Similarities and differences of a selection of key accreditation standards between chiropractic councils on education: a systematic review

All CCEs documentation included the requirement for educational programs to clearly define their mission/vision/goals/aims/objectives (Table 3). The CCE-Australasia expected the mission statement to be based on input by its principal stakeholders. Principal stakeholders were listed as staff, students, community, education and health care authorities, professional organizations and post-graduate educators. The CCE-Europe and CCE-USA made it a requirement to make the mission statement known to all stakeholders.

There was a diversity of descriptive terms for the intended purpose of the mission/vision/goals/objectives statement. The accreditation standard of the CCE-USA recorded that the intention of the mission statement was to provide for the design of an educational program leading to the qualification of a chiropractor with measureable goals that enable the assessment of the effectiveness for achieving this. The remaining regulatory / licencing bodies intended the mission statement to be used as a measure of the standards to be achieved for a student to graduate. These included becoming a life-long learner, competent, safe, and someone who would serve the community and work with other health professionals.

The CCEs mission statements were more similar than dissimilar when compared to the WFME standards. They were similar in that the CCEs and WFME required that they should be made known to the constituency and community, as well as resulting in the production of a competent practitioner. It was uncommon that CCEs’ mission statements (see Table 3) were found to have included the WFME requirement that the mission statement should result in the production of lifelong learners, be socially accountable, include research, and prepare graduates for post graduate education. It is not unexpected that CCEs would universally include preparation for post graduate education as they are primarily focused on undergraduate training.

Accreditation Standards in all CCEs’ documents stated that staff should be appropriately or adequately qualified and experienced. Three CCEs (Australia, Canada and International) quantified the minimum qualification as being 3 years full-time work experience and current registration for clinical staff. The CCEs of Australasia, Europe and USA expect that the staff should be capable of developing, delivering and monitoring courses and curricula. Two CCEs (Australasia and Canada) required the presence of a least one Ph.D. qualified staff member in the basic sciences.

A wide range of staff scaffolding measures were found in three of the five CCEs (see Table 3). These included induction procedures, professional development and appropriate support from administrative staff. The standards of the CCE-Europe and CCE-USA expected there to be a balance between full-time and part-time faculty though the ratio is not specified. Only the CCEs of Australasia and Europe require that there be a balance between chiropractic and non-chiropractic staff but this ratio is also not stipulated. Finally, all but CCE-Canada demanded the presence of a stable academic staff population.

When compared to the WFME standards the following differences were noted. CCEs used the words “adequate” or “appropriately” qualified staff as compared to “highly” qualified by the WFME. Further, not all CCEs required a balance in staffing levels for the basic sciences and clinical sciences, as well as a balance of full-time versus part-time staff. The WFME standards were unique in that they stipulated the need for a balance between teaching, research and service functions, as well as stating that faculty should have a sufficient knowledge of the total curriculum.

The WFME standards were more general in nature but were similar to the varying CCEs´ financial standards with the requirement that programs should have budgetary autonomy and a transparent plan to meet its educational objectives. No timelines for budgetary projections or proof of financial stability going forward were suggested by the WFME standards.

CCE standards generally met those of the WFME. The CCE-USA and the WFME both contained the requirement of the need to provide a safe learning environment for students. Detail as to what constitutes “adequate” or “appropriate” is not provided by WFME or CCE standards.

The educational standards of all CCEs expected the provision of adequate assets/facilities for the programs to meet their objectives. The standards of CCE-Australasia, CCE-Canada and CCE-Europe expected that these should meet legal and safety requirements.

The standards as recorded by the CCEs´ documents, although worded differently, appeared uniform and comprehensive and were comparable with the WFME standards within this subdomain.

The length of clinical training for chiropractic students was set at 1 year and a minimum of 35 new patient assessments by the CCE-Europe standards. The same number of new patient assessments was also found in the CCE-Canada accreditation standards, as well as 35 X-ray series and 250 patient treatments. This number was increased to 50 new patients, 60 X-ray series, 300 patient treatments and 25 clinical laboratory tests in the CCE-Australasia standards. The CCE-USA accreditation standard was found to record the length of clinic training as “a portion of the course”. The WFME require that a reasonable part (defined as one third of the program) should be spent in planned contact with patients in relevant clinical settings.

In summary, there appeared to be agreement between CCEs on the total program course length, but differing descriptors were used. However, there was considerable variation between clinical training requirements of CCEs and all of these were different to the WFME standards which contained the stipulation that at least one third of the program to be spent in patient contact.

Two of the standards (Australasia and Europe) and the WFME required that the curriculum committee should be represented by staff, students and other stakeholders and that the program should be modified in response to feedback from society.

There was uniformity among all CCEs and WFME standards that the curriculum should prepare students to be lifelong and self-directed learners. All CCEs also dictated that curriculum models and instructional methods should be consistent with the stated goals of the chiropractic program. The requirement that curriculum models should facilitate higher learning was found in the CCE standards of Canada and Europe. Only the Australasian and WFME standards made the demand that students should be responsible for their own learning processes.

All CCEs and WFME accreditation standards for chiropractic institutions were instructed to incorporate and integrate the basic sciences in a coherent manner that creates an understanding of the scientific knowledge, concepts, and methods fundamental to acquiring clinical science knowledge. However, only the CCE documents of Australasia and Canada required that the “average” student loads be “reasonable”. The CCEs of Australasia and Europe and the WFME documents expected evidence-based health care to be taught throughout the curriculum. This topic is covered in more detail in a previous publication [24].

There was wide agreement in all CCE documents that students should be taught adequate clinical, behavioural and social sciences, and ethics, and that they should have access to “experiences” with patients and opportunities to acquire sufficient clinical knowledge, skills, and desirable attitudes to assume appropriate ethical clinical responsibility upon graduation.

Some requirements were only recorded in one CCE accreditation standards: basic science and clinical staff should collaborate around clinical problems (CCE-Europe), and curriculum should be adapted to scientific developments and the health needs of society (CCE-Australasia).

In summary, some CCEs did not contain the following component areas found in the WFME standards; the curriculum committee should be represented by all stakeholders, the curriculum should be modified by stakeholders and should include appropriate learning models that require students to be responsible for the learning processes as well as facilitating life-long and higher learning processes, and average student loads should be reasonable.

Subjects that were in the WFME lists but not in all CCE lists included genetics, immunology, public health, biostatistics, clinical decision making, dermatology, epidemiology, first aid emergency procedures, geriatrics, gynaecology, legal aspects of practice, mental health assessment, obstetrics, ophthalmology, pain management, pharmacology, psychology, practice ethics, research methods and procedures, and sociology, and evidence-based medicine.

One strategic tool that both academics and practitioners have deemed critical to the success of any health-care organization is the development of a meaningful mission statement [33]. The presence of the requirement for a mission statement or objectives in all CCEs and the WFME standards reflects this attitude. There is literature on the difficulties in creating effective mission statements [33, 34], and it is important that CCEs put some effort into the formulation of mission statements with an understanding that they are used with the view of implementation.

There were considerable differences between CCE accreditation standards on who should define the mission statement. This varies from basing it on input from all stakeholders (staff, profession, patient groups and society) through to an obligation to make it known to them. The chiropractic profession is not homogeneous [25]. Programs may find themselves in an environment where there are two professional groups, one being vitalist or “philosophically” driven while the other is based on biological plausibility and, as far as possible, on evidence [35]. It is the authors’ contention, and that of others, that the greatest opportunities for chiropractic lie in the integration into mainstream healthcare and this must be founded on evidence-based health care [36, 37]. To this end mission statements cannot be based on all stakeholders input if they are non-evidence based, such as vitalism or “traditional” chiropractic philosophy. CCEs should be clear in their directives to programs on which input should and should not be given consideration for the construction of their mission statements.

It should be noted that some programs must align their mission statements with that of the university systems they are part of. Due consideration should be given to this imperative as more chiropractic institutions become integrated with government funded universities.

Tabulation of the mission statements revealed that they differed in purpose. Some intended it to be used as a standard for program self-evaluation, whereas others thought it should be used for describing the educational strategy for producing the competent graduate. Thus the graduate was described differently across CCEs standards. Careful consideration should be given to the use of detailed and specific terminology in order to remove descriptive vagueness. By doing this with mission statements they can be better used for their intended purpose of course evaluation and can fully inform educators of the “end product” they are required to produce. We would recommend an increase in the descriptive language specific with respect to their intended purpose for mission statements. Consideration should be given to including identified terms from this analysis such as “lifelong learner”.

Our review revealed that all but the CCE-USA mentioned the case-mix of patients. Although none addressed the issue of students having to recruit their own patients, CCE-Canada and CCE-Australasia limited the proportion of family and/or friends allowed. Case mix has been shown to be positively related to learning outcomes, practitioner reported self-confidence, comfort level and learning benefit in medical education [39]. This suggests that chiropractic students being exposed to a broader case mix, such as hospital settings, could enhance their learning and as such should be considered.

A particular problem could be that chiropractic programs amalgamated with universities may have a reduced capacity for input or control over their budgets. This should be guarded against by clearly stating this requirement in the CCE accreditation standards.

Accreditation standards in all CCEs stated that staff should be appropriately qualified, experienced and supported by appropriate administrative staff. The most commonly expressed qualification was registration and three years practice experience. The authors believe that if chiropractic education is to become a respected member of the health professions then its staff should be encouraged, via educational standard requirements, to attain the broader health industry standard i.e. a research doctorate such as a Ph.D. and that the number of staff with this requirement should be considerable. At a minimum the requirement should be to adopt the WFME standard of “highly qualified” for program staff.

CCE standards did not include the WFME standards for faculty to have a balance between teaching, research and service functions, as well as having a sufficient knowledge of the total curriculum. This would appear to be important. Medical faculty who had out-dated research methodologies, poor skills in critical evaluation of medical information and authoritarian teaching relationships were found to be barriers to the adoption of evidence-based medicine [41]. The major self-report vocational concerns of medical faculty also related to research publications and teaching [42]. It is likely that chiropractic educators would be similar, however no research could be found to verify this.

The curriculum / educational program was the largest domain for analysis. Two methods of determining a student’s preparedness for graduation were found. One was the student having attained a level of competence as specified in the graduate competency standards. The second was evidence of having completed a specified number of new and returning patient assessments and treatments. Medical education is moving away from a time or numbers-based system and toward attaining competencies [43]. However, some have suggested that both should be used [44, 45]. We could not find any research which gave direction as to what numbers of patient treatment encounters were optimal for producing competent chiropractic graduates. It is important that educators keep informed of recent developments in this area and that they re-consider the old system of counting numbers of patient visits to justify clinical competency. Research is needed to determine the impact that the number of clinical encounters or the amount of time spent in a training clinic has on students attaining competency to practice safely and effectively. It must be remembered, that when programs are aligned with universities, they have to meet the expectations also of the university.

All CCEs accreditation standards required curriculum models and instructional methods to be consistent with the goals of the institution. Although current evidence suggests that the best way to teach, at least for some subjects [46], is by combining multiple pedagogical resources to complement one another and that students appear to learn more effectively when multimodal and system-based approaches are integrated [40], this was not generally required across the CCEs. Therefore, CCEs need to recommend suitable staff development and upgrading in the pedagogic domain to ensure that not only the contents of the courses but also the delivery of the courses is suitable.

Program content was generally conceptualised in all CCE accreditation standards as consisting of four components. However, there was considerable diversity in the subjects mandated for each of these components among CCEs. It is possible that this was in part due to differing scopes of practice between the CCEs. Medical education has recognized the need to delineate the subjects, and areas within subjects, required for the purpose of graduating the safe and effective medical practitioner. For example studies have been conducted to try to identify which areas of anatomy constitute the required body of anatomy knowledge [47, 48]. No studies could be identified for purposes of graduating the safe and effective chiropractic practitioner. Such studies could create a clearly defined knowledge base from which programs could produce quality graduates. It is expected that this core or common body of knowledge would change over time. For example, it is possible that there will be an increasing emphasis on MRI and ultrasound imaging modalities [49, 50].

A potential weakness of this study is the subjective nature of the interpretation of the structure for the analysis of the domain and component statements. Our choice of sub-domains may differ from others. There may be other possible constructs for analyses which may impact on the differences and similarities observed.

The strengths of this review are that it did take a systematic approach and that the two investigators extracted the information blindly and with a high level of agreement. Further, all available information was covered and analysed.