Alan Borthwick

Strange new world: applying a Bourdieuian lens to understanding early student experiences in higher education

Occupational therapy pre‐registration education stands at the intersection of the fields of health and social care and higher education. UK Government agendas in both fields have seen an increase in the number of students entering with non‐traditional academic backgrounds, a group noted to experience particular challenges in negotiating the transition to, and persisting and succeeding within, higher education. Drawing on data from an ongoing longitudinal case study, a Bourdieuian lens is applied to exploring the early educational experiences of a group of these students during their first year of study and highlights a number of key issues, including the high‐value status of linguistic capital and its relationship to understanding the rules governing practices within the learning environment, the processes via which students manage to adapt to or interestingly, to resist, the dominant culture of the field, and some of the barriers to finding a foothold and legitimate position within the new field.

Challenging Medicine: The Case of Podiatric Surgery

This paper examines the establishment of National Health Service (NHS) podiatric surgery as a challenge to the dominance of medicine and its control over the provision of foot surgical services. The practice of surgery by non-medically qualified podiatrists and its integration within mainstream NHS service provision is evaluated as possible evidence of the diminishing authority of medicine in determining the scope and boundaries of paramedical practice and in successfully resisting encroachment from other ‘health professions’. The centrality of medical power in the organisation of healthcare has characterised much of the existing sociological literature on the health professions, most evident within the professional dominance perspective (Freidson 1970a, 1970b). This approach, and its variants, particularly highlight the autonomous control of medicine over its knowledge base, clients and clinical activities, in addition to its hegemonic position in relation a range of subordinate healthcare occupations (Freidson 1970a, 1970b; Johnson 1972; Larkin 1983, 1988, 1993, 1995; Wolinsky 1993).

Welcome to Journal of Foot and Ankle Research: a new open access journal for foot health professionals

Journal of Foot and Ankle Research (JFAR) is a new, open access, peer-reviewed online journal that encompasses all aspects of policy, organisation, delivery and clinical practice related to the assessment, diagnosis, prevention and management of foot and ankle disorders. JFAR will cover a wide range of clinical subject areas, including diabetology, paediatrics, sports medicine, gerontology and geriatrics, foot surgery, physical therapy, dermatology, wound management, radiology, biomechanics and bioengineering, orthotics and prosthetics, as well the broad areas of epidemiology, policy, organisation and delivery of services related to foot and ankle care. The journal encourages submission from all health professionals who manage lower limb conditions, including podiatrists, nurses, physical therapists and physiotherapists, orthopaedists, manual therapists, medical specialists and general medical practitioners, as well as health service researchers concerned with foot and ankle care. All manuscripts will undergo open peer review, and all accepted manuscripts will be freely available on-line using the open access platform of BioMed Central.

Contested professional role boundaries in health care: a systematic review of the literature

BackgroundAcross the Western world, demographic changes have led to healthcare policy trends in the direction of role flexibility, challenging established role boundaries and professional hierarchies. Population ageing is known to be associated with a rise in prevalence of chronic illnesses which, coupled with a reducing workforce, now places much greater demands on healthcare provision. Role flexibility within the health professions has been identified as one of the key innovative practice developments which may mitigate the effects of these demographic changes and help to ensure a sustainable health provision into the future. However, it is clear that policy drives to encourage and enable greater role flexibility among the health professions may also lead to professional resistance and inter-professional role boundary disputes. In the foot and ankle arena, this has been evident in areas such as podiatric surgery, podiatrist prescribing and extended practice in diabetes care, but it is far from unique to podiatry.MethodsA systematic review of the literature identifying examples of disputed role boundaries in health professions was undertaken, utilising the STARLITE framework and adopting a focus on the specific characteristics and outcomes of boundary disputes. Synthesis of the data was undertaken via template analysis, employing a thematic organisation and structure.ResultsThe review highlights the range of role boundary disputes across the health professions, and a commonality of events preceding each dispute. It was notable that relatively few disputes were resolved through recourse to legal or regulatory mandates.ConclusionsWhilst there are a number of different strategies underpinning boundary disputes, some common characteristics can be identified and related to existing theory. Importantly, horizontal substitution invokes more overt role boundary disputes than other forms, with less resolution, and with clear implications for professions working within the foot and ankle arena.

Achieving professional status: Australian podiatrists’ perceptions

BackgroundThis paper explores the notion of professional status from the perspective of a sample of Australian podiatrists; how it is experienced, what factors are felt to affect it, and how these are considered to influence professional standing within an evolving healthcare system. Underpinning sociological theory is deployed in order to inform and contextualise the study.MethodsData were drawn from a series of in-depth semi-structured interviews (n = 21) and focus groups (n = 9) with podiatrists from across four of Australias eastern states (Queensland, New South Wales, Victoria and Australian Capital Territory), resulting in a total of 76 participants. Semi-structured interview schedules sought to explore podiatrist perspectives on a range of features related to professional status within podiatry in Australia.ResultsCentral to the retention and enhancement of status was felt to be the development of specialist roles and the maintenance of control over key task domains. Key distinctions in private and public sector environments, and in rural and urban settings, were noted and found to reflect differing contexts for status development. Marketing was considered important to image enhancement, as was the cache attached to the status of the universities providing graduate education.ConclusionPerceived determinants of professional status broadly matched those identified in the wider sociological literature, most notably credentialism, client status, content and context of work (such as specialisation) and an ideological basis for persuading audiences to acknowledge professional status. In an environment of demographic and workforce change, and the resultant policy demands for healthcare service re-design, enhanced opportunities for specialisation appear evident. Under the current model of professionalism, both role flexibility and uniqueness may prove important.

Occupational therapy in Oman: the impact of cultural dissonance.

Occupational therapy theory and philosophy are broadly considered to be based on Western cultural values. In contrast, the application of theory and practice in the Sultanate of Oman, historically based on traditional Middle Eastern and Islamic cultural values, provides a case exemplar, which highlights both paradigmatic differences and cultural dissonance. Drawing on the experiences of occupational therapists working in Oman, this study found that the application of therapeutic goals aimed at patient independence and autonomy were difficult to achieve in an environment where family duty and responsibility for care were highly prized. Dressing and cooking assessments were challenging, and issues related to gender proved problematic. Therapists found the need to adapt practice to acknowledge these differences, and to adopt pragmatic problem-solving strategies, without resolving the underpinning philosophical contradictions. Occupational therapy in Oman is under-researched; further work is needed to confirm the cross-cultural validity of specific assessments and practice models.

Assisting role redesign: a qualitative evaluation of the implementation of a podiatry assistant role to a community health setting utilising a traineeship approach

BackgroundIncreasing demands for podiatry combined with workforce shortages due to attrition, part-time working practices and rural healthcare shortages means that in some geographic areas in Australia there are insufficient professionals to meet service demand. Although podiatry assistants have been introduced to help relieve workforce shortages there has been little evaluation of their impact on patient, staff and/or service outcomes. This research explores the processes and outcomes of a ‘trainee’ approach to introducing a podiatry assistant (PA) role to a community setting in the Australian Capital Territory (ACT) Government Health Service Directorate.MethodA qualitative methodology was employed involving interviews and focus groups with service managers, qualified practitioners, the assistant, service users and consumer representatives. Perspectives of the implementation process; the traineeship approach; the underlying mechanisms that help or hinder the implementation process; and the perceived impact of the role were explored. Data were analysed using the Richie and Spencer Framework approach.ResultsAlthough the impact of the PA role had not been measured at the time of the evaluation, the implementation of the PA traineeship was considered a success in terms of enabling the transfer of a basic foot-care service from nursing back to podiatry; releasing Enrolled Nurses (ENs) from foot-care duties; an increase in the number of treatments delivered by the podiatry service; and high levels of stakeholder satisfaction with the role. It was perceived that the transfer of the basic foot-care role from nursing to podiatry through the use of a PA impacted on communication and feedback loops between the PA and the podiatry service; the nursing-podiatry relationship; clinical governance around the foot-care service; and continuity of care for clients through the podiatry service. The traineeship was considered successful in terms of producing a PA whose skills were shaped by and directly met the needs of the practitioners with whom they worked. However, the resource intensiveness of the traineeship model was acknowledged by most who participated in the programme.ConclusionsThis research has demonstrated that the implementation of a PA using a traineeship approach requires good coordination and communication with a number of agencies and staff and substantial resources to support training and supervision. There are added benefits of the new role to the podiatry service in terms of regaining control over podiatric services which was perceived to improve clinical governance and patient pathways.

Attitudes towards Traditional Acupuncture in the UK

IntroductionThe practice and philosophy of traditional (classical) acupuncture (TA), as opposed to Western acupuncture, remains a contentious issue within mainstream healthcare in the UK. In spite of the relative integration of acupuncture within orthodox medical practice, a lack of paradigm conformity continues to divide traditional from Western approaches. This study sought to explore the perceptions and attitudes of existing acupuncture clinicians in the UK, from a range of professional backgrounds and affiliations, towards traditional acupuncture philosophy and practice. In doing so, it attempted to determine the extent to which traditional approaches were both regarded as legitimate and utilised in practice within mainstream healthcare.MethodA postal questionnaire was deployed that incorporated an ‘attitudes to TA’ scale developed from a validated ‘attitude to alternative medicine’ scale. The questionnaire was distributed to 250 randomly selected subjects, drawn from the membership of three key professional acupuncture associations: 100 from the membership of the British Medical Acupuncture Society (BMAS), 100 from the British Acupuncture Council (BAcC) and 50 from the Acupuncture Association of Chartered Physiotherapists (AACP).ResultsA response rate of 60.8% (n = 152) was obtained. Respondents held a broadly positive attitude towards TA (65 ± 12; 95% CI 62.9, 67.1), which included 39 BMAS respondents (54 ± 11; 95% CI 50.5, 57.5), 36 AACP respondents (63 ± 7; 95% CI 60.7, 65.3) and 53 BAcC respondents (75 ± 5; 95% CI 73.7, 76.3). No difference was found in attitude between 27 general practitioners and 13 hospital doctors (p > 0.1). More positive attitudes towards TA were found among younger BMAS respondents (Spearman’s rank correlation coefficient [rs] = −0.353; 0.01 < p < 0.05). Of BAcC respondents, 62% used ‘trigger point’ theory, whereas 59% and 72% of respondents in the BMAS and AACP groups respectively used ‘channels’ theory.ConclusionsThese findings confirm broadly positive attitudes towards TA within each of the professional groups from which data were drawn, although they do reveal a range of disparate attitudes to TA among the groups, particularly between the BMAS and BAcC members.

Symbolic power and professional titles: the case of “podiatric surgeon”

Interprofessional conflict has largely been understood in terms of jurisdictional disputes centred on contested task domains and role boundaries, with less attention paid to the symbolic value associated with specific professional titles. Bourdieus concepts of symbolic power and capital help to shed light on the opposition of the medical profession in the UK to the adoption of the title “podiatric surgeon” by non-medically qualified podiatrists undertaking foot surgery. Focusing on the medical discourse evident in press and media coverage of the dispute over a 12-year period gives insights into the use of strategies of symbolic violence aimed at retaining control over the exclusive use of prestigious forms of professional title. Titles, as symbolic capital, are understood as central to professions’ struggle for legitimacy and recognition.

JFAR's role in publishing believable research findings

Health research published in journals provides an ever-increasing number of studies and trials that espouse the benefits of all sorts of interventions. But how do consumers of research, for example the readers of Journal of Foot and Ankle Research (JFAR), know whether to believe the findings of research articles that they read? Clearly, health journals have an unambiguous responsibility to support good quality research that provides believable findings. Equally, they also have a responsibility to filter out poor quality research that provides findings that are not believable. JFAR steadfastly supports good quality research and the editorial team (with the assistance of the peer-reviewers) work conscientiously to publish only those studies that are of the highest quality; that is, studies with believable findings. While this is not always easy, and the goal posts that define quality of research are constantly being repositioned, the editors strive to bring the readers of JFAR the best foot and ankle research. Unfortunately, not all studies use perfect methods, so if a study does have limitations and is published, then the editors are careful to ensure that the authors clearly acknowledge the limitations in their articles, affording readers an insight into the pitfalls of the study. To assist the editors in this task, there is a burgeoning array of guidelines and recommendations for the conduct and reporting of different study designs. For example, there are the CONsolidated Standards Of Reporting Trials (CONSORT) Statement [1] and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement [2]. Each guideline has been developed to ensure that important aspects of a trial or review are reported by the authors. To assist in this process, there is a checklist for each item in the guideline, which covers key aspects of a study (e.g. blinding, sample size determination and statistical analysis) that authors should report to ensure that they have included essential pieces of information, which ultimately makes the study’s findings more believable. That is, it prevents authors from deceiving the reader, by concealing that they did not do something they should have, or equally bad, done something that they should not have. As an added bonus to readers of such articles, if guidelines like CONSORT and PRISMA are followed they invariably make an article less ambiguous and much easier to understand what has occurred in the study. The developers of such guidelines are experts, with most having decades of highly active experience researching and practicing these study designs. They are also generous individuals that have provided the guidelines in consumer friendly packages that are freely available. Potential users of these guidelines can easily access them through the well-developed CONSORT [3] and PRISMA [4] websites. Further to the guidelines mentioned above, there are many others for different study designs, for example; the Guidelines for Reporting Reliability and Agreement Studies (GRRAS) [5] and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement [6,7]. Authors are recommended to consult these where appropriate and an excellent resource when writing manuscripts is that of the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network [8], which is a virtual one-stop shop for guidelines that are relevant to publishing in health science journals. The EQUATOR Network includes guidelines for both quantitative and qualitative research. JFAR, as a BioMed central journal, adheres to these guidelines and authors of studies that use these study designs are obliged to include such checklists upon submission of their article. Few foot and ankle journals ensure this or even worse, do not even recommend this. However, JFAR is setting the benchmark in this area because the editors believe that it leads to the highest possible quality research articles for its readers, and consequently the most believable findings will be presented in JFAR. Furthermore, if clinical trials – where participants receive an intervention that is evaluated – are considered in more detail, JFAR also demands that authors must register their trial with a recognised clinical trial registry. Ideally, clinical trials should be registered prior to recruitment. Up to now, JFAR has accepted clinical trials that have been registered with a recognised clinical trial registry after the first participant has been recruited. However, from now on, JFAR will only accept clinical trials that are registered prior to recruitment. Why is this important? To begin with, it means that all clinical trials can be tracked and the results of clinical trials are less likely to be not published, which occurs more frequently in ‘non-significant trials’ (where no difference is detected between interventions). However, an equally important reason is that it prevents investigators changing their protocol or analysis in light of their findings if they unwisely assess the results prior to the completion of the trial, or once they have evaluated the results but before publication (often referred to as over-analysing the data or “cherry-picking” the results, which results in bias). By default, this means that investigators have to commit to their protocol and analysis, thus keeping them honest, which again leads to more believable findings. There are many recognised clinical trial registries and a list of recommended registries can be found on the International Committee of Medical Journal Editors website (http://www.icmje.org/publishing_j.html). With all of this information in mind, two key points need to be considered. Firstly, consumers of articles that are published in JFAR should be assured that they are reading articles that present findings from high quality research. Secondly, potential authors of research manuscripts being submitted to JFAR need to adhere to the standards set by the journal; that is, they must read the guidelines for authors and carefully follow them when preparing their manuscripts. The journal’s guidelines are clear (http://www.jfootankleres.com/authors/instructions/research) and it is now, more than ever, not acceptable for authors to plead ignorance. As the impact of JFAR continues to increase, the editors are receiving more and more manuscripts to be considered for publication. This allows the editors more freedom to choose only the best quality research articles. If a manuscript is poorly written at the outset – for example, it has not adhered to the journal’s guidelines – then it has a much greater chance of rejection. Currently, JFAR rejects over 40% of the manuscripts submitted to it, and this figure is rising as the journal becomes more popular. For the best health journals in the world, such as New England Journal of Medicine and Lancet, this figure is about 95%. This means that they only publish the highest quality research. While there are exceptions, this research will generally be the most believable and will have the most impact. In conclusion, the editors of JFAR work hard to ensure that they provide a vehicle for the best quality foot and ankle research. While a small number of mistakes will undoubtedly be made and errors detected only after publication, readers can be assured that JFAR is trying to set the highest standards possible to foster a culture of believable research. We trust that readers of the journal can appreciate that such standards lead to better, more believable information for them. Some may view this as being elitist or exclusive, but if this is the price for believable research findings then that is a label the editors are prepared to wear. Conducting good research is not easy, and clear evidence can sometimes take years to compile (take the evidence for the ill-effects of tobacco smoking as a perfect example). Journals that follow an easy formula, where there are few checks and balances, ultimately provide a ‘fast food’ approach to health information – it may look fabulous and satiate ones appetite for knowledge easily, but it is not good for anyone in the long term. Professional journals have a responsibility to ensure that statements made in manuscripts can be supported by the study findings (i.e. good-quality evidence). This responsibility should not be viewed as being elitist or exclusive and in no way suppresses freedom of expression. Indeed, the fundamental premise of scientific publication is the reporting of empirically verifiable facts, which means believable information.