title: Quiet dissent: The attitudes, beliefs and behaviours of UK osteopaths who reject low back pain guidance - A qualitative study.
abstract: Clinical guidelines are derived from best research evidence and aim to: improve quality of non-specific low back pain (nsLBP) management and identify patients at risk of suffering chronic pain. However, guideline discordant attitudes and beliefs have been identified in healthcare students and practitioners, including osteopaths.
  
  
  
  A qualitative approach with elements of grounded theory was used to explore underlying attitudes and beliefs of practitioners/students working in a British osteopathic education institution. All participants rejected guideline recommendations for managing nsLBP. A constant comparative method was used to code and analyse emergent themes from transcript data.
  
  
  
  Purposive sampling identified 5 clinic tutors and 7 students; all participated in semi-structured interviews.
  
  
  
  Our central theme was a 'Precedence of Osteopathy' over medicine and other manual therapies. Three subthemes were: 1) beliefs about self; 2) perceptions of others; 3) attitudes to guidelines and research.
  
  
  
  Participants possess a strong professional identity fostered by their education. This bestows autonomy, authority and distinctness upon them. The central theme was modelled as a lens through which participants viewed research: the evidence pyramid appears inverted, explaining why participants value expert opinion above all other evidence. Guidelines and research are perceived to threaten professional identity. In contractual situations that oblige practitioners to follow guidelines management, perhaps reflecting a pragmatic response to health-care market forces, clinical practice is modified. Developing further understanding of osteopaths' attitudes and beliefs and behaviour in respect of evidence-based guidance in education is important to enhance the quality of clinical practice in osteopathy.
authors.affiliation: Research Department, European School of Osteopathy, Boxley House, Boxley, Maidstone, Kent, ME14 3DZ, UK. Electronic address: figglatham@gmail.com.
authors.forename: Joanna
authors.initials: J
authors.lastname: Figg-Latham
authors.affiliation: Research Department, European School of Osteopathy, Boxley House, Boxley, Maidstone, Kent, ME14 3DZ, UK. Electronic address: devanrajendran@eso.ac.uk.
authors.forename: Dévan
authors.initials: D
authors.lastname: Rajendran
mesh_terms: D000293:Adolescent; D000328:Adult; D001291:Attitude of Health Personnel; D034462:Dissent and Disputes; D005260:Female; D007722:Health Knowledge, Attitudes, Practice; D006801:Humans; D017116:Low Back Pain / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D010021:Osteopathic Medicine / Q000592:standards*; D055360:Osteopathic Physicians / Q000523:psychology*; D026761:Physical Therapy Specialty / Q000592:standards*; D017410:Practice Guidelines as Topic; D010818:Practice Patterns, Physicians' / Q000592:standards*; D036301:Qualitative Research; D011795:Surveys and Questionnaires; D006113:United Kingdom; D055815:Young Adult
keywords: Clinical guidance; Education; Low back pain; Osteopathy