Manual Therapy 19 (2014) 44e51

Contents lists available at ScienceDirect

Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Clinical decision-making and therapeutic approaches in

osteopathy e A qualitative grounded theory study
Oliver P. Thomson a, b, c, *, Nicola J. Petty b, Ann P. Moore b
a
Research Centre, The British School of Osteopathy, 275 Borough High Street, London, United Kingdom
b
Clinical Research Centre for Health Professions, School of Health Professions, University of Brighton, Darley Road, Eastbourne, United Kingdom
c
Research Department, The British College of Osteopathic Medicine, Lief House, Finchley Road, London, United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: There is limited understanding of how osteopaths make decisions in relation to clinical practice. The aim
Received 18 April 2013 of this research was to construct an explanatory theory of the clinical decision-making and therapeutic
Received in revised form approaches of experienced osteopaths in the UK.
5 July 2013
Twelve UK registered osteopaths participated in this constructivist grounded theory qualitative study.
Accepted 12 July 2013
Purposive and theoretical sampling was used to select participants. Data was collected using semi-
structured interviews which were audio-recorded and transcribed. As the study approached theoretical
Keywords:
sufficiency, participants were observed and video-recorded during a patient appointment, which was
Clinical reasoning
Decision-making
followed by a video-prompted interview. Constant comparative analysis was used to analyse and code data.
Osteopathy Data analysis resulted in the construction of three qualitatively different therapeutic approaches which
Grounded theory characterised participants and their clinical practice, termed; Treater, Communicator and Educator.
Participants’ therapeutic approach influenced their approach to clinical decision-making, the level of
patient involvement, their interaction with patients, and therapeutic goals. Participants’ overall
conception of practice lay on a continuum ranging from technical rationality to professional artistry, and
contributed to their therapeutic approach. A range of factors were identified which influenced partici-
pants’ conception of practice.
The findings indicate that there is variation in osteopaths’ therapeutic approaches to practice and
clinical decision-making, which are influenced by their overall conception of practice. This study provides
the first explanatory theory of the clinical decision-making and therapeutic approaches of osteopaths.
Ó 2013 Elsevier Ltd. All rights reserved.

1. Introduction concepts and theories, many of which focus on the anatomical and
physiological capabilities of the human body (Seffinger et al., 2003;
Currently, the number of osteopaths in the UK exceeds 4500 Paulus, 2013). Currently osteopaths tend to be defined by their
(GOsC, 2012b) and practitioners are increasingly being considered application of techniques, such as treatment applied to the: neuro-
as significant providers of manual therapy (NICE, 2009). Osteopaths musculoskeletal system often termed ‘structural osteopathy’
in the UK are autonomous practitioners who diagnose and manage (Hartman, 1996); internal organs, termed ‘visceral osteopathy’
patients with a range of musculoskeletal conditions (Fawkes et al., (Hebgen, 2010) and applied to the skull, termed ‘cranial osteopathy’
2010). Practitioners employ an array of therapeutic interventions, (Liem et al., 2004). Although these characterisations provide some
with ‘hands-on’ manipulative techniques (e.g. spinal manipulation) useful description of the therapeutic techniques osteopaths
preferred by practitioners in the UK (Fawkes et al., 2010) and employ, they offer a superficial understanding of practitioners’
internationally (Johnson and Kurtz, 2003; Orrock, 2009). clinical practice and decision-making.
Osteopathic practise is considered to be patient-centred (WHO, Over the last forty years researchers have been attempting to
2010; GOsC, 2012b) and underpinned by a core set of principles, understand the nature and processes of clinical practice and
decision-making. For example, in the physiotherapy profession
there is a growing body of research on a range of aspects of practice
* Corresponding author. Research Centre, The British School of Osteopathy, 275
Borough High Street, London, United Kingdom. Tel.: þ44 (0)20 70895332.
such as the processes of clinical decision-making (Edwards et al.,
E-mail addresses: [email protected], [email protected] 2004; Cruz et al., 2012) and the nature and development of
(O.P. Thomson). expertise (Jensen et al., 2000; Petty et al., 2011a,b). This research

1356-689X/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.math.2013.07.008
 O.P. Thomson et al. / Manual Therapy 19 (2014) 44e51 45

demonstrates that well-developed clinical decision-making skills Table 1

are fundamental to expertise (Jensen et al., 2008). There is currently Biographical information of study participants.

little-to-no research of osteopaths’ clinical decisions-making and Participant Gender Years Qualifications Teaching position
their approaches to practice (Thomson et al., 2011). A research- since held
based knowledge of these areas of osteopathy would be valuable graduating

to educators and practitioners and ultimately help enhance patient 1 M 13 BSc (Hons) Ost Clinic tutor and
care. The aim of this study was to develop an explanatory theory of lecturer
2 M 14 BSc (Hons) Ost Med, Clinic tutor and
the clinical decision-making and therapeutic approaches of expe-
Dip Ost lecturer
rienced osteopaths in the UK. 3 M 6 BSc (Hons) Ost Med, Clinic tutor and
Dip Ost, MSc lecturer
2. Methods 4 M 16 Dip Ost Clinic tutor and
lecturer
5 F 13 BSc (Hons) Ost Med, Clinic tutor
2.1. Study design Dip Ost
6 M 25 BSc (Hons) Ost Med, Clinic tutor and
The study used constructivist grounded theory (Charmaz, Dip Ost, MSc lecturer
2006). By exploring the different meanings and experiences of 7 M 9 BSc (Hons) Ost, Med, Lecturer
Dip Ost,
clinical practice and decision-making raised by participants, the
Dip Naturopathy,
main researcher (OT) co-created the data and ensuing analysis MSc
through an interactive process, and developed an “interpretive 8 M 22 BSc (Biochem) Clinic tutor
portrayal” (Charmaz, 2006, p. 10) of participants’ views, perceptions \Dip Ost
and experiences. 9 F 22 BSc (Hons) Ost Med, Clinic tutor and
Dip Ost, lecturer
Dip Naturopathy
2.2. Participants 10 M 6 BSc (Hons) Psych, None
BSc (Hons) Ost Med,
Twelve UK registered osteopaths took part in this study. Dip Ost, MSc
11 M 14 BA, BSc (Hons) Ost, Clinic tutor and
Recruitment adverts placed in osteopathic educational institutions
Dip Ost, lecturer
(OEIs) and the osteopathic press nationally, invited practitioners to 12 M 19 BSc Ost None
contact OT should they wish to take part in the study. Upon initial
OEI: Osteopathic Educational Institution; BSc: Bachelor of Science; DO: Diploma in
contact, practitioners were provided with information and given the osteopathy; MSc: Master of Science.
opportunity to ask any questions regarding the study. Having then
expressed a wish to participate, details of practitioners’ professional
background (e.g. teaching/clinical experience, education, interests/ Non-participant observations of ‘real-life’ patient appointments
specialities) were obtained and a list of potential participants was enabled the researcher to compare the similarities and differences
compiled. From this list, purposive sampling initially selected between the ‘espoused theory’ generated during interviews with
practitioners with a minimum of five years clinical experience, and ‘theory-in-action’ (Argyris and Schön, 1974). An observation guide
currently held positions as clinical educators at an OEI. Clinical ed- (Table 3) enabled OT to make theoretical connections between
ucators were expected to effectively communicate and verbalise what previous participants had said during interviews with what
their decision-making processes (Ajjawi and Higgs, 2008), enabling was observed during clinical sessions, providing further analytical
‘thick’ data to be generated and enhance the credibility of the insights. The video-recording deepened participants reflection
research findings (Lincoln and Guba, 1985). Subsequent theoretical during interviews, helping to ensure discussion were closely tied to
sampling (Charmaz, 2006), informed by data analysis, led to specific participants’ actions and decisions, which took place during the
participants being re-interviewed as well as additional participants clinical appointment (Haw and Hadfield, 2011). Towards the end of
being sampled who were not involved with osteopathic education. the study two participants (P1,10) were theoretically sampled and
Table 1 provides participants’ biographical information. re-interviewed to explore and test out the proposed core category
Each practitioner gave informed consent before participating. of ‘conception of practice’ (Fish and Coles, 1998) and further
All patients gave informed consent before commencing each develop the theory. The major analytical processes used were:
observation session.
2.3.1. Coding
2.3. Data collection and analysis The active construction of codes during analysis formed a link
between data collection and development of the theory and helped
Inline with the iterative nature of grounded theory, data explain and understand conceptual reoccurrences and patterns in
collection and analysis occurred concurrently (Charmaz, 2006). A the data (Birks and Mills, 2011). During the early stages of analysis
total of seventeen semi-structured interviews were transcribed initial line-by-line coding (Charmaz, 2006) was employed to define
verbatim, read/re-read and analysed throughout the course of the actions or events of a given situation. Focused coding, was then
study. During the data collection process, the interview guide used to assess which codes appeared to be the most significant
became progressively focused so that concepts constructed from (Charmaz, 2006). This led to the development of new focused codes
data analysis could be pursued and ideas explored (Table 2). which were used to analyse larger segments of data. This process
Data was initially collected from interviews with nine participants elevated the level of conceptual analysis so that broader categories
(P1e9). Three participants (P6e8) were theoretically sampled and could be developed.
re-interviewed as they each exhibited strong characteristics of the
therapeutic approaches which were developing from analysis. As 2.3.2. Constant comparative analysis
the study approached theoretical sufficiency (Charmaz, 2006), a This involved comparing data with data, data with category,
further three participants (P10e12) were observed and video- category with category (Charmaz, 2006). Constant comparison was
recorded during a patient appointment, which was followed by a used throughout data analysis, from initial coding to advanced
video-prompted reflective interview (Haw and Hadfield, 2011). levels of analysis when writing up the findings.
46 O.P. Thomson et al. / Manual Therapy 19 (2014) 44e51

Table 2 in the developing theory, which informed further data analysis and
Interview guides for initial, video-prompted reflective and theoretically sampled theoretical sampling (Charmaz, 2006).
participant interviews.

Initial interview guide 2.4. Trustworthiness

Imagine we are in your clinic, and you are about to see a new patient. Let’s say it’s
a patient with back pain. Take me through your thinking process, as you work out
what’s wrong with this patient. A prolonged engagement with the data (three years) and
Could you describe how you would structure an examination plan with a patient? repeated interactions and interviews with participants contributed
How do you structure a treatment plan for a new/returning patient? towards the credibility of this research (Lincoln and Guba, 1985).
Tell me how you go about deciding on what treatment approaches/techniques to
The researcher was an osteopath with clinical experience and
use with your patients.
Are there any aspects of clinical reasoning do you feel are distinct or unique to
knowledge and pre-existing awareness/knowledge of five of the
osteopathy? Why? twelve participants. During data collection, OT actively sought to
Tell me what role (if at all) osteopathic philosophy/principles play in your develop a trustful researchereparticipant relationship, which
decision-making/clinical reasoning. facilitated participants’ sharing of their views and experiences of
Guide e video-prompted reflective interview
clinical practice. These strategies helped to offset participant bias
Opening questions e ‘can you share your thoughts on that clinical experience’?
What were your initial aims with your patient? Why? How did you intend to and enhance data credibility.
meet those aims? A process of ‘member-checking’ (Bryman, 2008) was used; all
Could you comment on the information gathered from that action (e.g. patient participants were asked to read their interview transcript to check
discussion or treatment, examination procedure)
for accuracy, and were encouraged to add further comments that
What are your feelings and thoughts about the patient at this time?
Through the course of treating this patient, did you come to see their situation in a
they felt necessary.
different way? How? Finally, throughout the study, OT maintained a critically re-
How did you decide to examine the patient in that way? flexive stance, wrote copious field notes, memos and kept a re-
What were you thinking when you were carrying out that action (e.g. exami- flexive diary. These methods of reflexivity aimed to offset
nation or treatment procedure)?
researcher bias and meant that any feelings, assumptions or
What are your overall thoughts about the information you have obtained from
this part of the examination? analytical thoughts that arose could be put into writing then tested
How do you think you can help this patient? and checked-out with the data (Cutcliffe, 2003).
Where did you focus your treatment approach? Why, can you tell me a little bit
more?
3. Findings
Theoretically sampled
How do you see the patient’s role in your relationship? Why? Are there any
exceptions? The clinical decision-making and therapeutic approaches of the
What does it mean to ‘have a partnership’ with a patient? osteopaths in this study are illustrated fully in the explanatory
How do you perceive your role with patients? Why? Exceptions?
model (Fig. 1). Analysis of data generated during interviews with
What do you mean by (observe, palpate, talking etc). Why is this important/how
does that help you? participants and observation of their clinical practice resulted in the
Some participants have talked about treating the patient as an individual and construction of six major categories, these were participants’:
having to adapt to them- can you tell me what does this mean to and for you?
Can you think of any times when you have had to change your treatment  view of osteopathy
approach?
 interaction with patients and interpretation of cues
 approach to clinical decision-making and level of patient
2.3.3. Memo-writing involvement
Memo-writing throughout the data collection, coding and cat-  therapeutic goal
egorisation processes encouraged critical reflexivity, and helped  conception of practice
link data-gathering with analysis. Memo-writing enabled the  therapeutic approach
identification of codes, patterns and relationships in the data so
that codes could be defined and grouped to form categories with an Each category is presented in turn and supported by quotations
increasing level of conceptual abstraction. Identifying the charac- from participants’ interview data. A more detailed discussion of the
teristics and properties of categories helped give them shape and findings can be found elsewhere (Thomson, 2013).
multidimensionality. Importantly, developing properties of cate-
gories though memo-writing, facilitated the identification of gaps 3.1. View of osteopathy

Table 3 There was variation in how participants described their practise

Observation guide used during video-recorded clinical observation sessions. of osteopathy. For several participants (P1,2,5,8,11,12) the central
Observation guide feature of osteopathy was their application of specific osteopathic
- How does the interaction of patient and osteopath begin? How does the theories, knowledge and hands-on skills, suggesting a practitioner-
interaction proceed? centred view of osteopathy:
- The approach that the particular osteopath takes to examination and
treatment, with the three types of practice approaches in mind (Treater, You need to keep pure to osteopathic philosophy. [and] the
Communicator and Educator). How do they personalise these?
principles of osteopathy make me do what I do.
- The role that the patient takes in the encounter, for example, is the patient
actively engaging and participating or taking a more passive approach? ee(P1)
- Has the osteopath come across something new or unfamiliar/unexpected,
how does he react? Others valued working with patients so that decisions were
- During the ‘hands-on’ osteopathic treatment what is the verbal and non-
made together (P3,4,7). These participants emphasised collabora-
verbal interaction like?
- Are there any tonal changes of voice?
tion and partnership with patients, respecting them as equals:
- What is the body language, body reactions and responses of participants?
I don’t cure patients. Together we work out how come to a better
- Types of questions asked (e.g. open questions or closed questions?), and
the response of the patient. state of health.
- What does the practitioner focus the conversation on?
ee(P9)
 O.P. Thomson et al. / Manual Therapy 19 (2014) 44e51 47

Influencing factors
Educational experience
View of health and disease
Epistemology of practice knowledge
Theory-practice relationship
Practitioners’ perceived therapeutic role

Conception of View of Therapeutic Interacting with Approach to clinical Therapeutic

practice osteopathy approach patient and decision-making and level goal
interpreting cues of patient involvement
Technical Practitioner takes
rationality Practitioner- control and
Treater Body Low level Practitioner-led
centred responsibility

Practitioner shares
Collaborative Communicator Person Equal level Shared control and guides
patient

Practitioner
Empowerment Educator Patient High level Patient-led facilitates learning
Professional
artistry and control with
patient

Fig. 1. Theory of the clinical decision-making and therapeutic approaches of study participants.

Finally, some participants viewed osteopathy as a means by The first two quotes suggest a body-focused interaction where
which they could facilitate patient empowerment (P6,9,10). These the clinical gaze was fixed upon the biomechanical and physical
participants could not separate patient empowerment from their characteristics of patients’ bodies (P1,2,5,8,11,12). Moving, touching
practise of osteopathy, and facilitating patient-learning was central and observing the body was central in acquiring cues.
to their treatment and management interventions: The third quote suggests a person-focused interaction which
involved talking and listening, to construct knowledge of the
I really believe in patient autonomy, I think patients are responsible
patient as a person. These participants (P3,4,7) focused their
for themselves... it gives them control.
interaction on patients’ personal experiences of pain and
ee(P6) dysfunction.
3.2. Interacting with patients and interpreting cues The final quote suggests a patient-focused interaction where
talking and listening enabled the participant to learn from patients.
During clinical procedures (e.g. clinical assessment), partici- These participants (P6,9,10) tended to explore patients’ day-to-day
pants’ focus of interaction with patients, and the cues generated function, their preferences of treatment and management
and interpreted from this interaction varied. Body-focused interventions.
interaction enabled some participants (P1,2,5,8,11,12) to obtain
knowledge and understanding of patients’ bodies and physical 3.3. Approach to clinical decision-making and level of patient
problems: involvement
I use my palpation to assess and let the body tell me what it wants
me to do, and will permit me to do. There was variation in the level of patient involvement in
treatment and management strategies which was related to par-
ee(P1) ticipants’ approaches to clinical decision-making and therapeutic
goals (Fig. 2). The three different approaches to clinical decision-
As I watched the active shoulder movements I’m looking at areas of
making were; practitioner-led (low-level of patient involvement),
his back which are most restricted.
shared (equal-level of patient involvement) and patient-led (high-
ee(P11) level of patient involvement).
Participants taking a practitioner-led approach to decision-
I like spending time talking to the person about what’s going on and
making emphasised a low-level of patient involvement
how it’s impacting them.
(P1,2,5,8,11,12). They led the clinical decision-making and tended
ee(P7) not to encourage active patient involvement and input:
We take time to sit down, talk and make sure that he understands I’ll determine what [treatment] techniques I think the patient
what’s going on and what he can and can’t do to improve it. needs.

ee(P10) ee(P2)
48 O.P. Thomson et al. / Manual Therapy 19 (2014) 44e51

3.5. Conception of practice

Conception of practice was considered to be how participants

viewed the nature of their practice and this was closely associated
with their views on the nature of knowledge associated with their
practice; this has been explicated by various authors (Schön, 1987;
Fish, 1998; Fish and Coles, 1998) in relation to technical rationality
and professional artistry. Conception of practice was selected as the
core category of the explanatory theory, as it helped to organise the
categories into a process and explained the variations in the data
(Charmaz, 2006). It is explored in detail elsewhere (Thomson, 2013;
Thomson et al., 2013). Participants that conceived practice as tech-
nical rationality (P1,2,5,8,11,12) considered practice as involving the
straightforward application of propositional knowledge:
...my practice is based on genuine biomechanical principles...[and]
Fig. 2. Relationship between level of patient involvement, approach to clinical manual provocation techniques to reproduce patients’ symptoms.
decision-making and therapeutic goal.
ee(P5)
Whereas, other participants (P3,4,7) encouraged shared They sought to establish causeeeffect relationships and emphas-
decision-making with patients, promoting collaboration and an ised technical expertise and hands-on skills during clinical practise:
equal-level of patient involvement:
If the patient was complaining of posterior thigh pain, I want to
We’ve tried many different interventions,...[and] we’ve talked determine what I think the structure is and where it’s being
through options together. compromised.
ee(P10) ee(P8)
Some participants (P6,9,10) adopted a patient-led approach to Whereas, those participants that conceived practice as profes-
clinical decision-making and facilitated high-levels of patient sional artistry (P3,4,6,7,9,10) viewed practice as complex, dynamic
involvement. These participants encouraged patients to take the and appreciated different sources and forms of knowledge, which
lead in decision-making and educated patients so that they could were blended together to guide clinical action:
make informed decisions:
I put all of the information obtained from the examination with
...my process is “do you have any preference, what would you like, patient expectation, the relationship that I have with them and I
what do you think would help you most?” “Now that you’ve chosen, draw on all of it to point us in the right direction.
these are the side-effects. Are they acceptable?
ee(P10)
ee(P6)
Five factors were identified which influenced participants’
3.4. Therapeutic goal conception of practice, and help to explain their therapeutic
approach and clinical decision-making (Table 4).
Participants expressed a range of therapeutic goals which were
related to their approach to clinical decision-making and level of 3.6. Therapeutic approach
patient involvement (Fig. 2). Several participants (P1,2,5,8,11,12)
emphasised goals orientated towards them taking control and re- Three theoretical models of therapeutic approaches charac-
sponsibility of patients’ problems, and encouraging patient terised study participants and their clinical practice. This is not to
passivity: suggest that all participants fitted distinctly in each model, rather it
...treatment is a time for patients to relax...[and] to have the offers a broad differentiation of participants’ therapeutic approach
treatment. to allow for theoretical comparison. Fig. 3 illustrates the continuum
of conception of practice and its relationship with participants’
ee(P1) therapeutic approaches, level of patient involvement and approach
to clinical decision-making.
Other participants aimed to guide patients towards their per-
sonal goals (P3,4,7). This meant at times, participants would lead
3.6.1. The Treater
decision-making, but at other times they encouraged patients to
Treaters (P1,2,5,8,11,12) had a view of osteopathy which was
adopt more active approaches:
practitioner-centred, and they relied upon their application of spe-
I’ll take time to discuss what the options are with patients, I’ll say, cialised osteopathic skills, technical expertise and knowledge to di-
“this is what I can do and this is what you can do”. agnose, treat and manage patients. They appeared less flexible in their
clinical approach, and felt that the application of traditional osteo-
ee(P7)
pathic theories and concepts was central to their practice, and was
Whereas other participants (P6,9,10) emphasised the impor- important to distinguish them from other healthcare professionals.
tance of patients to control the possible directions that treatment They focused on patients’ physical and biological dysfunction and
and management could take. These participants aimed to facilitate how they could correct these through hands-on treatment:
learning and control with patients:
My primary aim is to treat, rather than ‘let’s sit down and discuss
I always try and empower my patients...to feel in control. your problem and see what we can do about it’.

ee(P9) ee(P1)
 O.P. Thomson et al. / Manual Therapy 19 (2014) 44e51 49

Table 4
Factors and properties which influenced participants’ conception of practice.

Influencing factor Technical rationality Professional artistry

Educational experience Teacher-centred, uncritically accepting Student-centred, critically constructing knowledge

knowledge Through reflection and time you begin to scrutinise
I still use the principles that I was taught things more and reject those fads and formulate your
as a student [and] they are still very relevant to me. (P1) own ideas about osteopathy. (P3)
View of health and disease Biomedical: reduce patients’ problem Biopsychosocial: considered patients’ problem in
down in a specific tissue or body structure the context of their lives and their illness experience
and separates it from their social and I like to see the other factors that would be influencing
emotional circumstances the way that they [the patient] experience
If you don’t have the basics like anatomy and their problem...it gives you a much rounder picture
physiology you are never going to get the of the person you’re treating. (P6)
right decision. (P12)
Epistemology of practice Positivist-post-positivist: Focused on cause-effect Constructionist: listening and using language to develop an understanding
knowledge relationships, knowledge is stable and factual of how patients’ made sense of their problem
If somebody’s got left-sided low back pain and I seem to talk so much to patients, as I find that talking opens up a deeper
their pelvis tilts down to the right then the structures level of understanding for them and me. (P3)
will be more compressed on that left side. (P8)
Theory-practice relationship Theories applied to practice: view theory as separate Theories developed from practice: Though learning from, and reflecting on,
from practice, apply existing theories (biomechanical practice they would develop their own personalised theories and
and osteopathic theories) to practice. practice models.
...my practice is based on genuine biomechanical I’m getting away from “I’ve got to get my hands on and get them better” to “right,
stuff [theories]. (P5) this is the situation and this is how we can approach it; it’s your decision,
what would you like to do?” So [my approach] has become much
more collaborative. (P6)
Practitioner’s perceived Paternalism: assuming responsibility for Patient autonomy: Patient as an active partner, views, knowledge
therapeutic role the decision-making and expectations exchanged and decisions negotiated
I am trying to get a little bit of mobility for him. By giving patients choice it treats them as an adult and gives them
To increase that range [of motion] for him, the autonomy. (P6)
so that does not hold on to the joint so that
he actually lets go of it. (P11)

Treaters analysed patients’ bodies and tissues, and in combi- patients and help guide their clinical decision-making and profes-
nation with their osteopathic knowledge and technical expertise, sional judgements:
they diagnosed and led the decision-making based on logical
I would judge treatment by how I relate to the patient personally.
connections between anatomy, physiology and biomechanics. In
this sense, Treaters conceived practice as technical rationality. ee(P3)

Communicators shared the responsibility of clinical decision-

3.6.2. The Communicator
making with their patients, resulting in treatment and manage-
For Communicators (P3,4,7) collaboration and partnership
ment decisions being mutually negotiated.
formed the foundations of their view of osteopathy. They respected
patients as equals, viewing them as individuals. Communicators
3.6.3. The Educator
focused on language and dialogue to encourage patients to ver-
Educators (P6,9,10) worked with patients to develop the skills to
balise their feelings and experiences about their problem. They
self-manage their health issue, looking to facilitate empowerment.
placed significant value on developing and nurturing an equal
They focused on teaching and motivating patients to enable them
relationship with their patients. Through talking and listening,
to manage their own pain and dysfunction. Educators emphasised
Communicators conceived practice as professional artistry, and
listening and learning from their patients, and they were focused
relied upon their interpersonal skills to interact and engage
on building an understanding of patients’ problems and how it
impacted their function in day-to-day life so that patient-specific
treatment plans could be developed:
I see the patient as an individual who owns their own body and can
make decisions about it.

ee(P9)

Educators saw their role to encourage, teach, and exchange

knowledge so that patients were active and informed decisions-
makers about their treatment and management. By learning from
their patients and their practice they developed their own personal
theories of practice and treatment approaches, which were facili-
tated by their professional artistry conception of practice.

4. Discussion

The findings from this study suggest that participants held

differing views of the purpose and practise of osteopathy. How
Fig. 3. Therapeutic approaches and the conception of practice continuum. these views and assumptions of osteopathy were enacted, shaped
50 O.P. Thomson et al. / Manual Therapy 19 (2014) 44e51

practitioners’ clinical actions, decisions and resulted in different The finding that some practitioners adopt practitioner-centred
therapeutic approaches to practice (Trede and Higgs, 2008). The approaches may not be congruent with shared models of
findings that there is diversity in how practitioners identify with decision-making promoted by the osteopathic regulator (GOsC,
their profession and their conceptions of being a professional is 2012a) and more widely by the NHS (DoH, 2012). Active patient
consistent with research in physiotherapy (Öhman and Hägg, 1998; involvement in decision-making is now widely considered funda-
Richardson et al., 2002; Lindquist et al., 2006). mental (Charles et al., 1997; Entwistle and Watt, 2006; DoH, 2012)
This study found that differences in therapeutic approach led to and is harmonious with conceptions of patient-centred care (Mead
variation in the focus of participants’ interaction with their patients and Bower, 2000; Stewart, 2001). As almost 90% of patients self-
and the cues they generated and interpreted. Practitioners’ con- fund their osteopathic services (GOsC, 2012c), practitioners may
ceptions of practice (Fish and Coles, 1998) and the assumptions and consider that a paternalistic approach to care, best-serves their
beliefs that they hold about the body (Thornquist, 1994, 2006) in- ‘customer’. However, if some osteopaths are not promoting shared
fluence what they ‘see’, how they see ‘it’ and their resulting models of decision-making in their private practice, then this may
decision-making and action. While all participants’ assessment of present difficulties for future opportunities of integration and
their patients involved case-history taking and clinical examina- collaboration within the public healthcare sector, where shared
tion, there was variation in their “gaze” (Thornquist, 1994, p. 9) models of decision-making are currently promoted (DoH, 2012).
during these clinical procedures. This resulted in diversity
regarding what clinical information participants found relevant, 4.1. Study limitations
and where and how they focused their interaction with patients to
generate cues. The explanatory theory developed from this study provides the
The findings suggest that clinical decision-making in osteopathy first research-based model of clinical decision-making and thera-
occurs with varying levels of patient involvement and is related to peutic approaches in osteopathy. The findings offer a number of
practitioners’ therapeutic approach. Participants characterised as theoretical insights into the clinical practice of osteopaths which
Treaters-adopted practitioner-led approaches to clinical decision- may have value to practitioners and educators of osteopathy and
making. This approach was associated with minimal patient different manual therapy professions. However, the reader is
involvement, and is consistent with ‘paternalistic’ models of reminded that the researcher co-constructed and co-created the
decision-making (Emanuel and Emanuel, 1992). The determination findings from this study with a sample of privately practicing
of these participants to obtain information from the patient’s body experienced osteopaths in the UK. Further research is necessary to
through skilled physical analysis and examination placed little establish the ‘reach’ of the substantive theory for example with os-
priority on exchanging or sharing information with patients, teopaths in other countries, practitioners and with less experience.
implying an ‘all-knowing’ practitioner (Emanuel and Emanuel,
1992). Whilst the hands-on skills and technical expertise of oste- 5. Conclusion
opaths may lead to high degrees of patient satisfaction, an approach
which promotes patient passivity may encourage patients to adopt Experienced osteopaths in this study adopted a variety of
a ‘sick role’, and risk them becoming dependant on passive manual therapeutic approaches in their clinical practice which influenced
therapy treatment (Beisecker and Beisecker, 1993). An approach to their interaction with patients, clinical decision-making, level of
decision-making which fails to consider patients’ perceptions and patient involvement and therapeutic goal. Participants’ therapeutic
expectations may not help develop a patient’s sense of control over approaches flowed from how they conceived their practice. Par-
their problem (Klaber Moffett and Richardson, 1997) and miss a ticipants’ overall conception of practice lay on a continuum, from
valuable opportunity to enhance their self-efficacy (Bandura, 1982). technical rationality to professional artistry. A number of factors
Patients’ illness perceptions, self-efficacy beliefs and catastrophis- were identified which influenced practitioners’ conception of
ing of their symptoms, have been identified as psychological ob- practice and help explain their therapeutic approach and clinical
stacles to recovery of low back pain (Foster et al., 2010; Grotle et al., decision-making. This study offers the first explanatory theory of
2010); therefore osteopaths should endeavour to acknowledge the clinical decision-making and therapeutic approaches of
these factors and facilitate their exploration in relation to their osteopaths.
patients.
The findings indicate that participants characterised as Com-
Ethical approval
municators shared their clinical decision-making with patients and
encouraged an equal-level of patient involvement. This is consis-
Ethical approval was granted by the research ethics committees
tent with shared models of decision-making in the medical litera-
at the University of Brighton and the British College of Osteopathic
ture (Ballard-Reisch, 1990; Charles et al., 1999) and with research in
Medicine.
musculoskeletal physiotherapy (Jensen et al., 2000; Edwards et al.,
2004). Sharing clinical decisions emphasises patients as active
Acknowledgements
partners, and involves both individuals contributing knowledge
and skills so that decisions can be mutually negotiated together
Thanks to the British College of Osteopathic Medicine and the
(Charles et al., 1999).
Osteopathic Educational Foundation for their support of this
Participants who were characterised at Educators adopted a
doctoral research.
patient-led approach to clinical decision-making and advocated
high-levels of patient involvement, analogous to the ‘informed
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