Attitudes, beliefs, and practices regarding medication prescribing for musculoskeletal conditions: a protocol for a national Q-methodology study of Swiss chiropractors.

BACKGROUND: Since 1995, chiropractors in Switzerland have been licensed to prescribe medications for treating musculoskeletal conditions. However, controversy remains over whether or not medication prescribing should be pursued within the chiropractic profession internationally. OBJECTIVE: To assess Swiss chiropractors' attitudes, beliefs, and practices regarding their existing medication prescription privileges. METHODS: A Q-methodology approach will be used to collect data for the assessment. In addition, scope expansion and frequency of prescribing by Swiss chiropractors will be queried using a 13-item questionnaire. Recruitment will be conducted by e-mail and all members of the Swiss Chiropractic Association will be eligible to participate. Data will be analyzed using by-person factor analysis and descriptive statistics. DISCUSSION: This will be the first national update on attitudes toward prescribing medications among Swiss chiropractors since 2003, and the first using Q-methodology. The results of this study are important as they will inform future directions and research regarding chiropractic prescription rights.

CONTEXTE: En Suisse, depuis 1995, les chiropraticiens sont autorisés à prescrire des médicaments pour traiter des affections musculosquelettiques. Cependant, la prescription de médicaments par les chiropraticiens à l'échelle internationale fait toujours l'objet d'une controverse. OBJECTIF: Évaluer les attitudes, les croyances et les pratiques des chiropraticiens suisses en ce qui concerne leur droit actuel de prescrire des médicaments. MÉTHODOLOGIE: Une méthodologie Q sera utilisée pour recueillir les données nécessaires à l'étude. En outre, l'élargissement du champ de pratique et la fréquence de prescription chez les chiropraticiens suisses seront étudiés à l'aide d'un questionnaire comprenant 13 questions. Le recrutement sera effectué par courriel et tous les membres de l'Association suisse chiropratique pourront participer à l'étude. Les données seront analysées par une analyse de facteurs personnels et par statistique descriptive. DISCUSSION: Il s'agira de la première mise à jour nationale sur les attitudes des chiropraticiens suisses à l'égard de leur droit de prescrire des médicaments depuis 2003, et la première étude à utiliser la méthode Q. Les résultats sont importants car ils permettront d'éclairer les orientations et les recherches futures sur le droit de prescrire des chiropraticiens.

Attitudes, beliefs, and practices among Swiss chiropractors regarding medication prescribing for musculoskeletal conditions: a national Q-methodology study.

BACKGROUND: Swiss chiropractors have been licensed since 1995 to prescribe from a limited formulary of medications for treating musculoskeletal (MSK) conditions. In January 2018, this formulary was expanded to include additional muscle relaxant, analgesic, and anti-inflammatory medications. Internationally, controversy remains over whether or not medication prescribing should be pursued within the chiropractic profession. OBJECTIVE: The purpose of this study was to assess Swiss chiropractors' attitudes, beliefs, and practices regarding their existing medication prescription privileges. This information will provide new insights on the topic and help inform research and policy discussions about expanding chiropractic prescription rights in other jurisdictions. METHODS: A 13-item questionnaire and Q-methodology approach were used to conduct the assessment. Recruitment was conducted by e-mail between December 2019 and February 2020, and all members of the Swiss Chiropractic Association were eligible to participate. Data were analyzed using by-person factor analysis and descriptive statistics. RESULTS: In total, 187 Swiss chiropractors participated in this study (65.4% response rate). Respondents reported prescribing analgesics, anti-inflammatories, and muscle relaxants to a median of 5, 5, and 0% of patients, respectively. Forty-two percent of respondents expressed interest in further expanding the range of current medications available to Swiss chiropractors for treating MSK conditions. Only 15% expressed interest in expanding this range to include medications for treating non-MSK conditions. In the Q-methodology analysis, four salient viewpoints/groups regarding medication prescribing emerged: prescribers, non-prescribers, collaborators, and integrators. All except non-prescribers thought medication prescription privileges were advantageous for the chiropractic profession in Switzerland. There was also strong consensus among all four groups that medication prescribing should not replace manual therapy in chiropractic practice. CONCLUSION: This was the first national survey on attitudes toward prescribing medications among Swiss chiropractors since the year 2000, and the first using Q-methodology. With this approach, four unique groups of chiropractic prescribers were identified. Even with diversity among clinicians, the findings of this study showed general support for, along with conservative use of, prescribing privileges within the Swiss chiropractic profession. Studies in jurisdictions outside of Switzerland are needed to assess whether chiropractors are interested in expanding their scopes of practice to include similar prescribing privileges.

A commentary on the implications of medication prescription rights for the chiropractic profession.

There is a growing desire within the chiropractic profession to expand the scope of practice to include limited medication prescription rights for the treatment of spine-related and other musculoskeletal conditions. Such prescribing rights have been successfully incorporated into a number of chiropractic jurisdictions worldwide. If limited to a musculoskeletal scope, medication prescription rights have the potential to change the present role of chiropractors within the healthcare system by paving the way for practitioners to become comprehensive specialists in the conservative management of spine / musculoskeletal disorders. However, if the chiropractic profession wishes to lobby to expand the scope of practice to include limited prescriptive authority, several issues must first be addressed. These would include changes to chiropractic education and legislation, as well as consideration of how such privileges could impact the chiropractic profession on a more theoretical basis. In this commentary, we examine the arguments in favour of and against limited medication prescription rights for chiropractors and discuss the implications of such privileges for the profession.

How do chiropractors manage clinical risk? A questionnaire study.

BACKGROUND: The literature on chiropractic safety tends to focus on adverse events and little is known about how chiropractors ensure safety and manage risk in the course of their daily practice. The purpose of this study was to investigate how chiropractors manage potentially risky clinical scenarios. We also sought to establish how chiropractors perceive the safety climate in their workplace and thus whether there is an observable culture of safety within the profession. METHODS: An online questionnaire was designed to determine which of nine management options would be chosen by the respondent in response to four defined clinical case scenarios. Safety climate within the respondent's practice setting was measured by seeking the level of agreement with 23 statements relating to six different safety dimensions. 260 licensed chiropractors in Switzerland and 1258 UK members of The Royal College of Chiropractors were invited to complete the questionnaire. Questionnaire responses were analysed quantitatively in respect of the four clinical scenarios and the nine management options to determine the likelihood of each option being undertaken, with results recorded in terms of % likelihood. Gender differences in response to the management options for each scenario were evaluated using the Mann-Whitney U (MWU) test. Positive agreement with elements comprising each of the six safety dimensions contributed to a composite '% positive agreement' score calculated for each dimension. RESULTS: Questionnaire responses were received from 76% (200/260) of Swiss participants and 31% (393/1258) of UK members of The Royal College of Chiropractors. There was a general trend for Swiss and UK chiropractors to manage clinical scenarios where treatment appears not to be successful, not indicated, possibly harmful or where a patient is apparently getting worse, by re-evaluating their care. Stopping treatment and/or incident reporting to a safety incident reporting and learning system were generally found to be unlikely courses of action. Gender differences were observed with female chiropractors appearing to be more risk averse. CONCLUSIONS: Swiss and UK chiropractors tend to manage potentially risky clinical scenarios by re-evaluating the case. The unlikeliness of safety incident reporting is probably due to a range of recognised barriers, although Swiss and UK chiropractors are positive about local communication and openness which are important tenets for safety incident reporting. The observed positivity towards key aspects of clinic safety indicates a developing safety culture within the Swiss and UK chiropractic professions.

Creating European guidelines for Chiropractic Incident Reporting and Learning Systems (CIRLS): relevance and structure.

BACKGROUND: In 2009, the heads of the Executive Council of the European Chiropractors' Union (ECU) and the European Academy of Chiropractic (EAC) involved in the European Committee for Standardization (CEN) process for the chiropractic profession, set out to establish European guidelines for the reporting of adverse reactions to chiropractic treatment. There were a number of reasons for this: first, to improve the overall quality of patient care by aiming to reduce the application of potentially harmful interventions and to facilitate the treatment of patients within the context of achieving maximum benefit with a minimum risk of harm; second, to inform the training objectives for the Graduate Education and Continuing Professional Development programmes of all 19 ECU member nations, regarding knowledge and skills to be acquired for maximising patient safety; and third, to develop a guideline on patient safety incident reporting as it is likely to be part of future CEN standards for ECU member nations. OBJECTIVE: To introduce patient safety incident reporting within the context of chiropractic practice in Europe and to help individual countries and their national professional associations to develop or improve reporting and learning systems. DISCUSSION: Providing health care of any kind, including the provision of chiropractic treatment, can be a complex and, at times, a risky activity. Safety in healthcare cannot be guaranteed, it can only be improved. One of the most important aspects of any learning and reporting system lies in the appropriate use of the data and information it gathers. Reporting should not just be seen as a vehicle for obtaining information on patient safety issues, but also be utilised as a tool to facilitate learning, advance quality improvement and to ultimately minimise the rate of the occurrence of errors linked to patient care. CONCLUSIONS: Before a reporting and learning system can be established it has to be clear what the objectives of the system are, what resources will be required and whether the implementing organisation has the capacity to operate the system to its full advantage. Responding to adverse event reports requires the availability of experts to analyse the incidents and to provide feedback in a timely fashion. A comprehensive strategy for national implementation must be in place including, but not limited to, presentations at national meetings, the provision of written information to all practitioners and the running of workshops, so that all stakeholders fully understand the purposes of adverse event reporting. Unless this is achieved, any system runs the risk of failure, or at the very least, limited usefulness.

Medication prescription: a pilot survey of Bernese doctors of chiropractic practicing in Switzerland.

OBJECTIVE: The purpose of this survey was to assess the use of and the attitude toward prescribing medication among doctors of chiropractic in 1 of 26 Swiss cantons. METHODS: A Likert scale electronic questionnaire was sent to licensed doctors of chiropractic of the canton of Berne (n = 47). Percentages, mean values, and standard deviations were calculated. A follow-up survey was used to assess comments from the main survey. A probability value of P < .05 indicated a statistically significant difference. RESULTS: The response rate was 77%. Forty-one percent of the respondents stated that medications are a necessary component of the chiropractic treatment. Although 92% actively prescribe medication at least once a week, this is significantly less than asked for by their patients (P < .01). Seventy-two percent of the doctors of chiropractic rated the present privilege to prescribe nonprescription medications as an advantage for chiropractic care. Fifty-eight percent thought that chiropractic should aim at expanding the options of nonsteroidal anti-inflammatory drugs, analgesics, and muscle relaxants that can be prescribed. Ninety-one percent agreed on continuing education in pharmacology. Despite prescribing medication at least once a week, less than half of Bernese doctors of chiropractic perceived medications as a necessary component of their treatment, mainly using them to help patients who cannot sleep because of pain and to speed up recovery. When asked if they would be allowed to prescribe medications of the "B-list," the majority would want structured continuing education. CONCLUSION: Limited medication prescription was judged as an advantage for the chiropractic profession by this group of survey participants.

Usefulness of CanMEDS Competencies for Chiropractic Graduate Education in Europe.

PURPOSE: In 2008, the European Academy of Chiropractic decided to develop a competency-based model for graduate education in Europe. The CanMEDS (Canadian Medical Education Directives for Specialists) framework describes seven competency roles (fields) and key competencies identified as fundamental to all specialist doctors. It was not known how these fields are perceived by chiropractors in Europe. The purpose of this study was to compare perception scores of senior chiropractic as well as medical students with perception scores of licensed chiropractors and to analyze practitioners' remembered confidence in these competency fields. METHODS: An anonymous 5-point Likert scale electronic questionnaire was sent to senior students of two chiropractic schools and licensed chiropractors of five European nations. Age and gender differences as well as differences in appraisal of the competencies in respect to importance and remembered confidence were analyzed. RESULTS: Response rates were low to moderate. Agreement of importance of the seven competencies was not different between chiropractic and medical students as well as licensed chiropractors. Chiropractic students and chiropractors regarded all key competencies as important (averages >/=4.0). The importance versus remembered confidence was consistently judged higher by about 1/2 point on the 5-point scale, significant for all competency fields (p < .001). CONCLUSION: The seven competency fields seem to be of the same importance for chiropractic senior students and licensed chiropractors and might be considered as a base for future graduate training in chiropractic. The survey should be replicated with additional samples and further information should be gathered to reflect reality.

A model framework for patient safety training in chiropractic: a literature synthesis.

OBJECTIVE: The objective of this review is to develop an evidence-focused and work-based model framework for patient safety training, that is, reporting and learning from adverse events in chiropractic care. This article will not debate specific issues of adverse events from spinal manipulation. The main focus is on education for patient safety. METHODS: We conducted a systematic search and synthesized 196 articles on patient safety to provide guidance. The review was carried out by the 2 authors independently in 3 ways: research type, relevancy with respect to patient safety, safety culture or climate, and distinct description of one or more of the adapted Bland's characteristics. RESULTS: Fifty-five articles were included. Their review provided knowledge acquisition and practice behavior regarding patient safety issues and excellent baseline data on reporting and learning of adverse events for training purpose. CONCLUSIONS: Leadership, commitment, and communication together with trust and openness to build a culture of patient safety are prerequisites for successful reporting and learning.