finally, a relationship between chiropractic student personality traits and their clinical decisions has been demonstrated [
4]. These issues probably reach beyond pedagogy and have implications for patient safety, quality of care and workforce mobility [
8‐
15].
In Part One, the opinion was sought on each of these matters from CCE experts, as they may have valuable insights into CP regulatory matters and could corroborate and improve our understanding of the complexities of these concerns, as well as suggesting possible solutions (Part 1, Innes et al., in press). A qualitative approach was taken, because past research exploring these themes encountered an unexpected reluctance to respond to a survey [
16], and a qualitative methodology facilitates the exploration of complex phenomena like this [
17,
18].
When the CCE experts were asked for their views on these concerns, six common themes emerged across the five issues listed above. These were CCEs organizations had to negotiate a diverse profession with strongly held views that frequently resulted in conflict and they had to do this with limited resources. The respondents believed chiropractic should be integrated within the healthcare community, but efforts should be made to preserve its uniqueness. Concerns were expressed by respondents that profit motives often drove chiropractic program behaviours, and there was a wide range of views on how best to assess chiropractic programs for accreditation. These themes were over and above the interview questions and warranted separate reporting and discussion.
In this Part Two article we report on the responses of the CCE experts to each of the concerns posed in the interview questions and attempts to garner the diverse discussion and controversial professional responses found.
Aim
The primary aim of this study was to explore the experience and beliefs of CCE experts of (re)-accreditation standards and processes of CP by seeking their views on the following issues:
I.
All CCEs should perhaps implement an identical international set of competencies for all chiropractic students to achieve before graduation.
II.
All CCEs should implement an identical set of accreditation and re-accreditation standards for CPs. This would include minimal staff qualifications and student hospital placements.
III.
The processes and standards of site inspection teams of CPs.
IV.
CCEs should watch over CPs to ensure students learn important course material. For example, learning the appropriate contra / non-indications for chiropractic care or helping students and CPs educators understand how student personality, attitudes, and beliefs may impact on clinical decision making.
V.
Vitalism and evidence-based practice in CP course material.
Method
This was a qualitative study utilizing in-depth semi-structured interviews in-person via Skype or telephone. The derivation of the questions has been detailed in the first study (Part 1, Innes et al., in press) and the interview questions (
aide de memoire) are attached in Additional file
1. Ethics approval was obtained from the university Human Research Ethics Committee (2018/055) before recruitment and data collection.
Participants and recruitment
Nine expert participants were recruited from thirteen email approaches. The full details of CCE member sample size, recruitment, consent, and confidentiality management are detailed in the first study (Part 1, Innes et al., in press). Two key representatives were sought from each of the 5 CCEs. The final sample consisted of nine participants (6 men and 3 women) who had an average of 14 years-experience with at least one CCE, two of whom were non-chiropractors. The interviews were conducted from May to July of 2018 and lasted between 32 and 62 min, with an average duration of 44 min.
Data collection
Data were collected from consenting participants using a semi-structured in-depth interview process via Skype or telephone, because the respondents were located at a distance, both nationally and internationally.
The principle researcher conducted the interviews (
n = 9). The nine participants were provided with the interview questions, generated from previous research findings, prior to the interview and invited to reflect on the questions. Participants were invited to make further comments as they felt appropriate to the topics under discussion. An
aide de memoire was used to ensure consistency across all the interviews (Additional file
1).
Data analysis
The data analysis is also detailed in Part One (Part 1, Innes et al., in press) but in summary the issues of trustworthiness of data and interpretation of the study required addressing credibility, transferability, dependability and confirmability [
19]. The transcriptions were returned to the interviewees for verification of accuracy to increase credibility. The interviewer was familiar with relevant CCE documentation [
1‐
3,
20]. This helped ensure credible interpretation of the interactions with the participants, thus improving methodological rigour [
21]. To attain dependability and confirmability of the data, the analysis process (using NVivo 11 software) as outlined by Braun and Clarke [
22],was reviewed by another qualitative expert. The interviews were reviewed by the lead researcher and discussed with a qualitative research investigator, until they agreed that thematic saturation had been reached. They agreed this occurred after the ninth interview. Implications of these findings were discussed and a list of recommendations compiled.
Results
The CCE experts, when responding to the possibility of implementing identical international CCE standards, stated that their views were the same for both the expectations for students’ graduation competencies and the written accreditation standards for CPs. Consequently, the graduate competencies and accreditation standards findings were grouped together.
Standards for competencies of graduating chiropractors and accreditation
Suggestions for changes to improve the domains and subdomains of CCEs standards?
Six of the nine interviewees could not think of any changes to the domains and subdomains of their respective CCEs standards for the improvement of graduate competencies and accreditation standards. One third of the nine felt that the ‘real issue’ was how to facilitate CPs to want to seek compliance rather than be forced to achieve a set of standards. All respondents spoke of the inherent ambiguity in language. That is, one word may have different meanings for different cultures or societies. Consequently, the respondents spoke of the need for more work on definitions and on the terms commonly used in accreditation standards to resolve this lack of clarity. The words most often cited were “chiropractor” and “diagnosis”. The possession of more detailed definitions was thought to result in an increased ability to assess CPs as well as to create a more portable international workforce.
R2: “I don’t think actually it’s an issue of improving the standards per se. As it is to get compliance. And I think that’s the bigger issue”.
Is it possible to create identical international standards?
The task of achieving identical international standards was seen to be unachievable because of cultural differences and local jurisdictional variations. It was thought that a more appropriate expression was “equivalence of standards”. To this end three participants thought that it would be helpful if a core set of standards was created.
R1: “Absolutely not. The word is not identical competencies but equivalent competencies. We - again at the CCE – we struggled with that a whole lot and I think there needs to be core standards that are much the same across the board and across the world”.
This sentiment appears to be at odds with the thoughts of three other respondents who believed that even trying to achieve something fundamental, such as a definition of “chiropractor”, was highly unlikely.
R2: “Good luck with that (sic defining chiropractic) . . . . It’s a political issue rather than a clinical issue. And you know when you look at most of the studies on what chiropractors do, most of what they do is neuromuscular skeletal problems”.
Views on an EB approach to the formation of accreditation standards and processes
All CCE respondents acknowledged the importance of an EB approach to the formation of accreditation standards. One expressed the view that the entire healthcare community is adopting an EB approach to education and practice wherever possible. Therefore, it is nothing more than what should be expected of CCE’s. However, five of the nine respondents added caveats, such as, there is no evidence for everything a chiropractor does and the practitioner’s clinical experience is an important consideration in accreditation standard development. Two thirds of the CCE representatives thought that research into these standards was needed and that CCEs were strongly positioned to guide and inform it. However, it was contended that CCEs were under-resourced to do this research themselves.
R1: “To have a strictly evidence-based practice is probably not necessary and probably a hindrance in that you’ve got to keep yourself from using stuff that is truly valuable”.
The process and standards of site inspection teams of CPs
Views on the ability of site inspection teams to monitor CP compliance
There was widespread but conditional agreement that site inspection teams formed a valuable part of the monitoring process of CPs. At least one third of the respondents thought that important issues were obtaining team members who had the necessary personal qualities, such as interpersonal and critical thinking skills. Additionally, team members were deemed to require an understanding of the accreditation standards, be experts in their field, and have prior experience. Further, the teams themselves should be well resourced, carefully trained and led by a skilled leader. Two respondents commented that there was only a small pool of chiropractors available to choose from for this task and that more consideration should be given to including experts from outside the profession.
R5: “My view is that the training of the team members, generally speaking, is not very good. They need to be prepared to process lots of information. Some of the team members are not very good at this. They need to know how to collect data and interpret it. In other ways most of the team members tend to struggle with this task. They need to have critical thinking skills to be able to do all this. It is very difficult and involves a lot of training”.
Respondents also thought that inspection teams needed to be able to see through CPs that submitted “glowing” self-evaluation reports or attempted to hide deficiencies. Respondents also spoke of the importance of pre-inspection knowledge or intelligence from sources outside of the CP self-evaluation report (students, staff, and professional chiropractic association members).
Views on the ability of site inspection teams for quality improvement of CPs
Approximately half of the participants thought that carefully constructed experienced teams, which have developed a strong rapport with CPs were an important source of thoughtful and meaningful suggestions for continued improvement. Many respondents thought that site teams offered CPs located within a university setting a means for leverage to bring about changes with the threat of the removal of accreditation. Possible changes mentioned were more full-time staff, funding and removal of unnecessary curriculum requirements.
R6: “So I think it could go both ways, but I’ve seen many examples where the site evaluation report has been instrumental in making improvements. And also provided the impetus especially if they’re part of universities. So, they have this report, now this professional team’s accrediting body has said we need to do this. And that gives them ammunition. It’s not just the faculty or the management of the programme saying”.
Should final site inspection teams’ reports be made public?
Respondents were either strongly in favour of transparency or thought it was a “conundrum”. Reasons for publishing findings of CP site inspections included; exposure of bad behaviour forced change, the public has a right to know, it is standard practice around the world and in other health professions, and CPs are resourceful and can manage the stress of adverse findings. Reasons against disclosure were; it is distressing for CPs and can damage their image, confidentiality is a facilitator of open and frank disclosure by CPs to CCEs and the public cannot understand the complexities around (re) accreditation processes. One CCE expert reported no adverse effects from publishing the site inspection team’s final report on their website and could see no reason for others not to do so. Finally, several respondents thought that there is not uniformity in site team evaluations and this would mean that disclosure of inequitable levels of scrutiny was unfair for CPs.
R9: “But if they think that it’s going to be divulged to the public there’s so much competition that is out there for students - you know there are unscrupulous institutions, universities, CPs, you name it, that would use public information to damage the reputation of another programme ... And so if these - if the self studies were to be made public I think you would end up with them being much more benign, whitewashed, lacking some of the critical appraisal that we encourage institutions to have when they’re writing their self studies.”
Factors relevant to ensuring students learn important course material
Should CCEs ensure students learn core material e.g. contra/non/indications for care?
One third of respondents thought that it was necessary to make sure students know core material and that this warranted inclusion as a formal accreditation standard. However, half thought that this was likely to be contentious because of the lack of agreement on what core material would likely be. For example, there is a diversity of opinions on the reasons for spinal manipulation. Some groups of practitioners would believe that regular spinal manipulation prevents a range of non-musculoskeletal conditions, while others would see it as providing short-term pain relief. Consequently, the indications for spinal manipulation are better not prescribed.
R1: “But in as much as we feel that a chiropractic adjustment given from time to time or regularly has preventative value how do you measure something that you’ve prevented. . . . . . . This is the argument that would float around the table if we were in an accreditation setting.”
Should there be minimal faculty qualifications?
Two thirds thought that the difficulty with seeking faculty with high levels of academic qualifications, such as a PhD, was that it might preclude good teachers who have clinical experience. Many held reservations that a highly academically qualified person was not necessarily a “good” teacher with sound pedagogy. One expressed the view that mandating highly qualified staff imposed a much higher wages cost for CPs.
R3: “In other words, an instructor may hold a PhD but have no teaching credentials or competencies, which would not optimize the educational process”.
Should chiropractic students have a hospital placement experience?
Almost half of the participants believed hospital experience would be an important step for integration of chiropractic into mainstream health care. This experience was seen as improving communication between mainstream healthcare and chiropractic as well as enhancing student diagnostic skills. Two CCE responders thought that the benefits did not outweigh the likely cost and difficulty of arranging placements.
R7: “It’s the only way forward to get inter-disciplinary understanding of the profession and transfer of knowledge between professions”.
Should students be taught insight into their own personality?
One third of respondents commented that they had not thought of personality as being a factor in clinical decision making. The remainder thought that, although likely a factor, would not warrant inclusion as a consideration in a formal statement in accreditation standards.
What is the CCEs role in chiropractic students’ non-evidence-based beliefs?
Of all respondents, six stated that non-evidence-based beliefs of students should be dealt with by CPs teaching an EB approach and / or greater critical thinking skills, or as R3 stated “
how to learn, not what to learn”. Other suggestions included open debate about the curriculum regarding these issues, employing more faculty that are EB, and that this is a post-graduate continuing education issue rather than a requirement of an accrediting agency. Two respondents felt that it did not warrant a dedicated accreditation standard. Finally, one CCE informant felt that the phenomenon of non-evidence-based beliefs warranted careful exploration as to their origin and proffered that solutions most probably lay in regarding them as being analogous to religious beliefs.
R6: “But it needs - yeah we need experienced faculty. Evidence based faculty and then approach it that way.”
Evidence-based approaches and vitalism
Your thoughts on vitalism in CPs?
Half of the respondents thought that
vitalism in chiropractic education was an impediment for the integration of chiropractic into mainstream health care. Two respondents stated that it was too difficult to write standards to prescribe against
vitalism being taught other than in a historical context. Interestingly, one responded refused to comment on this question.
R7: “Because we’re seeing institutions graduating with a vitalistic model which is inconsistent with modern healthcare. And the reason they’re being accredited is because they’re ticking all the boxes. . . . On the one hand you’re teaching them (students) everything that’s evidence based. It’s physiology, it’s biology, it’s psychology. All the things that we have good evidence for understanding. And then we’re saying “And then you’ve got magic.” And those two things don’t mix very well. . It’s spoken and not written. . . . . And policing that is difficult.”
Some suggested it was better to do nothing and, to use the words of R1, “
turn a blind eye” to
vitalism, as it is always going to be there, is only championed by a minority of practitioners, and was too hard to deal with.
In contrast, two other respondents thought that the role of the CCE was to act as an accreditor and not a regulator. By acting as a regulator CCEs activities would likely result in inappropriate censorship.
R3: “The devotion to vitalism or other theories falls under the doctrine of “academic freedom”. Students and instructors should remain unrestrained in their pursuit of ideas and theories. Accreditation has no role in deciding which theories or beliefs are included in course material.”
Your thoughts on an EBP approach in accreditation standards for CPs?
One third of participants thought that there was insufficient emphasis placed on an EB approach to education and practice.
R1: “It (EBP) should be everywhere. Especially in patient care. It should be in lights.”
Four of the nine responders expressed reservations about a “totally” EB approach. Concerns were voiced that this involves a heavy emphasis on randomised-controlled studies, which may not always be applicable in specific instances. This in turn was thought to lead to the stopping of many helpful chiropractic techniques because of the lack of any supportive evidence. Finally, an EBP approach was thought to likely result in a reduction of the importance of the practitioners’ clinical experience and knowledge. No respondents mentioned patient preference, values or safety as a consideration.
Discussion
Summary of findings
The interviews revealed that respondents were, in general, satisfied with CCE accreditation standards, graduating competencies, and processes. They did not believe it was possible to implement an identical set of standards across all CCEs because of cultural differences. Rather, they stated that it would be better to create a core set of standards that were approximately the same or equivalent and these would require clear definitions of key words such as “chiropractic” and “diagnosis”.
Mixed views were expressed on the making public of final site inspection team reports of CP accreditations. Teaching skills and clinical experience of academic staff were valued at least as highly as attaining higher qualifications such as a PhD degree. A hospital placement for students was seen as offering a means to better integrate chiropractic into mainstream health care.
While respondents thought favourably of using an EB approach to accrediting CPs, they expressed some reservations that this might lead to the loss of valuable aspects of chiropractic practice, for which there is an absence of evidence. CCE experts thought that the most appropriate way to deal with students’ non-EB beliefs was for the CP to be evidence-based. Finally, there were mixed views on the presence of vitalism in CPs. Half of the respondents thought that the teaching of vitalism in CPs was an impediment to the integration of chiropractic in mainstream healthcare and that it was very difficult to police in CPs. It was also stated that so few held this view that it was probably not worth the effort of writing prohibitive standards. Others thought that vitalism was a matter of academic freedom, and accreditation has no role in deciding whether this should be included in CP curriculum.
General discussion of implications
Standards for competencies of graduating chiropractors and accreditation
The process and standards of site inspection teams of CPs
The respondents in this study expressed confidence in the site inspection process to monitor and apply accreditation standards. However, research has found that site inspections are of unknown reliability [
15], under-investigated [
30‐
32], the teams are often poorly trained [
33], poorly selected [
34] and in need of a standardised report structure for a comprehensive assessment measured against the accreditation standards [
31]. This raises the concern that the confidence expressed by the CCE experts in the site inspection processes may have been ill-founded. For example, a lack of standardization of site inspection is seen by the presence within the same CCE of CPs who openly adopt a
vitalist focused curriculum [
35] and those who have signed a declaration that
vitalism has no place in the modern curriculum, as the belief that it is the cause of disease is unsupported by any type of evidence [
36]. A move toward transparency by making final site inspection team reports public may create greater accountability and explain how this heterogeneous situation can exist.
CCE experts in this study viewed site inspection teams as an important lever for quality improvement. This monitoring and reviewing role places them in a position to facilitate the introduction of identified innovations to teaching found in recent research, such as the impact of students’ personality on their clinical decisions [
4]. Consideration may also be given to the common practice in academia of the inclusion of colleagues who come from different professional or academic backgrounds that often brings different and insightful points. Another common practice worthy of consideration, as the consumers of the education under review, is the obligatory inclusion of student reviewers as members of inspection teams [
37]. In addition, they could also address deficiencies like inadequate case mix in chiropractic teaching clinics [
38] by helping CPs explore hospital placements, also recently shown to address this issue for chiropractic students [
39]. To this end CCEs could develop a core standard for clinical competency that encourages CPs to provide greater interprofessional clinical training opportunities.
Factors relevant to ensuring students learn important course material
Evidence-based approaches and vitalism
Strengths and limitations
The strengths and limitations of this study have been discussed in the article titled A perspective on Councils on Chiropractic Education accreditation standards and processes from the inside: A narrative description of expert opinion. Part 1: Themes. In brief, this was a qualitative study with few participants, meaning that the findings are not representative of the views of all members of all CCEs internationally. Consideration should also be given to the possibility of community bias. However, the sampling had been designed to garner views from experts within all CCEs and 9 of 12 CCE experts accepted participation. The CCE participants had an average of 14 years’ experience, which caused us to be confident they have provided a rich insight into the issues surrounding CCE matters. Anonymity probably ensured honest and open answers and the responses were in line with concepts already encountered in previous surveys and in personal communication with this type of persons. Also, the authors are confident they have addressed the issues surrounding rigour in qualitative research through reflexivity [
54], credibility, transferability, dependability and confirmability [
21].
Recommendations
As in Part One of this study, the interviews with CCE Experts has raised several issues and, based on these as well the available literature, the authors make a number of recommendations (Table
1), in particular, the concerns about variability in accreditation standards and processes for chiropractic programs (CPs) and chiropractic practice in general.
Table 1
Summary table of recommendations
1. | Creation of an internationally acceptable set of equivalent accreditation standards and processes | For greater public confidence, graduate chiropractic homogeneity and workforce portability. |
2. | An EB approach be adopted for accreditation standards and processes. | Facilitate the integration into mainstream health care. |
3. | Standardized inspection team member selection, training and format for reporting. | Improve the quality of CP assessment and quality improvement processes for improved educative processes. |
4. | Broaden the scope for site inspection team composition e.g., students, academic colleagues | Gain broader insights into the issues facing CPs and their possible solutions. |
5. | Facilitate research to explore the optimal mix between an outcomes-based and prescriptive (hybrid) approach to the competency levels of graduating chiropractic students. | This will develop, inform and improve accreditation standards. |
6. | Make site inspection team reports public. | This is the broader societal expectation and will align chiropractic with the mainstream standards of transparency. |
7. | Move toward minimum faculty qualifications of a PhD. | This would improve the educational standing of CPs and enhance research capability and quality. |
8. | CCEs standards may include expectations for courses in adult learning & pedagogy for chiropractic faculty. | This would address reservations that having a PhD does not make one a “good” teacher. |
9. | CCEs standards could encourage the CPs to hire faculty with advanced degrees in education. | To scaffold the teaching quality of CPs to improve student learning outcomes |
10. | Provide student hospital placements | Improve graduate student quality and interdisciplinarity skills. |
11. | Develop a core standard for clinical competency that ensures a meaningful student clinical training experience | Graduates are better prepared to engage in safe and effective practice. |
12. | Investigate innovative dimensions of student clinical decision making such as personality type. | Improve graduating students’ clinical decision-making skills. |
13. | Address unorthodox (vitalism and ‘subluxation’) practice patterns in CCE accreditation standards. | Align chiropractic education with contemporary EB approaches to health profession education. |
14. | The development of a core standard for literacy in critical thinking | This would result in an increased ability to consume research evidence and translate this into practice for improved patient outcomes. |
The intent is for the tables from Part One and Part Two to complement each other and not repeat common issues. These recommendations are intended to create a uniform high standard of practitioners who are more likely to be in accord with the mainstream healthcare standard of an EB approach across all CCE-controlled regions. This would ensure and safeguard the international trust in chiropractors’ ability to deliver ethical, safe and valid care across and within international borders.
Conclusions
The overarching aim of this and the previous study (Part 1, Innes et al., in press) was to explore the experience and beliefs of CCE experts about variability in accreditation standards and processes for chiropractic programs (CPs) and chiropractic practice in general as well as making recommendations for improvements.
We found that when experts are queried about the ‘inner life’ of the CCEs, they can discern between positive and negative elements in the CCEs procedures. They can also explain, in an understandable way, the difficulties encountered in determining the aims, objectives of the CCEs standards and also in the actual execution of the accreditation process.
However, there was a considerable diversity of opinions on many topics.
We interpreted the reasons for the considerable variability between chiropractic programs worldwide to be embedded in a political negotiation process of CCEs determining their standards. The result has been a polite acceptance of ‘philosophical’ or “ideological” views of some chiropractors. In other words, the group of chiropractors, who favour mainly a musculoskeletal approach, co-habitats with those chiropractors who believe that chiropractic treatment also has an effect on a range of non-musculoskeletal conditions. This results in standards and procedures that are sufficiently non-specific to allow for both types of institutions to pass the CCE accreditation requirements.
This has real world implications. From a public health perspective, chiropractors who are practicing from a ‘philosophical’ perspective (non-EB) are more likely to prevent the adoption of chiropractors in the mainstream medical world.
We argue that the “raison d’être” of CCEs is not to solely oversee a chiropractic education that encompasses all understandings of chiropractic practice. We recommend that the key question for accreditation bodies is “Does it make for better patient care?” and we call on CCEs to take a stand and better serve the patients’ best interests and not the conservative chiropractic profession.
To this end we have made recommendations that include CCEs embracing and pursuing an EB approach, which in the end will place the interests of the patient above that of vested segments of the profession.
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