The objective of this study was to explore the literature on the factors that influence scope of practice of chiropractic in Australia. Four factors were highlighted by the authors of the retrieved articles: education, professional identity, patient safety and organisational structure.
Chiropractic education in Australia has two components: pre-and post-professional. Pre-professional training involves a 5-year program at one of four universities accredited by the Council on Chiropractic Education Australasia (CCEA) . Training involves studies in anatomy, neuroanatomy, physiology, microbiology, histology, pathology, diagnosis, and management, including joint manipulation, of MSK conditions of the spine and extremities. In keeping with government and CCEA guidelines, protection of the public is prominent in Australian chiropractic educational programs . Our study highlights that dissimilar or diverse teachings among educational institutions impact a students’ attitudes and ideologies regarding scope of practice .
For example, despite receiving a mostly science-based education, Australian chiropractic students were divided on the issue of whether the historical rationale for chiropractic intervention was as important as ‘science-based’ clinical reasoning . Innes et al.  propose that the heterogeneity of teachings between chiropractic educational institutions raises two important questions. First, who decides what is chiropractic and its attendant scope of practice? Second, what is the best model to deliver the most relevant education for those seeking to become chiropractors in the twenty-first century ?
We could find no definitive mechanism as to how education interacts with scope of practice. de Luca et al.  argued that it may be the result of a combination of chiropractic institution and level of education before commencing chiropractic study. It is possible that the of scope of practice is influenced by (1) content from both delivered and hidden curricula with pre- and post graduate education ; (2) guidance (or lack of thereof) provided by the accreditation bodies (e.g. CCEA) in relation to graduate capabilities ; and more broadly, (3) an education institiution’s health care ideology may influence (or support) student views on future scope of practice . This is a complex area that requires exploration in a future study.
In Australia, post-professional training falls under the heading of ‘continuing professional development’ (CPD). To maintain registration, a chiropractor is required to complete a minimum number of CPD activities or hours that fulfil the following goals:
Seek to improve patient health outcomes, safety and experiences;
Draw on best available evidence, including well-established and accepted knowledge that is supported by research where possible, to inform good practice and decision-making;
Contribute directly to maintaining and improving competence (performance and behaviour) and keeping up to date in the chosen field or setting of practice; and
Build on the existing knowledge .
In 2019, the criteria for the types of CPD activities that could be considered acceptable for chiropractors were relaxed. A more flexible approach has been adopted which allows a practitioner to plan their CPD activities so that they meet the specified CPD goals and reflect on how they will improve their practice based on what they have learned . Given the influence of heterogeneity between chiropractic schools regarding professional identity and scope of practice in pre-professional training , a high degree of flexibility in the post-professional area has the potential to promote further disparity .
Although a clear understanding of professional identity is paramount for the progression of any healthcare profession , the problem of conflicting professional identity is well reported in the chiropractic literature . However, since its inception, professional identity within chiropractic has been a source of controversy [48, 49]. Attempts to establish a single professional identity for the profession have been met with resistance based on disagreements over terminology , philosophy (e.g. approach to care) , technique (e.g. intervention) , and the role of chiropractic within the broader healthcare framework .
The Australian profession continues to be beleaguered by more than one intra-professional group, with each asserting differing views on identity . For example, the majority of chiropractors identify with, and practice within an evidence-based ‘biopsychosocial’ model of care . This is in contrast to a vocal minority of chiropractors who identify with a historical ‘vitalistic’ model of care which is based around diagnosis of the ‘vertebral subluxation’ , a concept unique to the chiropractic profession. This diversity appears to exist across chiropractic educational institutions [38, 45]. This situation has been exacerbated by some within the profession seeking to operate outside the accepted framework [45, 55]. As a result, the chiropractic profession has failed to establish a clear professional identity due primarily to the absence of a formulated scope of practice .
Simply stated, scope of practice is in part defined by whether chiropractors model their behaviour on a ‘subluxation-based’ model, where misaligned vertebrae are viewed as the cause of disease, or on an ‘evidence-based’ model where decision making around the diagnosis and management is based on current best evidence . The situation is further complicated where there is direct evidence of efficacy and/or biological plausibility around the effect of one, but not the other .
The lack of clarity regarding professional identity was one of the drivers for developing accreditation standards that acknowledge both models . It has been suggested that chiropractic educational institutions and the national accrediting body (CCEA) review their procedures for evaluating program curricula and accreditation standards to create a consistent standard across institutions, a strategy that may alleviate the incongruity that exists among students regarding professional identity .
Confusion around professional identity within the chiropractic profession is well reported in the literature . This circumstance is contrary to other health professions. For example, in nursing, professional identity is clearly defined as a sense of oneself that is ‘influenced by the characteristics, norms and values of the discipline, resulting in the individual thinking, acting and feeling like a nurse’ . The lack of clarity regarding chiropractic’s professional identity may be driving recent concerns raised by government , and the media , around patient safety.
Patient safety aims to prevent injury, and reduce risks, errors and harm that can occur to a patient during the provision of a healthcare service. This is true for all healthcare professions, including those that use spinal manipulation as a therapeutic intervention, particularly in the field of paediatrics [13, 25, 58].
At first glance, it may not be easy to see how patient safety influences scope of practice, but international and Australian data help to clarify the issue. For example, the Nursing and Midwifery Board of Ireland  asserts that an “individual nurse’s scope of practice [the ‘personal scope’ mentioned previously] is dynamic, and is influenced by a number of factors including patient safety, patient needs, and care outcomes”. Additionally, the Federation of State Medical Boards of the United States contends that the concept of “patient safety should be considered by health care regulatory boards and legislative bodies when making decisions about changes in scope of practice” .
Furthermore, a small Australian study undertaken by Engel et al. , found that personal scope of practice of chiropractors can be negatively influenced by a perceived notion amongst surveyed GPs that chiropractic is unsafe. As GPs are a primary contact point for many MSK presentations, negative views of the chiropractic profession could translate into reduced referrals (number and type) from GP’s to chiropractors.
Healthcare organisational structures (e.g. a hospital) are social systems purposely designed for the delivery of necessary healthcare services by specialised workforces within the system [61,62,63]. When the structure, or more correctly the health professionals within the structure, are unable to provide suitable care, it is the responsibility of those within the structure to co-ordinate care from other providers outside of the primary care setting . However, Netto et al’s. study  highlighted that Royal Australian Air Force (RAAF) physicians showed little interest in referring fighter jet pilots who commonly suffered from acute or chronic neck pain from aerial manoeuvres, for chiropractic treatment, until the on-base medical care had failed, a situation that potentially limited chiropractors from utilising and/or further developing their scope of practice.
There are several limitations associated with this study. It is possible that some articles may have been missed or excluded due to the chosen search parameters. Additionally, while relevant journal databases and grey literature were searched extensively, the number of included studies was small and varied in both aim and methodology. Therefore, the factors identified within this review may be incomplete.
As innovative technology and new treatment modalities emerge, the importance of understanding scope of practice is increasing for health care professions, as they are called upon to navigate the increasingly complex realm of patient care. This is true for chiropractic. Although this review was limited to the scope of practice of chiropractic in Australia, we recognise that a broader picture exists across the spectrum of health professions in the country. Future research could address whether the regulated professions function better without a defined scope of practice as in medical practice, or whether the approach seen in dentistry with a formal, defined scope of practice is more acceptable for a profession and its patients. Such studies may help determine if it is necessary to have a common defined scope of practice for the various professions. This would assist in determining the best framework for guaranteeing competency and patient safety.