MOVING TOWARDS A CONTEMPORARY CHIROPRACTIC PROFESSIONAL IDENTITY
 
   

Moving Towards a Contemporary
Chiropractic Professional Identity

This section is compiled by Frank M. Painter, D.C.
Send all comments or additions to:
   Frankp@chiro.org
 
   

FROM:   Complementary Therapies in Clinical Practice 2020 (May);   39:   101105 ~ FULL TEXT

Tanja T.Glucina, Christian U.KrAgeloh, PanteáFarvid, Kelly Holt

Centre for Chiropractic Research,
New Zealand College of Chiropractic,
Auckland, New Zealand.
tanja.glucina@nzchiro.co.nz


Since the inception of the chiropractic profession, debate has continued on differing practice objectives and philosophical approaches to patient care. While the political and academic leaders of the profession continue to dominate the discourse, little is known on the perspectives of the everyday practising chiropractor on their professional identity. In this paper, professional identity within the profession of chiropractic was evaluated using a systematised search strategy of the literature from the year 2000 through to May 2019. Initially 562 articles were sourced, of which 24 met the criteria for review. The review confirmed three previously stated professional identity subgroups; two polarised approaches and a centrist or mixed view. The musculoskeletal biomedical approach is in contrast to the vertebral subluxation vitalistic practice approach.

Whilst these three main chiropractic identity subtypes exist, within the literature the terminology used to describe them differs. Research aimed at categorising the chiropractic profession identity into exclusive subtypes found that at least 20% of chiropractors have an exclusive vertebral subluxation focus. However, deeper exploration of the literature shows that vertebral subluxation is an important practice consideration for up to 70% of chiropractors. Patient care with a musculoskeletal spine focus is dominant in clinical practice. This review found that practising chiropractors consider themselves to be primary care or primary contact practitioners with a broad scope of practice across a number of patient groups not limited to musculoskeletal management. Across the research, there is a marked difference in the categories of practice objectives evaluated, and future research could examine the relatedness of these. Additionally, future research could explore the professional identity construct over time and within different practice contexts to help facilitate the progression of the profession.

KEYWORDS:   Chiropractic; Managerial change; Organisational change; Professional identity; Professionalisation; Scope of practice



From the Full-Text Article:

Introduction

The changing nature of health professions and the relationship between professions in the public sector has been the focus of much interest (Hotho, 2008). Chiropractic is no exception, with a large degree of discourse being from within (Good, 2016; Villanueva- Russell, 2011). Contention exists on what characterises the chiropractic profession relating to philosophy and scope of practice, and chiropractic researchers and academics provide much commentary on the continued difficulty to define its identity (Brown, 2016; Good, 2016; Hart, 2016; Nelson et al., 2005; Rosner, 2016; Schneider et al., 2016). The importance of professional identity is paramount to the survival of any profession - as former secretary-general of the World Federation of Chiropractic, Chapman-Smith (2000) stated, "quite simply, a product or service not understood is not used" (p.150). For this to occur, a profession must first understand itself.

Chiropractic has been described by the World Health Organisation as “a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal (NMS) system and the effects of these disorders on general health; there is emphasis of manual techniques used such as joint adjustments and/or manipulation, with particular focus on subluxations” (World Federation of Chiropractic, 2009, p.3). An evaluation of this definition suggests that there is a range of approaches within chiropractic, yet in general, patients typically report a high level of satisfaction with the chiropractic care that they receive (Davis and Bove, 2008; Gaumer, 2006; MacPherson et al., 2015; Rowell and Polipnick, 2008; Weigel et al., 2014).

Within the chiropractic profession, there is debate around the contrasting practice objectives of a short-term biomedically focused musculoskeletal (MSK) treatment style of practice (Chapman-Smith, 2005; Nelson et al., 2005; WFC Task Force Presentation, 2005) versus a long-term vitalistic vertebral subluxation wellness focus style of practice (Hawk et al., 2005; Jolliot, 2006; Senzon, 2011; WFC Task Force Presentation, 2005). Vertebral subluxations (VS) are hypothesised to be biomechanical derangements of the spine (as a result of stresses on the body), producing clinically significant maladaptive effects on neurological function and sensorimotor integration (Henderson, 2012; Taylor et al., 2010). For the individual, reduction of VS is theorised to improve health and quality of life (de Souza & Ebrall, 2008; Ebrall, 2009; Kent, 2018).

By analysing and correcting VS through the chiropractic intervention, the adjustment, it is posed that an individual is placed on a more optimum physiological path, with the potential to increase resilience and adaptability (Kent, 2018). The MSK framework of chiropractic care considers that chiropractic treatment improves dysfunctional joints by mobilisation, which in turn reduces pain and improves function (Schneider et al., 2016). Some chiropractors with a MSK-focus practice objective make claims that the VS-focus chiropractors are held in older concepts - that subluxation is the cause of all disease, even though there has been evolution of VS theory (Haavik, Holt, & Murphy, 2010; Kent, 2018; Senzon, 2018b). There is a large group within the profession, the ‘centrists’, that incorporates the traditional philosophy of VS-focused chiropractic, while also having a practice objective of treatment of general MSK complaints (WFC Task Force Presentation, 2005).

These differing practice objectives have been at the centre of robust debate with considerable disagreement on practice scope and lexicon (Villanueva-Russell, 2011). As it currently stands, the progression of chiropractic may be hindered by this division on foundational concepts and by the clustering of those who practice into rival camps (McDonald et al., 2004). Attempts to bridge the gap between the approaches have been contentious (Briggance, 2005; Villanueva-Russell, 2011), and the profession has not yet resolved issues of professional and social identity (Leboeuf-Yde et al., 2019; Meeker and Haldeman, 2002).

Chiropractic has been successful in attaining the formal criteria of a health care profession (Brosnan, 2017), and over the last 50 years, the professional focus of chiropractic has included obtaining formal recognition by government agencies, achieving insurance equality, and gaining greater acceptance in health care (Jolliot, 2012; Peck, 2015). Nonetheless, the chiropractic profession continues to be globally underrepresented in most discussions on health care delivery (Rosner, 2016) and remains largely marginalised from public health systems, with chiropractors increasingly forced to defend their professional status (Brosnan, 2017). The following information will introduce the importance of professions, professional identity and how it relates to the chiropractic profession.

      Professions and Professional Identity:

The word profession comes from the Latin word profiteor, as the act of publicly declaring to offer a service as a means of social utility. Sociologists and psychologists have examined professional identity for many decades (Abbott, 1988; Goode, 1960; Saks, 2012). It can be accepted that the term traditionally profession relates to a group of people having the same intellectual/artistic job, who share a specific field of knowledge that requires special education, training, skills and experience (Abbott, 1988; Evetts, 2006). More recently, what defines a profession has shifted from trait and functionalist theories through to those concerned with the "essence" of a profession (Freidson, 1994).

The social process of an occupation transforming into a profession is termed professionalisation. Professionalisation is the process in which professionals create and control a market for their professional skills and knowledge to secure their social and economic position (Larson, 1977). This process can occur for many reasons, such as the advancement of science and its ramifications on the division of labour (Larson, 1977). This has been observed with the rise of the importance placed on managerial dominance to guideline industry which has been said to contribute to stratification within medicine (Harrison and Ahmad, 2000). Division of labour can be within the domain of scope of practice (SCOP), which is the regulation of professionals in a specific jurisdiction and legally creates boundaries by restricting a specified profession’s permissible activities (Cassidy, 2013).

Professions are often a perceived singular unit concerned with defence of a status quo as opposed to adapting to changing needs and demands of the market (Hotho, 2008). Another view argues that change provides an opportunity for professions to renew themselves (Nancarrow and Borthwick, 2005). In order to preserve a profession, strategies are applied to maintain the status of its identity through its professional boundaries (Hotho, 2008). Where there is contextual change within a marketplace, professions deploy defensive strategies to either protect boundaries or reject or make claim to new areas of knowledge (Abbott, 1988). Control over specialised scientific or expert knowledge is deemed necessary for a profession’s achievement, and abstract knowledge delineates the profession’s jurisdictional control.

This control of knowledge also forms the basis of practical techniques and political autonomy in distinguishing itself in a competitive marketplace (Abbott, 1988). Freidson (1994), a leader in the professional identity field, argues that it is the responsibility of professions to establish the rationale and justifications of their professional status, and postulates that professionalism is now being re-created through hierarchical control whereby everyday practitioners are subject to the control of professional elites who exercise administrative and cultural authority. These newer professionalisation tactics have been said to create internal divisions within medicine (Harrison and Ahmad, 2000; Martin et al., 2009) and homeopathy (Degele, 2005).

Professional identity is the ownership of a core set of values, beliefs and assumptions about a profession's unique characteristics, that differentiates it from others (Weinrach et al., 2001). Professional identity has commonly been explained in terms of Social Identity Theory. Social identity refers to an individual’s self-concept derived from membership to social groups and the values and emotional significance that they attach to belonging to those groups (Tajfel, 1974). Professional identity is one aspect of a person’s social identity, and professional socialisation provides a sense of belonging, stability and esteem, which is constructed and developed over time through interaction (Hotho, 2008).

Professional identity relating to an individual’s chosen field develops during one’s whole life, providing a sense of continuity with the past, meaning in the present, and future direction (Beijaard et al., 2004). A unified profession is said to be essential for both the personal and social wellbeing of the individuals who comprise it as well as the greater community (de Luca et al., 2018). In this way, in order for a profession to thrive, it is paramount to seek to understand and research its identity.

      Chiropractic Professional Identity:

Amongst every profession there is a tendency to stratify into new groups in order to differentiate between areas of specialty. However, these intra-professional factions can provide specific challenges (Abbott, 1988; Hotho, 2008; McGregor et al., 2014), which is also evident within the chiropractic profession. Since its development, tensions have existed on chiropractic professional identity (CPI) and its SCOP. Historically, this has centred around differences in practice, intervention approaches and epistemological backgrounds, which is being played out today as the VS versus the MSK chiropractic approaches (Carey et al., 2005; Senzon, 2018b). Attempts have been made to reconcile intra-professional division: In 2004, the World Federation of Chiropractic (WFC), through a global consultative process, sought to deliver an international identity of chiropractic that encompassed the majority of views held amongst practitioners and organisations (Carey et al., 2005).

From this, the identity statement to be “the experts in spinal health care within the health care system” (WFC Task Force Presentation, 2005, p.1.) was created. Since then, this statement itself continues to be hotly debated and is contentious amongst leaders and practitioners alike. Much commentary continues to revolve around terminology as well as philosophical and therapeutic orientations towards patient care (Carey et al., 2005; Meeker and Haldeman, 2002). Some argue that a professional unity for chiropractic does not seem possible (Good, 2016; Institute for Alternate Futures, 2013; Leboeuf-Yde, Innes, Young, Kawchuk, & Hartvigsen, 2019).

While intra-professional debate surrounding CPI continues, it remains unclear what actual research exists that has examined this emotionally loaded and hotly debated subject. The aim of this paper is to critically evaluate the literature on CPI from the perspective of the practising chiropractor. The importance of this groups’ viewpoint lies in that everyday chiropractors are the ground force providers for the patients care seeking their form of health care, and hence would be most affected by organisational directives on CPI.



Method

A systematised approach was employed for this critical literature review. A literature search was conducted using the Index to Chiropractic Literature, Medline, CINAHL Plus with Full Text and SPORTDiscus with Full Text through the EBSCO Health Database. Search criteria included that articles needed to be in the English language, in peer-reviewed academic journals and published between January 2000 and May 2019. These dates were selected to represent the most current research available. Searches were conducted using the following terms included in the abstract: chiropract* AND (“professional identity” OR identity) OR chiropract* AND character* OR chiropract* AND perception* OR chiropract* AND perspect* chiropract* AND “scope of practice”.

Studies that investigated (either qualitatively, or quantitatively) analysis of SCOP (e.g., VS or MSK practice objectives) and/or views and attitudes of practising chiropractors on identity were included for review. Professional identity evaluation was not necessitated to be the primary objective of the entire research. If aspects of professional identity were examined, the paper was included in this critical review. Commentaries, letters, dissertations, theses, conference proceedings and poster presentations were excluded.

From the search terms above, a total of 562 articles were identified through database searches. After 59 duplicates were removed 503 articles remained. Additional hand searches and reference tracking searches revealed 6 articles, leaving 509 articles for screening of abstracts and articles. Full-text articles were retrieved for 35 articles that were read to ascertain whether they met the inclusion/exclusion criteria of this review. After this eligibility assessment, 24 articles were retained for evaluation (Figure 1).



Results

      Data abstraction and synthesis:

Analysis was conducted to identify the main characteristics and differences between studies systematically. Extracted data included author(s), study focus and location, year of data collection, sample characteristics, methods/methodology, and summary of results relating to CPI and SCOP. Since many of the articles were quantitative analyses of survey instruments, psychometric properties such as validity/reliability were also obtained. The main characteristics of the 24-studies are presented in Table 1.

Studies in this review are from diverse international locations, with the majority of research being conducted in Europe (Ailliet et al., 2010; Gislason et al., 2019; Hennius, 2013; Humphreys et al., 2010; Jones-Harris, 2010; Malmqvist and Leboeuf-Yde, 2008; Nielsen et al., 2015; Pollentier and Langworthy, 2007), and the United States of America (Chang, 2014; Duenas et al., 2003; Lisi et al., 2010; Redwood et al., 2008; Smith and Carber, 2009, 2008; Villanueva-Russell, 2011). Research was also conducted in Canada (McGregor et al., 2014; Puhl et al., 2014), Australia (Adams et al., 2019, 2017), and South Africa (Johl et al., 2017; Myburgh and Mouton, 2007).

Multiple geographic locations were used for three projects; Canada, United States, Mexico, Hong Kong, Japan, Australia, and South Africa (Leboeuf-Yde et al., 2005), the United States, Canada and Mexico (McDonald et al., 2004), and the United Kingdom and Australia (Brosnan, 2017). Sample size varied in this review from a single-case study (Hennius, 2013) through to responses from 3,559 participants (Smith and Carber, 2008). The mean sample size was 406 per study, with a bimodal distribution that peaked around 50-99 (Ailliet et al., 2010; Chang, 2014; Nielsen et al., 2015; Villanueva-Russell, 2011) and 500-999 (McDonald et al., 2004; Puhl et al., 2014; Smith and Carber, 2009).

The majority of articles were quantitative analyses of survey instruments (Adams et al., 2019, 2017; Ailliet et al., 2010; Blaich et al., 2018; Chang, 2014; Gislason et al., 2019; Humphreys et al., 2010; Johl et al., 2017; Leboeuf-Yde et al., 2005; Lisi et al., 2010; Malmqvist and Leboeuf-Yde, 2008; McDonald et al., 2004; McGregor et al., 2014; Nielsen et al., 2015; Pollentier and Langworthy, 2007; Puhl et al., 2014; Redwood et al., 2008; Smith and Carber, 2009, 2008), with the exception of one mixed-methods study (Jones-Harris, 2010) that used qualitative inquiry to inform an instrument that was analysed quantitatively.

One study used a questionnaire aimed at quantifying the professional stratification (of six pre-defined subgroups) among Canadian chiropractors (McGregor et al., 2014), which formed the basis for other studies both with (Gislason et al., 2019) or without (Puhl et al., 2014) additional adapted questions. Another questionnaire was created using the National Board of Chiropractic Examiners (United States) Job Analysis Survey as a template, as well as adapting questions from the United Kingdom survey from the General Chiropractic Council, to examine Swiss chiropractic practice characteristics (Humphreys et al., 2010). This questionnaire was also used by Johl et al. (2017), with adapted additional questions.

Four qualitative studies (Brosnan, 2017; Hennius, 2013; Myburgh and Mouton, 2007; Villanueva-Russell, 2011) were included in this review. Of these, one examined methods of professionalisation used by the two CPI poles e.g., the vitalistic VS focused and biomedical MSK focused practice objectives (Brosnan, 2017), with another evaluating the literature using Critical Discourse Analysis (Villanueva-Russell, 2011). Further examination of the eligible articles found three overarching concepts. Studies were divided into three types of research approaches, with some overlap (Table 2). These include: 11-articles with a research focus on philosophical notions and concepts of professional identity, 15-articles with a research focus on practice characteristics and SCOP, and 5- articles with a research focus on grouping chiropractic into wider health care categorisations.

Table 2: Summary of study focus for articles in critical literature review For research relating to CPI philosophical notions, this review confirmed the three main practice objectives previously stated in the literature. These include the MSK, centrist and VS focused approaches. Notably, these main groupings are at times labelled differently. For example, in the qualitative study by Myburgh and Mouton (2007), the vitalist chiropractor is referred to as a technician, and the biomedical chiropractor is referred to as a physician. Some of the studies contrast the two historically polarised MSK and VS approaches by categorising practice objectives into these dichotomous groups (Gislason et al., 2019; McGregor et al., 2014; Myburgh & Mouton, 2007; Puhl et al., 2014), hence the proportion of those who may hold a centrist practice objective is not researched or explicitly quantified.

Whilst SCOP is under jurisdictional control by individual state or country, papers in this review that investigated SCOP reported on chiropractors utilising traditional chiropractic interventions alongside soft tissue approaches (Adams et al., 2019, 2017; Ailliet et al., 2010; Chang, 2014; Hennius, 2013; Humphreys et al., 2010; Johl et al., 2017; Leboeuf-Yde et al., 2005; Lisi et al., 2010; Malmqvist and Leboeuf-Yde, 2008; McDonald et al., 2004; Nielsen et al., 2015). All studies that investigated SCOP relating to patient subgroups (e.g., acute, chronic, paediatric, athlete, older adult etc. patient groups) found that chiropractors care for multiple patient subgroups across multiple ages (Adams et al., 2019, 2017; Ailliet et al., 2010; Humphreys et al., 2010; Johl et al., 2017; Pollentier and Langworthy, 2007).

Results varied for healthcare categorisation within wider health care. Some chiropractors consider themselves as Integrative Medicine or Complementary and Alternative Medicine providers (Redwood et al., 2008). Chiropractors have also demonstrated their preference as being Primary Contact Practitioners (Jones-Harris, 2010; Pollentier and Langworthy, 2007), Primary Care Providers (Duenas et al., 2003), MSK specialists (Hennius, 2013; Humphreys et al., 2010; Smith and Carber, 2009) and back pain specialists or primary care generalists (Smith and Carber, 2009).



Discussion

Te purpose of this review was to evaluate the body of knowledge on practising chiropractors’ perspectives on their professional identity. This study confirmed that the literature mostly uses the following terms to classify the different approaches of chiropractic professional identity (CPI): the vitalistic VS-focused (or subluxation-based), centrist, and biomedical MSK-focused approaches. Three key and overlapping areas of study focus are found to assess professional identity as it relates to philosophical concepts, practice characteristics and SCOP, and grouping of chiropractic into wider healthcare categorisations. The following discussion summarises the main findings of the review.

      Competing Identities:

Polarised, and at times competing, intra-professional identities are not unique to the chiropractic profession and is apparent amongst many professions including counselling services (McLaughlin and Boettcher, 2009; Remley and Herlihy, 2014), physiotherapy (Fornasier, 2017), homeopathy (Brindle and Goodrick, 2001) and osteopathy (Cummings, 2006). Within the literature on the practice of family medicine, for example, at least three models have been discussed ranging from: a holistic biopsychosocial orientation that cares for the under-served; a pragmatic approach that considers market forces and personal practice styles; and family medical practitioners acting as gatekeepers for specialty care referral (Carney et al., 2013).

Within family medical practice, two distinct divergent approaches have been identified with potential future implications on the profession: The ‘generalist’ works to preserve traditional functions while adapting to changing contexts with a large SCOP compared with the ‘specialist’ that concentrates on increasing specialisation amongst general practitioners (Beaulieu et al., 2008). This differentiation is said to be the result of a rapidly expanding scope of practice, as well as the high value attributed to specialisation from society and the professional system (Beaulieu et al., 2008).

The existence of multiple identities within health care may not be as important as how one feels about the group that they belong in – a positive, strong, self-selected and flexible professional identity has been shown to influence an individual’s satisfaction and professional success (Skorikov and Vondracek, 2011). Within the nursing profession, it has been observed that a strong coherent professional identity creates a more productive and committed professional who is beneficial to other healthcare workers as well as patients (Cowin et al., 2013).

How nurses think and feel about themselves also supports patient care within a positive environment and enhances job satisfaction and retention rates (Horton et al., 2007). It has been posed that a unified profession is essential for both the personal and social wellbeing of the individuals who comprise it as well as the greater community (de Luca et al., 2018). Perhaps it is not the unified aspect that is the function of personal wellbeing and professional confidence – instead it may be the result of intra-professional respect that professional identity is individual and may evolve and change that promotes strong social and professional wellbeing? In this way, it may be useful for the chiropractic profession to continue to investigate ways to establish a more contemporary CPI.

From the papers in the review with a focus on CPI in terms of philosophical notions and concepts, research was directed on the different chiropractic identity subtypes and practice objectives. McDonald (2004) expressed the three main identities along a graded continuum from one (broad/mixer) to ten (focussed/straight), with five representing the middle scope. Research that categorised pre-prescribed chiropractic identities into discreet subtypes, further grouped the findings (Gislason et al., 2019; McGregor et al., 2014; Puhl et al., 2014) into two polarised approaches; these are referred to as orthodox (MSK biomedical) and unorthodox (vitalistic VS) approaches (Gislason et al., 2019).

McGregor et al. (2014) found that 18.8% of chiropractors use a VS approach in clinical practice. In this research, McGregor et al. (2014) asked participants to self-select their practice objective into one of six groupings. These subgroups were then summated with the VS subgroup termed as unorthodox and the remaining five categories as orthodox. However, when you also consider that one of the so-called orthodox categories also utilised the term VS, the percentage of chiropractors who self-categorise as having a VS focus increases to 26.5%. The authors of this study chose not to group these two categories together as unorthodox. Gislason et al. (2019) adapted the original categorisations of practice objectives of McGregor et al. (2014) from six to five categories.

This research found 20.1% of chiropractors to practice within the unorthodox paradigm, however, when adding the two categories that include VS as a practice objective option for the chiropractor to self-select, the percentage increases to 27.1% (Gislason et al., 2019). In both studies, it should not be understated that, when adding both categories of practice objectives that have a VS focus, the percentages reflect a significant proportion of the profession. This is in contrast to Smith and Carber (2008), whose research evaluated the degree of importance and prevalence of a VS focus in clinical practice, which found that over 70% of study participants used VS to guide their practice.

Within the chiropractic profession, there has already been some critique on the original categorisations used by McGregor et al. (2014). Senzon (2018a) argued that these categorisations do not capture the historical complexity of the VS approach with respect to discrete practice styles. He further stated that many of the groupings overlap and hence may not accurately capture a true impression of the diversity in chiropractic practice.

Notably, further reading on the primary research for the original construction of these categorisations shows some potential flaws to generalisability. The six strata groupings (McGregor-Triano, 2006) were derived from survey information relating to the identification, means of evaluation and treatment of health problems that chiropractors address, gathered from 64-individuals, 25% of which were practising chiropractors. Of the three individuals that were asked to post-evaluate these subgroups (for validity), none were stated to be practising chiropractors, instead they were involved in research, policy or publication - potentially introducing bias. These potential limitations could affect generalisability of some studies in this review of CPI, which used this classification system as a basis for their research (Gislason et al., 2019; McGregor et al., 2014; Puhl et al., 2014).

      Scope of practice:

The chiropractic SCOP is important to several stakeholders including patients, health care providers, organisations and policy makers (Chang, 2014). In order to reduce confusion, some have advocated for a uniform chiropractic practice act in the United States of America (Duenas et al., 2003). However, this may be challenging given the United States of America does not have a unified SCOP for most health care professions (Chang, 2014). Studies that demonstrate the effect of utilising chiropractic legislative SCOP on actual clinical practice have not yet been conducted. What research has been conducted, suggests that individual chiropractors and/or patient preferences set their own limit on their SCOP (Gaumer et al., 2002).

Chiropractic SCOP is relevant to CPI to differentiate it from other manual therapies which use similar modalities with an MSK focus; it has been suggested that VS is central to chiropractic, which sets it apart from other professions (Russell, 2019), however the general public may not be aware of the VS-focus which may be the result of to the lack of a coherent CPI. A New Zealand study explored how various MSK providers discussed their treatment approaches compared to other primary care practitioners (Norris, 2001). It was uncovered that many professions (e.g., chiropractors, osteopaths, physiotherapists and general practitioners) are seen to employ similar modalities or methods to treat a condition. In this way, the division of labour or SCOP overlaps (Abbott, 1988). This implies that in some cases the what or how a practitioner practices may be less important than the why in terms of professional identity (Norris, 2001). This could mean that there may be merit in preserving and promoting traditional aspects of chiropractic philosophy both within the chiropractic profession, and to the wider health care profession and general public.

According to Freidson (1994), professions are distinct from other occupations in their ability to control their own work and have professional autonomy. No matter how specialised, professionals can seldom free themselves from stereotypical assumptions of people outside the profession irrespective of the profession’s resources (Freidson, 1994). If the public has a stereotype of chiropractic being related to the spine, then a unified identity of a spine focus for the public’s understanding as the management emphasis of the chiropractic profession may be the most marketable approach (Briggance, 2005; Roeckelein, 2006; Schneider et al., 2016). However, two recent studies suggest that perceptions (and thus potentially stereotypes) on the purpose of chiropractic care can be changed when communicating and educating individuals on VS based care – this was found to occur with both the general public (Russell, Glucina, Sherson, & Bredin, 2016) and for new patients who received VS focused chiropractic care (Russell, Glucina, Cade, Sherson, & Alcantara, 2017).

      Professional unification or dissolution:

Larson (1977) stated that internal unification of a profession involves a process of conflict and struggle about who shall be included or excluded. Thus, a crucial comparative research question becomes how and in what ways the discourse of professionalism is being used (by employers and managers, and by some relatively powerful occupational groups themselves) as an instrument of occupational change (including resistance to change) and social control (Evetts, 2006). Some papers in this review identified this organisational control (Brosnan, 2017; Villanueva-Russell, 2011). Brosnan (2011) discusses the strategies of the academics and MSK chiropractors who prioritise building the MSK evidence and becoming more aligned with medicine and allied health professions as compared with the vitalistic VS chiropractors who prioritise the formation of new chiropractic institutions and ongoing education and conferences to promote their views.

There is evidence that additional self-directed post-graduate education contributes to changes in practice characteristics (Injeyan and Mutasingwa, 2006). If one relates this to the VS group attending seminars and conferences to preserve their philosophy, then this indeed may be a powerful strategy. Brosnan poses the potential of separate futures within chiropractic, based on these polarised factions. Villanueva-Russell (2011) also argued that everyday chiropractors are being silenced by academic elites who have an agenda to push for the MSK model for chiropractic.

A strategy called Organisational or Managerial Change tactics (Diefenbach, 2007) can further explain the process of academic elites silencing others that occurs in professions. Managerial Change Tactics, within any organisation, proposes that due to perceived challenging and hostile environments, there is a threat to the future of an organisation (Diefenbach, 2007). In this instance, this can be seen as the competitive health care market – ‘the enemy outside’. The managerial elite are also concerned with a perceived enemy inside, seen to resist their ‘new vision’ strategy to advance the organisation, and hence suggest change within an organisation. Using this process to explain chiropractic, the managerial elite would be considered to be academics, political elites and heads of associations with a directive towards the orthodox, MSK chiropractic practice objective approach. The hierarchical leadership of both individual associations and international organisations highlight the unwilling unorthodox members within the group who resist the new order of an MSK evidence based model of chiropractic.

Members of the unorthodox group are portrayed as apathetic, sticking to an invalid old model of academia. The MSK orthodox view sees resisting change as unfavourable, regressive and inappropriate (Clegg and Walsh, 2004), while those who resist change, the VS unorthodox approach, choose words and orient towards values and theories of more traditional approaches (Suddaby and Greenwood, 2005). A paper in this review highlights the struggle from an orthodox perspective remarking that the unorthodox group has been said to hold a mix of philosophical, scientific and pseudo-scientific elements towards the evolution of a new health care paradigm (Gislason et al., 2019). Gislason et al. (2019) further remarks that the internal battle of the polarised paradigms continues to impede progression towards inclusion in a modern multidisciplinary health care setting having an impact on chiropractic gaining social and cultural legitimacy.

Organisational change can occur where individuals in power, the managerial elite, create change initiatives, justified and implemented through organisational discourses and politics (Blum et al., 2008; Diefenbach, 2007). Recently, research leaders, members, and the chair of the World Federation of Chiropractic Research Council co-authored a paper suggesting that the centrist group might be responsible for the current state of the profession insofar that their apathy has allowed the traditionalist VS views to continue (Leboeuf-Yde et al., 2019). These leaders also commented further that the centrist group should clearly state their allegiance to either of the polarised factions and for the profession to consider a split (Leboeuf-Yde et al., 2019).

In this light, there may be an agenda that CPI is being influenced by Managerial Change Tactics by the political and academic elites. In a time where diversity is celebrated around the world, it is interesting that within chiropractic, separatism is actively being encouraged with diversity being stated to be a weakness rather than a strength (Leboeuf-Yde et al., 2019). Villanueva-Russell (2011) suggested the need for greater involvement by the everyday chiropractor so that their views can be heard. Individuals are capable of transforming structures through their choices, decisions and actions (Yuthas et al., 2004) and change created in context can create shifts in power, influence and status (Hotho, 2008). Perhaps more engagement and involvement of the centrists, the largest group within the profession, could silence the polarised factions that may be the driving force behind this rift.

      Under-representation of VS-focused practice objective:

If on face value, approximately 20% of the profession has an exclusive VS-focus (Gislason et al., 2019; McGregor et al., 2014), with at least 60% who incorporate aspects of VS in practice (Leboeuf-Yde et al., 2005; McDonald et al., 2004; Pollentier and Langworthy, 2007; Smith and Carber, 2008), the proportion of the literature that relates to VS is much less so. This lack of research on subluxation-based chiropractic has even led some to question the existence of VS (Keating et al., 2005). However, there is growing evidence espousing the existence of VS including studies on reliability of subluxation indicators (Holt, Russell, Cooperstein, et al., 2018; Holt, Russell, Young, Sherson, & Haavik, 2018) and increased emphasis on VS focussed research (Huijbregts, 2016; Russell, 2019). Recently, within the literature there are greater numbers of studies on VS care in patients on improving an array of health presentations and patient outcomes (Christiansen et al., 2018; Haavik, Niazi, Holt, & Murphy, 2017; Haavik et al., 2018; Holt et al., 2019; Holt, Haavik, Lee, Murphy, & Elley, 2016).

An apparent theme in the discussion elements of many papers evaluated in this critical review is the emphasis on MSK research and patient outcomes such as back pain and disability. However, research based on the explanatory frameworks and neurological mechanisms of the VS-focussed chiropractic approach that demonstrates positive patient outcomes (Andrew, Yielder, Haavik, & Murphy, 2017; Daligadu, Haavik, Yielder, Baarbe, & Murphy, 2013; Haavik et al., 2010; Haavik & Murphy, 2012; Holt et al., 2016) are not presented in the discussion, which could imply it does not exist. At times, those that advocate the biomedical MSK model of chiropractic seem contradictory - the importance of a spine-focused identity and MSK intervention approach are highlighted, yet it also seems recognised that chiropractic patients themselves frequently report chiropractic interventions to be effective in additional benefits such as sleep and digestion improvements (Leboeuf-Yde et al., 2005), asthma (Bronfort et al., 2001) and infantile colic (Olafsdottir et al., 2001).

It has been reported that up to 15% (Holt & Beck, 2005; Leboeuf- Yde et al., 2005) of patients present for chiropractic care with a non-MSK complaint, supporting the rationale that chiropractic intervention may impact positively on a wide array of presentations not exclusive to MSK complaints. VS-focussed chiropractic care has shown improvement in both MSK and non-MSK conditions as well as patients reporting improvement in aspects of health unrelated to their initial presenting complaint (Russell et al., 2017).

Potentially, CPI may not be best measured as a concept with mutually exclusive subcategories. As a chiropractor, it may be possible to have a practice objective of relieving a patient’s symptomology while also addressing VS – this would not necessarily make one categorise themselves as centrist as it could vary upon individual patient needs. A recent qualitative study showed that the practice objective was patient-centred to improve health and wellbeing including symptom status, and yet was still VS based (Glucina et al., 2019). Forcing individuals to choose one categorisation over another may oversimplify the complicated entity that is professional identity. Professional identity has been found to develop over time (Lordly et al., 2012) and can even occur before formal education (Khalili et al., 2013). Future longitudinal studies are needed to examine this for CPI. Three of the papers included in this review gave VS as a response option for questions on identifying practice objectives for research that was targeted at practice characteristics and SCOP (Table 2) (Leboeuf-Yde et al., 2005; McDonald et al., 2004; Pollentier & Langworthy, 2007).

Hence, VS as a practice objective has not been examined extensively. It is noteworthy that researchers may focus on the more obvious treatment questions, although, in clinical practice, deeper discussions around chiropractic philosophies and the chiropractic connection to health and wellbeing may occur in everyday practice (de Souza and Ebrall, 2008), and research questions that relate to these aspects could be explored. VS as a clinical focus has been said to place emphasis on promoting wellness by engaging in positive health practices (Epstein, Senzon, & Lemberger, 2009; Kent, 2002; Kent, 2018). Research such as this, oriented at salutogenic approaches to health, are also gaining popularity in public health and health education (Stellefson et al., 2019).

      Study quality and limitations:

The research that employed surveys (Adams et al., 2019, 2017; Ailliet et al., 2010; Gislason et al., 2019; Humphreys et al., 2010; Johl et al., 2017; Jones-Harris, 2010; Leboeuf-Yde et al., 2005; Lisi et al., 2010; Malmqvist and Leboeuf-Yde, 2008; McDonald et al., 2004; McGregor et al., 2014; Nielsen et al., 2015; Pollentier and Langworthy, 2007; Puhl et al., 2014; Redwood et al., 2008; Smith and Carber, 2009, 2008) had usual but obvious limitations. External validity generalisability issues exist as to whether the findings are applicable to a wider population than the study sample. Despite often high response rates and sample sizes, potential limitations may also include a recall bias. As being a VS-focused chiropractor or MSK-focussed chiropractor is a contentious issue within chiropractic, a social desirability bias in practitioners’ responses may also be present. Non-surveyed and non-responder attitudes and profiles could also affect generalisability. For all papers in this review, no exploration on the strength of the attitudes and beliefs underlying CPI responses were evaluated.

Further to generalisability, the issues of validity and reliability must be considered. Content validity which refers to the degree to which the content of an instrument is an adequate reflection of what is meant to be measured (Mokkink et al., 2010) and face validity, which ascertains whether an instrument appears to measure whatever it is supposed to measure (Hecker and Violato, 2009) were said to take place for a third of the studies in this review (see table 1). Many of the papers in this review included adapted questions, which often had not been tested for their psychometric properties. Of further importance, cross-cultural validity (Stevelink and van Brakel, 2013) had not been established for any papers in this review that adapted previous surveys (Gislason et al., 2019; Humphreys et al., 2010; Johl et al., 2017).

Reliability, which has to do with the consistency of measurement at repeated times, was measured in this review only by Chang (2014) who added a duplicate question to test reliability of the survey questions . Factors that influence reliability include unclear or misinterpreted questions (Hecker and Violato, 2009), and ways to further enhance reliability include testing convergent/ discriminant validity, to evaluate the relatedness of concepts across groups or strata (Lohr, 2002). For many of the surveys, limitations could also exist in the lack of definitions for various strata or description of the variables that were assessed. Future studies could explore the relatedness of concepts such as those used in primary care, generalist, specialist, primary contact, spinal dysfunction, VS, MSK specialist, and strata subtypes for practice philosophies.



Conclusion

Chiropractic professional identity is complicated. Chiropractors have struggled to define their work both within the profession and in parallel to other health disciplines. This review sought to examine what studies have been conducted on professional identity and SCOP. The number of studies on CPI that are not commentary or narratives are relatively small, and the methodologies are varied. Furthermore, the literature selection was limited to English. The primary author, a chiropractor may also introduce a bias in their evaluation of the articles due to their own epistemological views, which could have influenced the analysis. However, this was mitigated by three other reviewers, two of whom were not chiropractors, also examining the papers in this review.

Articles in this review found that chiropractors had a predominately spine-based MSK practice focus utilising a wide array of interventions. Practising chiropractors consider themselves to be primary care practitioners with a broad scope of practice not limited to MSK intervention with their care including NMS, non-MSK and organic-visceral practice approaches across multiple patient demographic groups. On the surface, at least 20% of chiropractors have an exclusive VS focus. However, from this critical literature review, it is apparent that VS is an important practice consideration for a much larger proportion of chiropractors, which may be up to 70%. Of the papers in this review, less than half examined philosophical concepts of professional identity, and most papers were centred around categorising practice characteristics and SCOP. There could be a benefit for the profession to explore deeper issues of professional identity, such as how it may change over time, or investigating potential relationships between practitioner clinical confidence, patient outcomes and professional identity.

Much work is still needed to create a coherent objective and contemporary CPI. The marked difference in the concepts evaluated and potential methodological differences have highlighted areas for future development. Further empirical research into the theoretical concepts that underline professional identity and the factors that influence changes in this crucial construct is required. Future recommendations could include studies that use conceptually derived and psychometrically robust instruments capable of detecting the subtle changes in the construct over time. Further research is needed to better understand the tensions between personal and professional values and the role of workplace learning on professional identities. It is crucial that the understanding of chiropractors’ professional identity is not limited to the undergraduate identity of students, academic directive, or leaders of the professions.

Comprehensive exploration to discover specific practice settings that meet the daily demands of the practising chiropractor is paramount. An adequate understanding of professional identity must include the diverse contexts in which chiropractors conduct their practice, such as family care, sport performance or acute/chronic injuries and health conditions. After all, it is the everyday chiropractor in everyday practice settings that are the ground forces that have led to the high patient satisfaction rates that the profession prides itself on. Further empirical work on CPI is needed to guide and inform chiropractic education, as well as serving to inform political groups and guide policy direction. Through continued focus and exploration of evolving chiropractic professional identity, a more coherent identity may be possible, which could involve celebrating and embracing its diversity.



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