Qualitative Article
Figg-Latham, J., & Rajendran, D. (2017). Quiet dissent: The attitudes, beliefs and behaviors of UK osteopaths who reject low back pain guidance – A qualitative study. Musculoskeletal Science and Practice, 27, 97-105. Web.
Introduction and Aim of Research
This paper aims to critically appraise the article titled “Quiet dissent: The attitudes, beliefs and behaviors of UK osteopaths who reject low back pain guidance – A qualitative study” written by Figg-Latham and Rajendran (2017). The Critical Appraisal Skills Programme (CASP) tool is used to assess the selected article and guide through the process of article critique (CASP, 2018). The CASP critiquing framework allows for identifying strengths and weaknesses of the research, appraising credibility, results and the findings’ implementation to practice.
The selected article emphasizes the existent issue related to osteopathic professionals’ ignorance of clinical guidelines in managing non-specific low back pain (nsLBP). According to Figg-Latham and Rajendran (2017), clinical guidelines are supposed to frame healthcare practitioners’ professional practice and clinical reasoning and improve the quality of care in managing LBP. Rutten et al. (2010) claim that guideline adherence improves function and decreases the number of treatment sessions. Moreover, practitioners following guidelines tend to identify earlier patients with the risk of poor health outcomes and chronic disability development (Grimshaw et al., 2004). Thus, Figg-Latham and Rajendran (2017) aim to explore the osteopathic professionals underlying beliefs and attitudes explaining the guidelines’ discordance in treating nsLBP. The authors justified the relevance and importance of their work by highlighting the lack of research examining osteopathic students’ and practitioners’ beliefs and attitudes related to LBP guidelines. The investigators conducted a qualitative study to explore the dimensions of British and student osteopaths’ perceptions of LBP guidelines to identify the reasoning for rejection following conventional guidelines.
Methods and Design
The current study has a qualitative research design and describes the use of semi-structured interviews to examine the attitudes and beliefs of the participants regarding disregard for LBP guidelines. The authors stated that an objectivist approach was adopted and “chose an exploratory qualitative method that used elements of grounded theory: data collection with contemporaneous analysis, constant comparison of codes and note-making” (Figg-Latham & Rajendran, 2017, p. 98). Thomson et al. (2014) defined that grounded theory includes “systematic methods of gathering, analyzing and conceptualizing data so that a theory can be built to explain a social process, action or interaction” (p. 168). Many researchers in the field of manual therapy applied grounded theory to understand and explain the discrete, multidimensional, and complex areas of practice (Thomson et al., 2014). Describing the study design, the authors highlighted the utilization of the questionnaire for the detection of osteopaths and osteopath students that prefer to avoid guidelines. The proper methodology supported the current qualitative study to address the aim of research and examine sophisticated dimensions of British osteopaths’ beliefs and attitudes towards LBP guidelines.
Although the study aims to interpret and explain the subjective experiences of selected participants and qualitative research is the appropriate methodology to address the investigation purposes, the article has a weakness. The CASP (2018) checklist shows that the study’s methods and design were not sufficiently covered. The methods section appears relatively indigent: the researchers have not adequately justified the study’s methodology and design. The article lacks an in-depth discussion explicating the decision to use selected methods. It is noteworthy that ethical issues were considered in the study: the researchers briefly mentioned receiving participants’ contests and maintaining the anonymity of their data. Figg-Latham and Rajendran (2017) highlighted obtaining ethical approval from the Research Ethics Committee at the European School of Osteopathy. The investigators provided sufficient information to evaluate whether ethical standards were maintained.
Recruitment and Selection of Participants
The researchers selected adequate to the purposes of the study recruitment strategy. Following the CASP (2018) checklist, it may be concluded that the authors explained how the selection of participants was carried out. However, the article includes relatively vague explanations of why the selected participants were the most appropriate and what were the inclusion criteria. The authors carried out a recruitment process within one British osteopathic education institution. The article reveals the process of participants’ recruitment sufficiently, but there is no clear statement of inclusion criteria.
Initially, all tutors and students of the institution received an email with the questionnaire designed to identify appropriate participants. The questionnaire was based on the awareness-to-adherence model that describes the steps to comply with clinical guidelines (Pathman et al., 1996). The mentioned model presupposes four steps for guidance compliance: awareness, agreement, adoption and adherence (Pathman et al., 1996). According to the table included in the article, inclusion criteria were participants’ awareness of, disagreement with, unwillingness to adopt guidelines and lack of adherence to them. Over a twelve-week period, the authors received 106 completed questionnaires and identified 52 eligible participants though 40 respondents could not participate in the interview due to timetable incompatibility (Figg-Latham & Rajendran, 2017). The final purposive sample included twelve participants – five osteopath tutors and seven students (Figg-Latham & Rajendran, 2017). Those participants were identified as rejecting to follow clinical guidelines and were invited to the semi-structured interviews. Although the recruitment strategy was appropriate for the current research design, the doubtful feature was that one of the authors was educated at the selected osteopathic institution and knew all the participants prior to the research.
Data Collection and Saturation
The authors reasonably described the data collection process and supplemented it with figures and tables; information was gathered in a way that addressed the study issue. The critical appraisal of this section was conducted with the help of the CASP (2018) checklist, namely, with questions for consideration. It is clear how the information was gathered: data collection was conducted via in-depth semi-structured interviews that were carried out face-to-face. A semi-structured interview is a common qualitative research method, implying that participants are asked to answer the suggested questions and are expected to expand upon their beliefs and views (Hicks, 2009). The researchers used the topic guide according to the research purposes: exploring participants’ attitudes regarding LBP guidance and indicating the reasoning of participants’ beliefs. The topic guide was peer-reviewed by two independent persons and verified by conducting two pilot interviews.
The authors have made the data collection strategy explicit: they adjusted an indication of how interviews were conducted. The authors stated that they ended interviewing “when data saturation occurred and the final number of interviews determined when no new viewpoints or beliefs were uncovered” (Figg-Latham & Rajendran, 2017, p. 98). The setting of the data gathering and the methods chosen were justified. In order to ensure the participants’ anonymity, each one was identified by a letter.
The participants were interviewed at the non-clinical or clinical site of the osteopathic education institution; participants chose the setting. The authors highlighted that interviews were carried out by one of the researchers. The form of the data is clear and reasonable: each interview lasted from 30 to 65 minutes and was audio-recorded and transcribed verbatim, supported by the interviewer’s field notes (Figg-Latham & Rajendran, 2017). The collected data were significantly processed since the researchers analyzed codes after each interview to ensure the completeness of the obtained information. The authors applied an investigator triangulation to confirm the validity and credibility of the transcribed data: a quarter of the emergent codes were examined by three independent practitioners with competence in qualitative research.
Results, Findings and Discussions
The article consists of comprehensive findings and discussion sections, sufficiently describing the outcomes and conclusions of the current qualitative study. The presented research results are assessed with the help of the CASP (2018) checklist, and the overall critique is satisfactory. The data analysis appears sufficiently rigorous, and the authors provide a clear statement of findings and explicit discussion. The article contains an in-depth explanation of the analysis procedure. In order to analyze transcribed data, the authors used “a constant comparative approach in which units of data were coded and compared with other units of data within a category” (Figg-Latham & Rajendran, 2017, p. 98). The thematic analysis was used, and the authors described how emerged themes were generated from the research data. The transcribed data were analyzed in four stages: applying descriptive codes against text sections, assigning conceptual codes into sub-themes, comparing sub-themes, and integrating them into main themes, and generating a theoretical concept. The identified weakness lies in the lack of critical examination of the role of the researchers, probable influence, and bias during analysis.
The authors provide a clear statement of explicit findings: from fourteen individual sub-themes, the researchers generated one main theme with three dependent ones explaining the reasoning for the LBP guidelines rejection. The central theme is the precedence of osteopathy over other manual therapies and treatment options. The researchers discovered that participants consider osteopathy a more comprehensive philosophy than any other manual therapy and mainstream medicine. The participants perceive osteopathy as autonomous and isolated from other therapies. Noteworthy, the respondents generally express skeptical attitudes towards medicine; hence, the clinical guidelines derived from conventional healthcare were ignored.
The second theme is beliefs about self, revealing that the participants feel disconnected from the healthcare system and experience challenges in interaction with non-osteopathic practitioners. The third theme is perceptions of patients and other practitioners: the participants claim that non-osteopathic healthcare professionals are more compliant with clinical guidance. Guidelines recommend treatment in a particular prescribed way, yet the osteopathic principles suggest practitioners think in a different way. The fourth team is attitudes to research and clinical guidance, emphasizing that studies are seen as potentially biased; statistics dehumanize patients; research frequently focuses on a particular body part or issue, ignoring the holistic view.
There is a sufficient discussion of the evidence for the author’s arguments, and the article includes the representation of the counterarguments. The discussion contains a substantial literature review supporting the researchers’ findings and conclusions. Discussion of the central theme is framed by highlighting the solid professional identity sense experienced by osteopathic practitioners. Driven by that feeling, practitioners are afraid to lose their identity and professional autonomy by adopting generally accepted guidelines. Within the second theme, the authors emphasize that the precedence of osteopathy is related to practitioners experiencing professional arrogance, high levels of self-confidence and expressing attitudes of superiority compared to healthcare professionals in other fields.
The researchers discussed the conception of osteopathic practice and evidence-based guidance in education. The study reveals that osteopathic practitioners who avoid guidelines value expert opinion above any other evidence and research results. The article includes sections with limitations and strengths of the research and proposals for future investigations. Eventually, the current research findings reveal the participants’ strong feelings of professional identity, belief in osteopathy’s precedence over other treatment options, and that practice is guided by osteopathic principles. Those findings explicitly explain the rejections to follow the conventionally approved clinical guidelines in managing nsLBP.
The authors discussed the credibility of their findings, highlighting the usage of triangulation on the part of the transcribed data. The researchers underlined the calculation of the reliability of the emergent codes and provided a value of 78% agreement (Figg-Latham & Rajendran, 2017, p. 98). Consequently, the findings are discussed accordingly to the initial study question and research purposes; the authors explicitly evaluated the obtained results.
Conclusion
The current study seeks to interpret the subjective perceptions and experiences of the participants related to LBP guidelines adherence and the reasoning behind LBP guidance rejection. The topic examined is relevant since the guidelines for avoidance in patients with nsLBP may lead to poor health outcomes or chronic disability. Therefore, it is crucial to understand the reasons for such attitudes of osteopathic practitioners to subsequently find ways to integrate evidence-informed practice and maintain guidelines compliance. The article provides an extensive explanation for understanding the osteopath tutors’ and students’ attitudes and beliefs associated with discordant guidance behavior. Further research should explore and identify ways to implement guidelines adherence in those osteopathic practitioners who reject it.
Among several weaknesses of the study, conducting research within one osteopathic facility and the personal relationship between the author and participants are the severest ones. The fact that all participants belonged to one educational institution potentially affected the study’s findings. Specific attitudes and beliefs could be instilled or transferred through a tutor-student relationship. For the creation of a representative sample, it is highly recommended to conduct research within different facilities. One of the authors is familiar with the participants, which decreases reliability: personal attitudes could interfere with the research process. The authors should be independent, indifferent, and unfamiliar with participants to maintain the trustworthiness of the research, its results and findings.
References
Critical Appraisal Skills Programme. (2018). CASP Qualitative Checklist [Online]. Web.
Figg-Latham, J., & Rajendran, D. (2017). Quiet dissent: The attitudes, beliefs and behaviors of UK osteopaths who reject low back pain guidance – A qualitative study. Musculoskeletal Science and Practice, 27, 97-105. Web.
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Rutten, G. M., Degen, S., Hendriks, E. J., Braspenning, J. C., Harting, J., & Oostendorp, R. A. (2010). Adherence to clinical practice guidelines for low back pain in physical therapy: Do patients benefit? Physical Therapy, 90(8), 1111-1122. Web.
Thomson, O. P., Petty, N. J., & Scholes, J. (2014). Grounding osteopathic research–introducing grounded theory. International Journal of Osteopathic Medicine, 17(3), 167-186. Web.