Similarities And Differences Of Graduate Entry-level .

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Innes et al. Chiropractic & Manual Therapies (2016) 24:1DOI 10.1186/s12998-016-0084-0SYSTEMATIC REVIEWOpen AccessSimilarities and differences of graduateentry-level competencies of chiropracticcouncils on education: a systematic reviewStanley I. Innes1*, Charlotte Leboeuf-Yde1,2,3 and Bruce F. Walker1AbstractBackground: Councils of Chiropractic Education (CCE) indirectly influence patient care and safety through theirrole of ensuring the standards of training delivered by chiropractic educational institutions. This is achieved byCCEs defining competence and creating lists of descriptive statements to establish the necessary standards forstudents to attain before graduating. A preliminary review suggested that these definitions and descriptive listslacked consensus. This creates the potential for variations in standards between the CCE jurisdictions and maycompromise patient care and safety and also inter-jurisdictional mutual recognition. The purposes of this studywere 1) to investigate similarities and differences between the CCEs in their definitions of competence, domainsof educational competencies, components of the domains of competencies, as represented by assessment anddiagnosis, ethics, intellectual development, and 2) to make recommendations, if significant deficiencies were found.Method: We undertook a systematic review of the similarities and differences between various CCEs definitions ofcompetence and the descriptive lists of educational competencies they have adopted. CCEs were selected on thebasis of WHO recommendations. Blinded investigators selected the data from CCE websites and direct contact withCCEs. This information was tabulated for a comparative analysis.Results: All CCEs’ definitions of competence included the elements of “knowledge”, “skills” and “attitudes” whereasonly one CCE included the expected “abilities” element. The educational application of the definition of competencyamong CCEs varied. A high level of similarity when comparing the domains of competence adopted by CCEs wasfound despite variations in the structure.Differences between CCEs became increasingly apparent when the three selected representative domains werecompared. CCEs were found to stipulate varying levels of prescriptiveness for graduate entry level standards.Conclusions: A series of recommendations are proposed to create uniform and high quality international standards ofcare. Future research should compare the levels of CCEs enforcement of standards to see if similarities and differencesexist.Keywords: Councils of chiropractic education, Competence, Practice profiles, Standards of education, Similarities,Differences* Correspondence: s.innes@murdoch.edu.au1School of Health Professions, Murdoch University, Murdoch, AustraliaFull list of author information is available at the end of the article 2016 Innes et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication o/1.0/) applies to the data made available in this article, unless otherwise stated.

Innes et al. Chiropractic & Manual Therapies (2016) 24:1IntroductionChiropractors are trained worldwide in different types ofinstitutions; most are private colleges but some are integrated into state funded universities. Accreditation authorities ensure that there are professional standardsthat must be met in chiropractic pre-professional training so that patients are protected and treated properlyby graduates from those programs. These accreditationauthorities are usually empowered or accredited to dothis by their respective governments. In this way individual colleges do not have full power to determine their owncourse criteria. For chiropractic educational institutionstandards this control mechanism of course accreditationis carried out by various Chiropractic Councils of Education (CCE). These CCEs are located in North America,Australia, Canada, and Europe. There is also an international umbrella council of chiropractic educationorganization known as the Chiropractic Council of Education International (CCE-Int) [1]. The World HealthOrganization (WHO) recommends the CCE-Int as theconsultative body for national health authorities whenevaluating chiropractic training programs [2].Educational standards of the various institutions aredefined and monitored by the CCEs which enforce thisby inspecting and evaluating the chiropractic institutions’ facilities and educational programs. CCEs achievethis, in part, by defining competence and creating lists ofdescriptive statements to clarify the necessary knowledge, understanding, skills, attitudes, and behavioursstudents should attain before graduating and enteringpractice [3]. These competencies are an importantmeans by which regulatory bodies can change professional standards of practice [4].Defining CompetencyThe conceptualisation of competence has important implications for the way that competence based medicaleducation is implemented [5]. The Oxford ConciseDictionary defines competence as “the ability to dosomething successfully or efficiently” [6]. However, it hasbeen suggested that one broad definition is not suitablefor all professions [7] and what is required are specificdefinitions and competencies that have sufficient detailand clarity to be professionally useful [8].Efforts to make the use of competencies more profession specific and effective increased in the 1960s as companies sought to assess an individual’s expectedperformance levels, skills and knowledge [9]. Todaycompetencies are extensively applied to describe expectations of graduating students in medical and alliedhealth professions [3]. This level of specificity is requiredto detail the domains for the practitioner to functionsuccessfully within that discipline. For this reason it isappropriate for CCEs to define and prescribe thesePage 2 of 14domains and their components which are required toproduce competent chiropractic clinicians. This processshould result in a high standard of chiropractic education at internationally comparable levels [10].There is not a universally agreed conceptualisation ofcompetence in medical education. A systematic reviewof medical definitions of competence, concluded that thewords “knowledge, skills and other” were the most commonly occurring components [5] The authors allocatedall other words to a general category “other components”. Here, “attitudes” and “abilities” were prevalentand also suggested as essential ingredients of competence. “Skills” were defined as being related to manualdexterity while “ability” seen to be was commonly composed of abstract reasoning, memory and the cognitiveprocesses associated with solving novel questions.ProblemThere is evidence of variations in practitioner profiles[11] as seen in a recent study of Canadian chiropractorsthat showed differences in vaccination beliefs, X-rayusage, referral patterns, and treatment types, some ofwhich must be considered unsuitable. These unsuitableprofiles were found to be stemming from a cluster ofaccredited educational institutions in North America[12]. Another Canadian study found a relationship between the accredited educational institution of graduation and chiropractors’ interactions with other healthprofessionals, as measured by receiving patient referralsfrom medical doctors [13]. The chiropractors less likelyto receive referrals were more likely to take their ownradiographs, treat a higher percentage of patients forsomatovisceral conditions and consider maintenance/wellness care as a main component of practice activity.These findings support the possibility that there arediffering standards of CCE requirements resulting indiffering graduate outcomes.This may be the case because laws and scope of practice may differ on a country-by-country basis. Thus, aCCE for a regional part of the world may reflect thosedifferences as a result of scope. Another possible explanation, which may account in part for these differencesare differing standards of the various CCEs because ofcontextual independence and in selections of definitionsof competence. This may result in differences in standards between jurisdictions perhaps resulting in dissimilarities in practitioner profiles. There is evidence thatthis is the case for medicine [14, 15].Some practice profiles are clearly undesirable. For example, information obtained from the ChiropracticBoard of Australia [16], Wisconsin Chiropractic Examining Board [17], and previous research [18] suggests thatthe competency domains of 1) patient assessment anddiagnosis, 2) ethics, and 3) intellectual and professional

Innes et al. Chiropractic & Manual Therapies (2016) 24:1development are matters that commonly appear in registration or licensing board complaint investigations. Consequently, analysis of similarities and differences in thesethree key domains between all CCEs is important whenlooking for differences in standards that may result indesirable or undesirable practice profiles and uniformityof standards worldwide.In summary, the literature confirms that competenceis not uniformly conceptualised in health education.Similarities and differences exist between and withinprofessions [5] and educational competencies used todescribe high standards of practice, need to be profession specific. Variations between the definitions of thedifferent CCEs and prescriptive lists describing competency may result in differing practitioner profiles, whichmay create differences in the quality of care and patientsafety. Ultimately, an unequal standard and overly variedtreatment approach may also impact on the international mobility of chiropractors.AimThe aim of this systematic review was to investigatesimilarities and differences between the various CCEs intheir definitions of graduate competency and the educational competencies they have adopted.ObjectivesThe objectives were to review: 1. CCE definitions ofcompetence; 2. domains of educational competencies; 3.components of the domains of competencies, as represented by assessment and diagnosis, ethics, and intellectual development, and 4. to make recommendations, ifsignificant deficiencies were found.MethodWe conducted a systematic review to investigate the firstthree objectives. Protocols for clinical systematic reviewsare recommended to be prospectively registered wherepossible (PRISMA [19, 20] PROSPERO [20]), However,as this systematic review focussed on the descriptive definitions in documents obtained from CCEs used foreducational standards for chiropractic competenceand not peer reviewed journal articles, it was not eligible for prospective registration with databases suchas PROSPERO [21].Eligibility criteriaThe WHO recommends the CCE-Int as the source ofinformation regarding evaluation of chiropractic education [2]. Consequently, for CCE inclusion, we used thisrecommendation meaning that a CCE used in our studyhad to be recognized by the CCE-Int and be a memberin good standing. The Council on Chiropractic Education (CCE-USA), Council on Chiropractic EducationPage 3 of 14Australasia (CCE-Australia), European Council on Chiropractic Education (ECCE), and Council on ChiropracticEducation Canada (CCE-Canada) all met the inclusioncriteria.Data extraction process and synthesis of resultsThe respective CCE websites were identified andsearched independently by the lead author and a research assistant. All CCEs were asked in writing whetheradditional relevant information was available that wasnot available on their respective websites.A Masters in Business Administration graduate experienced with organisational evaluation acted as a researchassistant and was instructed on the search domains. Atraining exercise was undertaken to establish a consistent process for extracting data from the websites. Theresearch assistant was instructed on the aims and objectives of the project. Further, the roles of the CCEs weredefined. The independent reviewer conducted a websearch to locate the CCEs. The lead author and the research assistant then independently searched the CCEwebsites to identify and extract a definition of competence. The extracted data was recorded and tabulated.The author and research assistant then compared thesefor agreement. A third investigator was available to resolve any conflicts. The table format for the definitionswas structured to identify similarities and differenceswith respect to the elements of “knowledge”, “skills”,“abilities”, “other components”, and “profession specificdetails”.The same process was repeated for the extraction ofcompetency lists for each CCE.Finally, the components of the three selected domains(professional and intellectual development, assessmentand diagnosis, ethics and jurisprudence,) were extractedand placed into a tabular format and analysed for similarities and differences (Fig. 1).The CCE definition of competence informs the comprehension and construction of undergraduate competencies. Competence is deconstructed into a series ofdomains thought to describe chiropractic practice. Eachof these domains is further deconstructed into smallersubdomains and finally components which are intendedto be measureable behaviours and outcomes.ResultsThe research assistant and lead author (SI) extractions agreed on 4 of the 5 definitions of competence.After discussion consensus was reached on the oneCCE definition mismatch and did not require independent adjudication. There was agreement betweenboth researcher and research assistant on all 4 of theCCE lists of competency. This resulted in a match on8 of the 9 data extractions.

Innes et al. Chiropractic & Manual Therapies (2016) 24:1Page 4 of 14Fig. 1 Illustrative diagram of structure of our systematic reviewThe CCE-Int and the four regional CCEs (CCE-USA,CCE-Aust, CCE-Canada, ECCE) were included for thefirst objective of comparing competency definitions. TheCCE-Int did not have any graduate entry-level standardsfor competency and could not be included in the analysis for the second and third objectives.All CCEs responded to the request asking about thepresence of additional information apart from theirwebsites, and all stated that there was no additionalinformation.The investigators agreed on all definitions and competency selections from the respective CCE websites.The ratios of CCE domains and components ofdomains were found to vary considerably. The largestwas found for the CCE-Aust which had 11 domains with299 components describing these domains (Table 1),resulting in a ratio of 27.2 components per domain. Thesmallest was noted for the ECCE with 3 domains and 21components (i.e. a ratio of 7.0).the expected third element of abilities and this was usedwith respect to problem solving.Three CCEs included words from the “other components” category. First, the CCE-Int definition specifiedthat the skills necessary for the competent practice ofchiropractic are psychomotor in nature, and that theseshould become “habits”. Second, the ECCE added “problem solving abilities and attitudes”. Third, the CCE-USAused the term “meta-competencies”.The CCEs did not have a common function or contextfor application of the definition of competency. TheCCE-Canada described the use of competencies as afeedback mechanism for “monitoring the educationalprogression toward becoming a chiropractor”. The CCEAust and the CCE-USA definitions were used to determine if a student was ready to graduate and enter solopractice. The ECCE applied the definition to “controlledrepresentations of professional practice while performingat maximum levels of ability”.Objective 1: definitions of competencyAll the CCEs used definitions of competence that included two of the three basic elements, namely knowledge and skills. Another word common to all five CCEswas attributes (See Table 2). Only the ECCE includedTable 1 Number of domains and component statements andratios of these among the onent statements2992132163Component/Domain ratio27.215.27.09.0Objective 2: domains of competencyThere was inconsistency in structure among the CCEsfor domains of competency and this affected the methodology for data extraction. For example, the CCE-USAhad only 7 areas or domains but the CCE-Canada hadthe greatest number with 14. Consequently the CCECanada domains were chosen as the basis for the tablestructure of comparative purposes because it includedall the available information found in the other CCEsand would therefore enable the identification of apparently absent domains. These 14 domains of competencywere presented in Table 3.

Innes et al. Chiropractic & Manual Therapies (2016) 24:1Page 5 of 14Table 2 Definitions of competency used by the major regulatory bodiesName of CCEDefinition of “competency”Knowledge Skills Attitudes ContextOtherCCE-Intthe practice of chiropractic requires the acquisition ofrelevant knowledge, understandings, attitudes, habitsand psychomotor skills (pg 3, 2010)XXXPractice ofchiropracticHabitsCCE-AustCompetencies: Written statements describing the levelsof knowledge, skills and attitudes expected of graduates(pg 18, 2009).XXXpractitionerECC-Europea measurable set of skills, knowledge, problem solving abilitiesand attitudes in controlled representations of professionalpractice when performing at maximum levels of ability(pg 57, 2013).XXXProfessionalpracticeCCE-Canadaa student’s knowledge, skills and attitudes with the goalsof providing feedback to enhance the educational progress,rating performance, and determining the appropriatenessof progression in the clinical phase of becoming a qualifiedchiropractor (pg 68, 2011).XXXQualifiedchiropractorCCE (USA)Mandatory meta-competencies have been identified regarding Xthe skills, attitudes, and knowledge that a doctor of chiropracticprogram provides so that graduates will be prepared to serveas primary care chiropractic physicians (pg 21, 2013)XXChiropracticphysicianAust. NationalIt refers to specific capabilities in applying particular knowledge, XHealth Work Force skills, decision-making attributes and values to perform taskssafely and effectively in a specific health workforce role(pg 5, 2011)XProblem solvingabilitiesHealthValues, decisionworkforce role making attributesTable 3 Comparison of common competency domains of CCEsMajor elements/ domains of ry takingXXXXPhysical examXXXXNeuromusculoskeletal examXPsychosocial assessment cultural gender ethnic diversitiesXXXXDiagnostic studies- interpret clinical laboratory findings and diagnostic imaging of NMSKXXXXDiagnosis & differential diagnosisXXXXCase management/ReferralXXXXChiropractic adjustment or manipulation skill, competent careXXXXEmergency careXXCase follow-up and reviewXXXRecord keepingXXDoctor-patient relationship/communicationXXXXXProfessional issues/continuing education/Sound business practice/ethical practiceXXXXOther therapeutic proceduresXXXXPublic health and community interaction*XHealth care system interaction*Professional interaction*XStaff and financial management*Information and technology**Indicates domains from other than CCE-Canada* CCEA** CCE-USAXXXXXXXX

Innes et al. Chiropractic & Manual Therapies (2016) 24:1Despite the differing structures, there was considerableagreement among CCEs. All stipulated that competencerequired the domains of history taking, physical examination, differential diagnosis, imaging, laboratory testing,chiropractic adjustment/manipulation skill, management, delivery of care and communication. Finally, competency was expected in the domains of ‘prof

Similarities and differences of graduate entry-level competencies of chiropractic councils on education: a systematic review . processes associated with solving novel questions. Problem There is evidence of variations in practitioner profiles

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