European Journal of Pain 2013 (May); 17 (5): 766–775 ~ FULL TEXT
A.M. Briggs, H. Slater, A.J. Smith, G.F. Parkin-Smith, K. Watkins, J. Chua
Department of Health,
Government of Western Australia,
BACKGROUND: Evidence points to clinicians' beliefs and practice behaviours related to low back pain (LBP), which are discordant with contemporary evidence. While interventions to align beliefs and behaviours with evidence among clinicians have demonstrated effectiveness, a more sustainable and cost-effective approach to positively developing workforce capacity in this area may be to target the emerging workforce. The aim of this study was to investigate beliefs and clinical recommendations for LBP, and their alignment to evidence, in Australian university allied health and medical students.
METHODS: Final-year students in chiropractic, medicine, occupational therapy, pharmacy and physiotherapy disciplines in three Western Australian universities responded to a survey. Demographic data, LBP-related beliefs data [modified Health Care Providers Pain and Impact Relationship Scale (HC-PAIRS) and the Back Pain Beliefs Questionnaire (BBQ)] and activity, rest and work clinical recommendations for an acute LBP clinical vignette were collected.
RESULTS: Six hundred two students completed the survey (response rate 74.6%). Cross-discipline differences in beliefs and clinical recommendations were observed (p > 0.001). Physiotherapy and chiropractic students reported significantly more helpful beliefs compared with the other disciplines, while pharmacy students reported the least helpful beliefs. A greater proportion of chiropractic and physiotherapy students reported guideline-consistent recommendations compared with other disciplines. HC-PAIRS and BBQ scores were strongly associated with clinical recommendations, independent to the discipline of study and prior experience of LBP.
CONCLUSIONS: Aligning cross-discipline university curricula with current evidence may provide an opportunity to facilitate translation of this evidence into practice with a focus on a consistent, cross-discipline approach to LBP management.
From the FULL TEXT Article:
What's already known about this topic?
Low back pain (LBP)-related beliefs among some
practising clinicians are discordant with evidence.
Clinicians’ beliefs influence patients’
beliefs and behaviours.
LBP-related beliefs and likely practice behaviours
among cross-discipline students before entering
the workforce have not been characterized
What does this study add?
Beliefs of physiotherapy and chiropractic students
are in closer alignment with evidence compared
to students of other disciplines.
Students’ beliefs are associated with their clinical
These results provide a direction for interprofessional
curriculum development in musculoskeletal
Low back pain (LBP) represents a significant public
health issue due to the associated personal and societal
burden and the unsustainable drain on public health
resources (Briggs and Buchbinder, 2009). Furthermore,
the majority of people with persistent pain are
not receiving best-practice care (Australian and New
Zealand College of Anaesthetists, 2010), prompting
calls for a paradigm shift in management approaches
and pain education for health professionals, educators
and the community (Henry, 2008; Australian and New
Zealand College of Anaesthetists, 2010). While a
myriad of barriers exist for the implementation of
evidence into clinical practice, a potential strategy to
facilitate the delivery of best-practice care is to educate
and influence the emerging workforce during their
In the context of LBP, while consistent evidence
points to the effectiveness of well-integrated and coordinated
interdisciplinary management delivered
within a biopsychosocial framework (Koes et al.,
2010), clinicians’ practice behaviours and beliefs in the
management of LBP can be discordant with such a
service delivery framework and with current evidence
(Linton et al., 2002; Buchbinder et al., 2009). Moreover,
these non-evidence-based behaviours and beliefs
result in poorer patient outcomes and management
approaches that are less cost-effective (Lin et al.,
2011a,b; Darlow et al., 2012). There are a range of
educational and practice culture factors that might
interact and drive discordance with best-practice care
for both the emerging and current workforce (Foster and
Delitto, 2011). While several studies have explored the
beliefs related to pain and/or LBP held by various
emerging health workforce cohorts, including physiotherapy
(Ferreira et al., 2004; Latimer et al., 2004; Ali
and Thomson, 2009; Burnett et al., 2009; Ryan et al.,
2010; Domenech et al., 2011), nursing (Burnett et al.,
2009) and medicine (Ali and Thomson, 2009), gaps
remain in the knowledge base informing this important
bridge between evidence and practice. Given that
beliefs are likely to underpin practice behaviours of an
emerging workforce, such as clinical recommendations,
understanding the relationship between LBPrelated
beliefs and likely practice behaviours is
important. Additionally, most studies have focussed on
single professional disciplines, despite evidence for the
effectiveness of interdisciplinary management for
chronic LBP and acknowledgement of the differences
reported between professional disciplines on the relationship
between LBP and disability (Rainville et al.,
Despite the recognition of the need to upskill the
health workforce, recent reports highlight that painrelated
curriculum for health students remains inadequate
(Watt-Watson et al., 2009; Briggs et al., 2011;
Jones and Hush, 2011). This raises the question as to
whether the emerging workforce has the appropriate
skills and knowledge to provide integrated co-care for
consumers with LBP; a condition that represents the
largest proportion pain presentations of musculoskeletal
origin in Australia. The aim of this study was to
measure beliefs and likely practice behaviours related
specifically to LBP among Australian final-year health
students in disciplines (including chiropractic, medicine,
occupational therapy, pharmacy and physiotherapy)
where the management of LBP lies within
their scope of clinical practice in a primary care context.
Participants and setting
This cross-sectional study was conducted during 2011,
across three publicly funded and one privately funded
university inWestern Australia (WA). Students in their
final year of study in physiotherapy (two universities;
4-year programme or 2.5 years if graduate entry with a
previous degree), chiropractic (one university: 5-year
programme), medicine (two universities: 6-year programme
or 4-year programme if graduate entry with a
previous degree), occupational therapy (one university:
4-year programme or 2 years if graduate entry
with a previous degree) and pharmacy (two universities:
one with a 4-year programme and one with a
2-year programme if graduate entry with a previous
degree) were invited to participate. Approval to
conduct the study was granted by local university’s
Human Research Ethics Committees and adhered to
the Declaration of Helsinki. The Department of Health,
Government of Western Australia, remained the coordinating institution for the project and custodian of the
pooled data set, while each institution was granted
access to data provided by their students.
Each discipline was approached at each facility and
asked to nominate a time at which their student cohort
was close to completion of their training (i.e., last
semester). At these nominated times, students were
invited to participate in the study by one of the authors
(J.C.). This author also liaised with all course coordinators,
to ensure that convenient times were negotiated
with each university department. Across all the student
cohorts, data were collected between 0 and 108 days
prior to completion of their university training. A
research officer was present during each nominated
data collection time for each cohort to briefly describe
the study and to answer questions. Each student was
given a survey, constructed as a four-page Teleform
booklet, and a study information sheet. Passive consent
was assumed upon completion and return of survey at
the end of the lecture or tutorial. Students were advised
by their tutor/lecturer and the research officer that
completion of the survey was voluntary. This information
was also reflected in the study information sheet.
Those students who elected not to complete the survey
exited the tutorial or lecture theatre.
Demographic and LBP history data
Demographic data included age, gender, degree course,
total years of education and international student
enrolment status. History about LBP and chronicity (an
LBP episode lasting 3 months) were collected, based
on the Nordic Musculoskeletal Pain Questionnaire
(Kuorinka et al., 1987). Respondents were also asked
to indicate whether they had accessed or utilized any of
the following options for a previous episode of LBP:
medication, physiotherapy, occupational therapy, chiropractic,
self-management and imaging.
Instruments to measure beliefs
The modified Health Care Providers Pain and Impact
Relationship Scale (HC-PAIRS) measures practitioner
beliefs regarding the relationship between LBP and
physical function. The modified HC-PAIRS consists of
13 items each rated on a 7-point Likert scale, scored
from 1 (completely disagree) to 7 (completely agree)
(Evans et al., 2005). Scores range from 13 to 91, with
higher scores representing less helpful beliefs about
the relationship between LBP and impairment. Validity
of the original HC-PAIRS and internal consistency
(a = 0.78–0.84) have been established previously
(Rainville et al., 1995; Houben et al., 2004), based on
cohorts of health professionals in disciplines comparable
with those student disciplines included in this
study. The instrument has also been used previously
in studies using health professional student cohorts
(Ferreira et al., 2004; Latimer et al., 2004; Burnett
et al., 2009; Ryan et al., 2010; Domenech et al., 2011).
Beliefs about inevitable consequences of future life
with low back problems were measured using the Back
Pain Beliefs Questionnaire (BBQ) (Symonds et al.,
1995). The BBQ consists of 14 items each rated on a
5-point Likert scale, scored from 1 (completely disagree)
to 5 (completely agree). Scores range between 9
and 45 with higher scores representing more helpful
beliefs about the consequences of LBP. The internal
consistency (a = 0.70) and test–retest reliability (intraclass
correlation coefficient = 0.87) of the BBQ have
been established previously (Symonds et al., 1996).
The BBQ has been used among students and adolescents
previously (Burnett et al., 2009; Smith et al.,
Instruments to measure likely practice behaviours (clinical recommendations)
Likely practice behaviour was measured using a patient
vignette and associated questionnaire described by
Evans et al. (2005), and adapted from an original
vignette (Bombardier et al., 1995). Justification for the
use of a vignette as a blueprint for practice behaviour
has been discussed extensively by Evans et al. (2005).
The vignette describes a 28-year-old woman with nonspecific
acute LBP and no ‘red flags’. The questionnaire
related to the vignette, based on the original format
developed by Rainville et al. (2000), consists of three
items each rated on a 5-point Likert scale, exploring
health professional’s recommendations for patient
behaviour in relation to work, activity and bed rest.
Lower scores represent more restrictive recommendations.
Responses to the vignette are considered either
‘guideline-consistent’ or ‘guideline-inconsistent’ and
thresholds for dichotomization have been determined
previously through expert opinion and evidence-based
guidelines (Evans et al., 2005). Although a similar
vignette has been used among students previously
(Domenech et al., 2011), the reliability of selecting
recommendations has not been explored previously
among students. For the purposes of examining test–
retest reliability for this instrument, a subgroup of 26
physiotherapy students from one institution responded
to the vignette questionnaire twice, 5 weeks apart.
Delivery of spinal pain-related education among disciplines
Following completion of the study, educators at all
participating institutions were asked the following
Please indicate the approximate number of hours
in your curriculum dedicated to knowledge and skills
related to the management of spinal pain conditions
over the duration of the training. Please indicate as ‘x’
Have your students had specific clinical experience
in the management of patients with LBP/spinal
pain (e.g. during clinical placements)? Please indicate
by circling one response: yes/no/do not know.
Have your students had any exposure to interprofessional
education or interprofessional practice in
their training in the context of management of spinal
pain conditions? Please indicate your answer on a
scale of 1–5, where 1 = nil; 2 = minimal; 3 = moderate;
4 = considerable; and 5 = a lot.
Standard descriptive statistics were used to summarize
demographic and baseline characteristics of across the
cohort. Odds ratios (ORs) and 95% confidence interval
(CI) were calculated to determine the odds of chiropractic,
physiotherapy and occupational therapy
students who reported LBP in the last 12 months
having sought chiropractic, physiotherapy and occupational
therapy care, respectively, compared with not
selecting those interventions. Scores for each instrument
were derived according to the developer’s
method (Symonds et al., 1996; Evans et al., 2005) and
compared between the clinical disciplines using a oneway
analysis of variance. To account for multiple comparisons,
a Bonferroni correction was applied to post
hoc tests. Categorical (recommendations) data were
examined using a chi-square as an omnibus test,
followed by comparisons between independent proportions.
To assess the association between guidelineconsistent
recommendations and beliefs, multivariable
logistic regression was used, with the guideline recommendation
as the dichotomous outcome variable and
either HC-PAIRS and BBQ scales as predictor, adjusted
for pain in the last months and discipline of study.
Interaction effects for both pain in the last month and
discipline with beliefs scales were tested. Test–retest
reliability of responses to the vignette was expressed as
overall percentage agreement for guideline consistency
and inconsistency, while the probability of disagreement
was determined using McNemar’s exact
test. Differences between disciplines in responses to
questions related to pain curricula were not statistically
analysed due to small cell numbers. Data were
examined using IBM Statistical Package for the Social
Sciences version 19 (SPSS Inc., Chicago, IL, USA).
Demographic and pain history characteristics
A total of 602 students participated in this study, representing
an overall response rate of 74.6%. Table 1
summarizes the demographic and pain history characteristics
and the questionnaire scores across each discipline.
There was strong evidence of differences
between disciplines for age, gender, years of tertiary
education, proportion of international students, LBP
prevalence and chronicity and interventions sought
for LBP (p < 0.0001). On average, medicine students
were slightly older and had undertaken a greater
number of years of tertiary education than students in
the other disciplines. Chiropractic students reported a
significantly higher lifetime, 12- and 1-month prevalence
of LBP compared with the other disciplines,
while occupational therapy students had the second
highest prevalence of LBP; significantly higher than
medicine and pharmacy students.
Care-seeking choices for LBP
Of the 42 (91.3%) chiropractic students who had
experienced LBP in the last year, 100% reported previously
seeking chiropractic care. Physiotherapy students
who experienced LBP in the last year were likely
to select physiotherapy as a treatment option (OR
4.26; 95% CI: 2.01–9.01), compared with not selecting
physiotherapy as a treatment option. No association
was observed between occupational therapy students
reporting LBP in the last year and their selection of
occupational therapy as a treatment option (OR
1.08; 95% CI: 0.18–6.38). Across all students, selfmanagement
was the most commonly reported intervention
used (54.7%; range: 49.8–90.7%) (Table 1).
LBP-related beliefs across student disciplines
There was strong evidence for differences between the
discipline groups in the HC-PAIRS and BBQ scores
(p < 0.001) (Table 1). Compared with all other students,
physiotherapy students reported significantly
more helpful beliefs (lower score) on the HC-PAIRS,
while pharmacy students reported the least helpful
beliefs on the HC-PAIRS, with a significantly higher
score compared with chiropractic and medicine students.
Both physiotherapy and chiropractic students
reported significantly more helpful beliefs on the
BBQ (higher scores) compared with all other disciplines.
Pharmacy students reported the least helpful
beliefs on the BBQ, with a significantly lower score
compared with chiropractic, medicine and physiotherapy
Recommendations for physical activity, work and bed rest across student disciplines
The proportions of students in each discipline who
reported guideline-consistent responses for physical
activity, work and bed rest recommendations differed
significantly (p < 0.0001). A significantly greater proportion
of chiropractic and physiotherapy students
reported recommendations that were guidelineconsistent
compared with other disciplines, while a
significantly lower proportion of occupational therapy
and pharmacy students reported recommendations
that were guideline-consistent compared with other
disciplines (Table 1). The percentage agreement in
guideline responses to the patient vignette over time
was moderate to high (physical activity: 84.6%; work:
80.8%; bed rest: 65.4%), supported by the absence of
significant disagreement as tested with the McNemar’s
statistic (p = 0.38–1.00).
Associations between clinical recommendations and beliefs
HC-PAIRS scores were strongly associated with clinical
recommendations. Results of multivariable logistic
regression indicated that a 1-point increase in
HC-PAIRS (i.e., less helpful beliefs) was associated
with a decrease in the odds of guideline-consistent
responses of 4% for physical activity (OR: 0.96; 95%
CI: 0.94, 0.98; p < 0.001), 6% for work (OR: 0.94;
95% CI: 0.92, 0.96; p < 0.001) and 7% for bed rest
recommendations (OR: 0.93; 95% CI: 0.91, 0.95;
p < 0.001). These estimates are adjusted for the experience
of pain in the last month and discipline. There
was no statistical evidence for differences in these
associations according to either experience of pain in
the last month or discipline (i.e., no interaction effect).
BBQ scores were also associated with clinical
recommendations. Results of multivariable logistic
regression indicated that a 1-point increase in BBQ
(i.e., more helpful beliefs) was associated with an
increase in the odds of guideline-consistent responses
of 5% for physical activity (OR: 1.05; 95% CI: 1.01,
1.09; p < 0.001) and 12% for bed rest recommendations
(OR: 1.12; 95% CI: 1.08, 1.16; p < 0.001). These
estimates are adjusted for the experience of pain in the
last month and discipline. There was no statistical evidence
for an association of BBQ with guideline recommendations
for work after adjustment for pain and
discipline (OR: 1.03; 95% CI: 0.99, 1.06; p = 0.114), or
for differences in any associations according to either
experience of pain in the last month or discipline (i.e.,
no interaction effect).
Spinal pain curricula characteristics across student disciplines
Table 2 summarizes responses collected from institutions
regarding the volume and nature of spinal
pain-related curriculum delivered to students. The
approximate number of hours in the curricula dedicated
to knowledge and skills related to the management
of spinal pain conditions over the duration of the
training varied considerably across the disciplines
(range 2–310 h) with chiropractic students having
the highest volume of training hours.
Discussion and conclusions
This is the first study to examine beliefs and clinical
practice recommendations related specifically to LBP
among multidisciplinary Australian health professional
students. We observed strong evidence for differences
in self-reported LBP-related beliefs and
clinical recommendations. Physiotherapy and chiropractic
students demonstrated more helpful beliefs
about LBP, and a greater proportion of these students
made guideline-consistent recommendations in
response to a patient vignette, compared with medicine,
pharmacy or occupational therapy students.
While domain-specific knowledge and skills necessarily
vary between disciplines, more consistent alignment
of LBP-related beliefs, attitudes and clinical
behaviours across disciplines may have bilateral
benefits for the health workforce and consumers.
While the pooled prevalence and chronicity of LBP
aligned with Australian adult population norms
(Walker et al., 2004) and student-derived data (Smith
and Leggat, 2007; Burnett et al., 2009; Falavigna et al.,
2011; Moroder et al., 2011), chiropractic students
reported a significantly higher prevalence of LBP.
Given the response rate, it is unlikely this finding is
related to responder bias. Consistent with earlier
research, physiotherapy students reported a significantly
higher prevalence of LBP compared with
medical students (Falavigna et al., 2011), yet comparative
data for chiropractic students are unavailable.
Although the use of management strategies by students
in each discipline was closely related to their
discipline, suggesting a domain-specific orientation to
the choice of intervention, a large proportion of students
from all disciplines adopted self-management as
an intervention for their LBP. While this finding indicates
a guideline-consistent approach to LBP management,
we cannot speculate on the nature of the
self-management strategies used.
Although students’ beliefs varied significantly across
disciplines, our pooled data, representing a preemergent
workforce, overall indicate more helpful
LBP-related beliefs compared with the Australian
general population (Buchbinder et al., 2001; Urquhart
et al., 2008; Briggs et al., 2010), with BBQ data
derived from practising Australian health care professionals
(HCPs) (Buchbinder and Jolley, 2004), and
with other final-year health student cohorts (Burnett
et al., 2009). Similarly, our data point to more helpful
beliefs overall, evident from lower HC-PAIRS scores,
compared with data reported for physiotherapy students
from Australia (Latimer et al., 2004; Burnett
et al., 2009), Spain (Domenech et al., 2011) and Brazil
(Ferreira et al., 2004). Both the pooled BBQ and
HC-PAIRS scores from our study were similar to scores
[BBQ mean (standard deviation): 34.3 (6.8);
HC-PAIRS: 43.2 (9.3) ] reported recently for crossdiscipline
clinically active HCPs from regional WA
(Slater et al., 2011), collected over the same period as
data were collected for this current study. Collectively,
these data suggest that the pre-emergent and current
clinical workforce inWA generally have helpful beliefs
related to LBP, possibly reflecting both contemporary
health policy (Department of Health Western Australia,
2009) and contemporary LBP-related education
models that increasingly adopt a biopsychosocial
Across the disciplines, chiropractic and physiotherapy
students demonstrated significantly more
helpful beliefs regarding LBP compared with medicine,
occupational therapy and pharmacy students,
and these differences were clinically and statistically
significant. Physiotherapy students’ beliefs regarding
the relationship between LBP and physical function
were the most helpful. These data likely reflect the
substantially greater volume of spinal pain-oriented
curricula and clinical placements in physiotherapy and
chiropractic courses. The HC-PAIRS score reported
by physiotherapy students may reflect the greater
emphasis of functional restoration in physiotherapy
curriculum, compared with chiropractic. Notably,
Ryan et al. (2010) observed HC-PAIRS scores in physiotherapy
students to reflect more helpful beliefs compared
with non-health students, and also showed that
HC-PAIRS scores improved among physiotherapy students
over the course of their university training.
Despite pharmacy students reporting the least helpful
beliefs, their BBQ scores were still higher than scores
reported from community-based Australian cohorts
(Buchbinder et al., 2001; Urquhart et al., 2008; Briggs
et al., 2010); a finding that aligns with BBQ data collected
from community pharmacists in England
(Silcock et al., 2007). These data suggest that while
emerging pharmacists’ beliefs relating to LBP could be
improved relative to other disciplines, their beliefs
remain more helpful than those held by the general
community. This highlights the importance of involving
pharmacy students (and pharmacists) in interprofessional
learning activities related to spinal pain
conditions, particularly given the central role of community
pharmacists in providing evidence-informed
information to consumers with spinal pain.
While we do not have access to each specific discipline’s
curricula content, it is likely that differences in
beliefs scores and clinical recommendations may
partly reflect domain-specific orientation of university
curricula, for which there is a significant focus in chiropractic
and physiotherapy disciplines related to the
management of spinal pain. Nonetheless, given that
even a short (6.5 h), targeted, spinal pain education
intervention can encourage health professionals to
adopt more evidence-based beliefs and attitudes and
self-reported clinical behaviours related to LBP, and
these changes are sustained at 2 months postintervention
(Slater et al., 2012), a targeted session
within the current curricula could also be effective
for students across disciplines.
In the context of spinal pain, HCPs beliefs are recognized
as key factors influencing treatment approaches
to LBP and the beliefs of their patients. For example,
there is evidence that HCPs demonstrating a biomedical
orientation or elevated fear avoidance beliefs are more
likely to offer people with LBP guideline-inconsistent
advice regarding work and physical activities (Darlow
et al., 2012). Paradoxically, doctors who profess a
special interest in back pain may offer advice that is
discordant with evidence (Buchbinder et al., 2009).
Houben et al. (2004) found that back pain beliefs were
significantly correlated with work and activity recommendations.
Our data support this literature, where
multivariable logistic regression models confirm that
more positive beliefs are associated with greater odds of
respondents generally selecting clinical recommendations
that are guideline-consistent, independent of
their clinical discipline and prior experience of LBP.
Therefore, optimizing LBP-related beliefs and attitudes
across disciplines may be effective in encouraging
young clinicians to select recommendations in clinical
practice that are consistent with clinical guidelines. This
approach may be particularly important for occupational
therapy and pharmacy students, of whom
55–83% did not recommend guideline-consistent
approaches for physical activity, work and rest.
Given that epidemiologic data predict a substantial
increase in the burden of musculoskeletal pain over the
next three decades (Woolf et al., 2010), and in LBP
specifically (Hoy et al., 2010), this area of health care
need requires cooperation between health policy,
health services, professional bodies and health discipline
training facilities such as universities. Effective
and sustainable management of pain requires systemwide
changes, particularly at the primary care level.
In Australia, state (e.g. Models of Care; http://www.
and national (e.g. National Pain Strategy; http://
national-pain-strategy.html) policies emphasize the
importance of addressing pain using a multidimensional
approach, involving development of workforce
capacity, upskilling consumers, disseminating appropriate
public health messages and improving information
exchange between consumers and health systems
and providers. While strategies to improve beliefs and
likely practice behaviours among practising clinicians
have been shown to be effective (Buchbinder and
Jolley, 2004; Evans et al., 2010; Domenech et al.,
2011), a more sustainable approach and one that can be
undertaken in parallel, could be to educate the emerging
workforce in evidence-based practice for managing
people with LBP. Indeed, this approach has been advocated
strongly in the fields of musculoskeletal and pain
medicine (Chehade et al., 2011; Jones and Hush, 2011;
Briggs et al., 2012). Given the evidence for the effectiveness
of interprofessional management for LBP
(Turk, 2002; Lamb et al., 2010; Davies et al., 2011), this
approach would adopt an interprofessional framework
(Ali and Thomson, 2009) as a means to lever an interdisciplinary
health professional culture shift regarding
best-practice management. Despite recognition of the
benefits of an interprofessional approach, a recent
study identified limited opportunities for pain-related
interprofessional learning opportunities across university
health courses in the United Kingdom (Briggs et al.,
2011). Delivering interprofessional education in a
single location may be most effective, since at least
some, if not a majority of students, would be likely to
interact in a clinical network or community of practice,
a model that has been shown to be effective for improving
health outcomes and building effective professional
relationships, and ultimately delivering better quality
care (Cunningham et al., 2012).
The strengths of this study are reflected in the crossdiscipline
and primary care-oriented approach and,
consequently, the large sample size, a very good
response rate and the assessment of likely clinical recommendations
through the use of a patient vignette.
To our knowledge, the use of a clinical vignette in this
context has only been used by Domenech et al.
(2011), and represents an approach that is considered
to provide information more representative of practice
behaviour and quality of care (Peabody et al., 2004).
The study was cross-sectional in design, relied on selfreport
and was based only on Australian students.
Therefore we cannot speculate on the temporal stability
of the results we reported, the accuracy of the
outcome measures in predicting actual practice behaviours
and beliefs of the students upon commencing
clinical practice, or the generalizability of the findings
to students studying in other nations. An important
area of future research would be reassessing international
cohorts following their engagement in the
workforce in order to determine any shifts in clinical
behaviours and beliefs.
All authors discussed the results and commented on the
manuscript. A.M.B. and H.S. were responsible for the conception,
design and management of the study. H.S., G.F.P.,
K.W. and J.C. were responsible for data collection. A.M.B.,
H.S. and A.J.S. were responsible for data analysis. All authors
were responsible for interpretation of the data, drafting of
the manuscript and approving the final version.
The authors acknowledge in kind support provided by Curtin
University (Ingrid Van Zyl), Murdoch University, Notre
Dame University (Ajanthy Arulpragasam) and the University
of Western Australia (Eva Schluchter, Liza Seubert and Neil
Boudville). Dr. Andrew Briggs and Dr. Anne Smith are supported
by Fellowships from the Australian National Health
and Medical Research Council and Curtin University, respectively.
The authors acknowledge the support of the WA
Spinal Pain Model of Care Group within the WA Musculoskeletal
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