Discussion now takes place around the distinctive professional and personal attributes demonstrated by paediatric osteopaths. The impetus for such discussion relates to an unexpected finding of the study; one that is similarly recognised as a topic of interest in the contemporary health care literature. It relates to the concept of professional practice expertise, which is generally demonstrated by osteopath participants when responding to new mothers and young babies, in what is an inherently complex and unpredictable clinical practice situation. Expertise is characterised by osteopaths’ practice knowledge, skill, sensitivity, and professional judgement in response to a range of diverse clinical breastfeeding problems and practice situations, which were, overall, dealt with effectively in a caring, competent, and professional manner. This finding relates also to another general finding that, regardless of individual breastfeeding outcomes, mothers were essentially satisfied with their experiences of osteopathy and believed that it could benefit other mothers in similar situations. The researcher is aware also that the study’s substantive theory portrays an overwhelmingly positive view of paediatric osteopathic practice, which is not considered a common feature of clinical practice in general, and thus requires closer examination. Discussion of expertise in paediatric osteopathic practice begins with a statement that explains the researcher’s interpretation of the concept, based upon analysis of data, before making comparisons with the literature.
Expert practice in the situation of responding to dyads struggling to breastfeed satisfactorily, rests upon paediatric osteopaths’ abilities to blend personal and professional values and judgement with technical manual therapy skill and practice knowledge to assist dyads, in individualised ways, to achieve their end goal of optimal breastfeeding. It is founded upon their expressed interest in understanding dyads and their breastfeeding problems from a biomedical and social perspective206 and to organise and use different forms of knowledge and action, according to perceived need, at the time, and over a
206 See Chapter 9.2.
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period of time207. They skilfully combine clinical reasoning, technical manual and interpersonal skills by moving between positivist (scientific) and interpretivist (psychosocial) paradigms, according to their reading of the practice situation. In other words, expertise, in a generic sense, lies in taking a disciplined yet dynamic and flexible multidimensional view of practice to apply a range of professional and personal knowledge and skills, wisely. Some of the distinctive features of expert practice that arise from the study are the quality of interpersonal osteopath-dyad relationships, osteopaths’
judicious use of therapeutic touch, specific manual techniques, and time, and their open reflexive practice approach.
In the osteopathic technical and conceptual literature, the discipline is described frequently as a philosophy, science, and art (Cameron, 1998; Di Giovanna, Schiowitz, &
Dowling, 2005; Parsons & Marcer, 2006; Stone, 1999; Ward, 2003) but what this means as a unified concept remains unclear. The elements of philosophy and science are generally well-articulated but the artistic component of professional practice has not been investigated or well defined. Traditionally, osteopaths draw upon a set of principles208 combined with scientifically based treatment models209 to ultimately inform clinical practice. When discussing their approach to assisting dyads with breastfeeding difficulties, paediatric osteopaths refer often to these principles and biomechanical, anatomical and physiological treatment models. They do not, however, discuss research pertaining to the social processes of clinical practice and the complexities of decision-making, interpersonal relationships, and practitioner-patient interaction. A similar situation has been articulated in the literature by (Schửn, 1991), who, in his seminal book, The Reflective Practitioner, describes a gap between expert knowledge of the science-based health professions, and the complex demands of clinical practice. On this basis, he argues for a shift toward a new epistemology of practice called “reflection-in-action” (Schửn, 1991, p. 49) in which technical problem solving is placed within a broader context of reflective enquiry.
‘Reflection-in-action’ is a complex concept that fits with the notion of ‘professional artistry’
in a health care setting, as proposed previously in Thomson et al’s study210. The more subtle elements of practitioner-patient interaction, have become more visible, in recent times, through investigation, across a range of health disciplines, into the complex phenomenon of expert practice or professional artistry; concepts that are closely linked but the distinction between them remains unclear (Chapparo & Ranka, 2008; Paterson &
Higgs, 2008).
207 See Chapter 12.3.3 for discussion of osteopaths’ strategic use of time to augment treatment results.
208 See Chapter 6. 2.2.
209 See Chapters 9.3 and 10.3 for a presentation of the background to some osteopathic treatment models, which are based primarily on the sciences of anatomy and physiology.
210 See section 13.2.
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Practice expertise has been investigated by studying and comparing the clinical reasoning skills of novice and expert practitioners across a range of health disciplines (Banning, 2008; Case et al., 2000; Chapparo & Ranka, 2008; Doody & McAteer, 2002; Jones et al., 2008; May et al., 2008; Schwartz & Elstein, 2008). Practitioner reflection, as discussed previously211, consistently emerges as a requisite feature of expert practice, and the notion of professional artistry is often attributed to a particular form of reasoning, called metacognition that is characterised by practitioner reflective self-awareness, intuition, and adopting a patient-centred approach (Banning, 2008; Fonteyn & Ritter, 2008; Jones et al., 2008). Banning (2008) summarises a number of other common attributes of expert practitioners by defining expertise in nursing as the ability “to undertake cognitive shortcuts during the thinking process but also to rely on schema, experience, and intuition (p. 182)”. This description of expertise fits well with paediatric osteopaths’ organisation of their clinical practice into the four categories that underpin the osteopathic therapeutic cycle. Intuition emerges from the data as a valuable form of practice knowledge that impacts upon their decisions and actions, particularly relating to what they feel or sense when interacting with dyads; such as sensing a baby’s responses to manual therapy.
Treating the baby by blending scientific knowledge with honed tactile skills based upon thinking about what they are feeling and observing in the moment (“reflection-in-action”), while attending to maternal wellbeing within a dynamic clinical context, represents a form of practice mastery or artistry; depending on how one perceives these concepts. The traditional idea of an artist, such as a painter, sculptor or musician, is someone who has much technical skill that is used for creative purpose in which the end result is something that is significant and other than ordinary. It is evident from the data, however, that paediatric osteopaths view Promoting optimal breastfeeding through the osteopathic therapeutic cycle in terms of good professional practice, grounded in expert skill and knowledge, rather than artistry. An observer or investigator, who uncovers the processes of expert clinical practice, however, might interpret their findings in a more theoretical light and conceptualise the processes involved as a form of professional artistry.
Such a theoretical model of practitioner expertise has been developed from a synthesis of the literature that relates to the conceptualisation of expert practice and professional artistry in the health professions (Paterson & Higgs, 2008). The proposed model, called
“professional practice judgement artistry (PPJA)”, combines four practice dimensions;
professionalism, multifaceted judgement, practice artistry, and reflexivity. Each dimension is complex but some of their underpinning elements, which are purported to be generally applicable across a range of health disciplines, align with similar findings from the current
211 See section 13.4.2 Assimilating.
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study. These elements relate to practitioners’ having a strong professional identity, attunement (being in tune with people), passion, and heightened self-awareness.
A distinguishing attribute of paediatric osteopaths is their strong sense of professional identity. Despite osteopathy, as a health profession, and more specifically, paediatric osteopathy, being relatively unknown and poorly understood212, osteopath participants demonstrate confidence and commitment to paediatric practice and, as a matter of routine, adopt strategies to manage patients’ and other health practitioners’
(mis)perceptions concerning their clinical work. This attribute links to their commitment to osteopathic paediatric practice, which for some, is expressed as a sense of passion.
Commitment is evidenced by accounts of their pursuit of a career in paediatrics without a clearly defined professional educational pathway. It is expressed also as a sense of belief in osteopathy and the benefits it can offer to the very young and their families213. Paediatric osteopaths’ ability to attune to dyads’ struggling to breastfeed satisfactorily, physically and emotionally, and to recognise and respond in sensitive ways to individual cues, needs, and circumstances is evident throughout the data and likely to be associated with their personal and professional motivation and ideology. Finally, paediatric osteopaths have a heightened self-awareness of how they might be influencing a vulnerable patient group. They recognise their breastfeeding knowledge limitations and are careful not to impose personal and professional breastfeeding and parenting views.
They rather adopt a collaborative mother-baby-led approach that is centred on balancing dyads’ individual, immediate, and long-term health goals and needs.