The study findings have implications for osteopathic practice in general, in the field of paediatrics, and more specifically, in the situation of assisting dyads with breastfeeding difficulties. They also have implications for osteopathic education and research. For convenience, the three elements of professional practice, education, and research are discussed separately; however, it is evident that they interlink and inform each other closely.
14.3.1 Implications for paediatric osteopathic practice
The theory derived from the current study, Promoting optimal breastfeeding through the osteopathic therapeutic cycle, is, to the researcher’s knowledge, the first theory of paediatric osteopathic practice. It is also one of a very limited number of studies that proposes a substantive theory of osteopathic practice. It specifically adds to osteopathic practice knowledge by including the patient’s (breastfeeding mother’s) perspective of osteopathy.
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One of the purposes of theorising is to create knowledge that can build on, extend, or modify existing theories (Strauss & Corbin, 1998, p. 24). Hence, the first implication is that the current substantive theory represents a beginning to the development of a theory of osteopathic practice. Although it pertains to paediatric practice and the situation of responding to dyads struggling to breastfeed satisfactorily; it emphasises also the complex and dynamic health care environment in which osteopaths must function, regardless of the specific clinical context. It is evident from contemporary qualitative studies of health care practice, discussed previously, that this situation is widespread across a number of disciplines. The literature emphasises the evolving roles and professional expectations of health practitioners who must use a range of clinical reasoning knowledge, skills, and judgement to provide evidence-informed, patient-centred care in dynamic practice situations. Trede, Higgs, Jones, and Edwards (2003) summarise this concept by describing the dual roles of health practitioners as moving between being
“scientific technicians” and “humanistic patient advocates” (p. 2).
A substantive theory, grounded in data from paediatric osteopathic clinical practice, is timely for a number of reasons. First, although there is widespread acknowledgement in the conceptual literature that osteopathy is underpinned by scientific knowledge, critical thinking and technical skill, research into these and other more tacit elements of professional practice such as interpersonal and communication processes, is limited.
Osteopathic practice, in general, incorporates biological, psychological and social domains and one of the challenges facing the profession is the development of a well- substantiated theoretical basis that explains the complex array of phenomena that influence clinical practice and patient health outcomes. A theory is thus a practical tool for guiding practice and ultimately improving interventions and the delivery of health care.
The osteopathic therapeutic cycle represents an abstraction that has generic dimensions that can be potentially applied to a range of clinical situations in paediatric practice and also in general osteopathic practice, and which can be studied, tested and further refined according to new insights and research outcomes.
The second reason why a grounded theory of paediatric osteopathic practice is timely concerns ‘Paediatrics’ as an emerging specialised area of osteopathic clinical practice that has not yet been defined by the profession. Study findings highlight the ambiguity surrounding paediatric practice in terms of the knowledge and skill sets required to deal competently with this patient population, and in particular, new mothers and infants.
Findings emphasise also paediatric osteopaths’ use of particular manual techniques that are gentle and seem to be well suited to babies. In addition, building therapeutic
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relationships, based upon taking an internal view of dyads’ breastfeeding problems and social circumstances, is an important element of paediatric practice. Overall, study findings highlight the level of practice expertise demonstrated by paediatric osteopaths, who claim to have learnt their professional skills through common self-directed learning pathways that focus on manual skill development, mentorship from other more experienced practitioners, and reflection of relevant personal and clinical experiences.
This type of informal learning approach raises a number of questions about paediatric osteopathic education, which are addressed in the following section.
14.3.2 Implications for breastfeeding
Breastfeeding research continues to report on the positive impact of breastfeeding on the health and wellbeing of mothers and babies, in the short and long-term. Despite this knowledge, duration of breastfeeding continues to decline in the postnatal period, particularly on discharge from hospital, and falls short of recommended breastfeeding targets219. Women in the current study, represent a group of well-informed new mothers who want to follow contemporary evidence-informed breastfeeding guidelines but have difficulty translating this information into practice. Their experiences of Struggling to breastfeed satisfactorily220 resonate with the literature that has identified a number of common barriers to breastfeeding221. Brodribb (2011) discusses these barriers and the recommended strategies to improve the flow of best breastfeeding practice along a research-to-practice pipeline. On this basis, collaborative care for breastfeeding dyads across the health professions and complex multi-strategy interventions to assist mothers to overcome breastfeeding difficulties, are recommended (Brodribb, 2011; Demirtas, 2012; Dyson et al., 2006;Renfrew et al., 2012), and that such strategies should span the antenatal, and extended postnatal periods (Meedya et al., 2010; Pannu et al., 2011).
Findings that relate to paediatric osteopaths’ therapeutic approach to assisting dyads with breastfeeding difficulties fit with this premise.
Paediatric osteopaths promote optimal breastfeeding through a range of strategies that broadly focus on two aspects; promoting breastfeeding self-efficacy and providing a form of social support. Their therapeutic approach incorporates building good therapeutic relationships (Connecting), analysing breastfeeding problems (Assimilating), rebalancing the baby’s body, and empowering mothers to enhance breastfeeding confidence and self- efficacy, as well as dyads’ overall health and wellbeing. Here is a potentially useful intervention that, for many health professionals, represents a new approach to an old
219 See Chapter 2.2.
220 See Chapter 7.2.1 and 7.2.2
221 See Chapter 2.7.
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problem. As little is generally known about osteopathic treatment of babies with breastfeeding difficulties, it is anticipated that access to the study’s research outcomes will make paediatric clinical practice more comprehensible and visible to health professional and lay audiences. Ultimately, it is hoped that insight into paediatric osteopathy will translate into improved inter-professional relationships and opportunities for collaboration when sourcing and providing timely and appropriate professional breastfeeding support.
14.3.3 Implications for osteopathic education
The study’s grounded theory of paediatric osteopathic practice aligns with the contemporary trend of shifting health care practice toward a biopsychosocial framework.
Historically, osteopathic education (and research), like physiotherapy (Jones et al., 2002;
Trede et al., 2003), has emphasised biomedical sciences, the physical body, and technical manual examination and treatment procedures and skills rather than psychosocial assessment and management, and the development of critical thinking, reflective, intuitive, and interpersonal communication skills. Findings from the study and the wider literature suggest that the latter skill set, otherwise collectively known as metacognitive skills, represent essential components of expert practice that enable practitioners to blend various forms of knowledge in order to deal with the unpredictable dynamic clinic environment. Schửn (1991) describes the expert or reflective practitioner as someone who becomes a researcher in the practice context; who “is not dependent on categories of established theory and technique, but constructs a new theory of the unique case” (p. 68). This idea represents an important change in perspective relating to professional education. In this case, practice informs theory rather than the other way round. Gaining insight into osteopaths’ therapeutic approaches in the everyday circumstances of their professional practice provides a valuable form of theoretical practice knowledge and helps to close the gap between theory and practice (Mann, Gordon, & MacLeod, 2009). Mann et al’s. (2009) systematic review of 29 studies that investigated reflective health care practice reports on a generic growing interest in this topic with a view to implementing educational strategies that promote reflective practice.
Results suggest that practitioner reflection is an important part of health care practice that seems to be amenable to development. However, understanding of this complex phenomenon and appropriate educational strategies is still in its early stages and requires ongoing investigation.
Insight into osteopathic clinical expertise in general, provides valuable information for advancing the profession. More specifically, in the field of paediatrics, it raises questions about what types of specialised professional knowledge and skills are required, how they 279
are learnt, and if, and how, they can be taught. Such insight would prove valuable to enhancing their development through targeted educational strategies. Current educational trends in osteopathic paediatric practice, evident in the data, are consistent with the notion of practitioners acquiring expert practice knowledge and skill through reflection on personal and clinical experiences and informal mentorship arrangements. As osteopathy in the field of paediatrics grows, this self-directed educational approach is not only unlikely to be sustainable but raises important questions about professional practice standards and safe-guards. If osteopathy is to be considered a consistently safe and good treatment option for breastfeeding difficulties, further questions arise concerning the setting up and maintenance of quality professional educational programs, specific to this patient population. If the current trend of paediatrics being perceived by members of the profession as a specialised area of osteopathic practice continues, then more efficient, relevant, and systematic educational methods and programs, such as the development of a post-graduate diploma, are required to prepare osteopaths for the demands of paediatric practice.
14.3.4 Implications for future research
An outcome of this study is that, as well as the grounded theory of Promoting optimal breastfeeding through the osteopathic therapeutic cycle, a number of potential areas for future study have emerged from data and through discussion. Overall, further research of an exploratory nature is recommended to build on the findings from the current study in order to uncover and better understand the processes of paediatric osteopathic practice in a range of clinical contexts. Although the osteopathic therapeutic cycle was developed from data taken from the inherently complicated and unpredictable circumstances of paediatric practice, and in the situation of struggling to breastfeed satisfactorily, the researcher contends that the schema is likely to be applicable to other osteopathic practice situations. Conceptually, the idea of an osteopathic therapeutic cycle potentially fits with a number of different clinical problems and practitioner therapeutic approaches because it can account for a blending of knowledge and skill sets that range from a technical rational perspective to a more humanistic and socially grounded view. Further grounded theory research is, however, required to substantiate or test this claim.
To date, the few studies that have explored osteopaths’ therapeutic approaches have involved experienced practitioners. Limited information is available concerning the thoughts, actions, and perspectives of novice osteopaths; in general practice, and in more specialised fields such as paediatrics. Such knowledge has proved helpful for professional education and practice in other disciplines and clinical situations, like physiotherapy,
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(Case et al., 2000; Doody & McAteer, 2002; May et al., 2008) and would likely be relevant to osteopathy for a number of reasons. It would add depth to current understandings of practice expertise, through self-development or specialised educational pathways, and shed light on the transition from novice to expert practitioner with a view to enhancing this process. In addition, patients’ perspectives of osteopathic practice, which are largely missing from the literature, would be helpful for better defining a patient-centred approach and providing osteopathic care that aligns with patients’ views and needs.
In the specific circumstances of investigating osteopathy as an effective intervention for promoting optimal breastfeeding, further research in the form of a clinical trial or mixed quantitative and qualitative methods is recommended, to study more closely the relationship between paediatric osteopathic treatment, specific breastfeeding strategies, and positive breastfeeding outcomes. In addition, as study findings support the notion, reported in other studies (Creedy et al., 2003; Kingston et al., 2007), that osteopaths’
therapeutic goals and strategies align with a breastfeeding self-efficacy framework, the researcher proposes that the breastfeeding self-efficacy scale would be a useful measure suited to such research. Such a line of enquiry could ultimately lead to the development of clinical guidelines for an osteopathic intervention to promote breastfeeding.
Other areas of research interest pertain to exploring, in more depth, three unexpected findings that were identified as important elements of the study’s theory of paediatric osteopathic practice, which have been largely overlooked in the literature. The first relates to the importance of sensitive interpersonal processes and effective communication skills (Connecting) in paediatric practice, which is founded upon practitioner attunement to mother and baby, as individuals, and as an interdependent functional unit. The second concerns the different forms of therapeutic touch that play a part in osteopath-dyad interactions and manual therapy intervention (Rebalancing). The third pertains to the role of time and timing in patient-osteopath interaction, which impacts across all categories. A consistent and distinctive feature of each practice visit was the taking of time to allow dyads to feel comfortable, gather relevant information, and for close interpersonal and physical interaction. When combined, these three practice elements potentiate a form of humanistic care that enhances manual treatment and other therapeutic responses, and which ultimately facilitate a beneficial transitional change experience; factors that are often missing in busy, less personalised, health clinics.
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