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Progression through osteopathic training in Australia: The student experience
International Journal of Osteopathic Medicine 13 (2010) 160–165
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International Journal of Osteopathic Medicine journal homepage: www.elsevier.com/ijos
Research report
Progression through osteopathic training in Australia: The student experience Jessica K. Hartup, Rachel A. Murphy, Loretta M. Plowman, Ray Myers* Division of Osteopathy, School of Health Sciences, RMIT University, PO Box 71, Bundoora 3083, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 December 2008 Received in revised form 27 April 2009 Accepted 21 January 2010
Background: The objective of this study was to explore the lived experience of being an osteopathic student. The paucity of published material on the experience of osteopathic students highlighted the need for such research to record the nature of this aspect of osteopathic culture in Australia. Methods: One on one in-depth interviews with participants were conducted and explored employing a phenomenological approach to information gathering and analysis. Setting: Students undertaking the five-year osteopathic program at RMIT University, Melbourne, Australia. Analysis: Colaizzi’s seven step approach to phenomenological analysis was utilised. Subjects: Purposeful sampling was used to select nineteen participants across all year levels to form the cohort of the study. Results: The RMIT osteopathic program was found to be described in relation to five main stages; Acceptance into and Commencement of the Program, Progression through the Program, The Clinical Experience, The Masters Program and Looking Beyond Graduation to the Future. Each stage provoked significant and varied emotional responses forming the major themes of the study; Stress and Anxiety, Happiness and Excitement, Contentment, Self-Satisfaction, Frustration, Fear of Failure and Self-Doubt, Anger and Resentment, Sense of Support, Fear of the Unknown and Sadness. Conclusions: The most prevalent emotional experience reported was that of stress and anxiety within the student’s journey. While this was of great significance, it was concluded that a student’s underlying passion for osteopathy and strong friendships formed within the program are what enable the student to get through the challenges and difficulties associated with undertaking the osteopathic program. Ó 2010 Elsevier Ltd. All rights reserved.
Keywords: Osteopathic medicine Education Lived experience Phenomenology
1. Background The profession of osteopathy was founded by an American pioneer, Doctor Andrew Taylor Still (1828–1917) in 1874.1 The practice of osteopathy has developed into two distinct forms, one the osteopathic physician with full medical practice rights, as seen in the USA, and the other as osteopaths with a scope of practice limited to manual therapy, as seen in Australia and the UK. The aim of this study was to explore the lived experience of being an osteopathic student throughout the full-time five-year program at RMIT University, Melbourne, Australia. For the purpose of this study the term ‘lived experience’ is used to denote the day-to-day feelings and emotions2 associated with being an osteopathic student. In the literature, there was no direct reflection on the notion of the osteopathic students’ lived experience per se. Quantitative
* Corresponding author. E-mail addresses: [email protected] (J.K. Hartup), rachel.murphy@ optusnet.com.au (R.A. Murphy), [email protected] (L.M. Plowman), ray. [email protected] (R. Myers). 1746-0689/$ – see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijosm.2010.01.003
studies generally measured student experience with regards to academic performance,3,4 and qualitative studies on students’ lived experience were most commonly from the field of nursing. Quantitative studies included those by Kurtz et al. (1991) and Crapse et al. (1993), who reported on how osteopathic students cope with their stressful lifestyle. They found the primary coping behaviours students used in response to stress included humour, leisure, exercise, and social activity.5,6 From a qualitative perspective, a study on medical students’ clinical experience by Dornan and Bundy (2004) reported on medical education as being vocationally driven and emotionally laden; students described entering the clinical environment as ‘‘being thrown in the deep end,’’ with the fear of being inadequate, but also exciting at the same time.7 Other studies8–13 investigated nursing students’ learning experiences and related emotional experiences. Factors identified as stressors for students were: difficulty balancing home and study demands, time pressure, financial concerns, feelings of distance from faculty and staff in the clinical setting, stress associated with feeling unprepared for clinical practice and feeling incompetent in clinical skills.
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In Australia, the osteopathic student’s journey spans five years of full-time study, comprising of a three-year Bachelor program followed by a two-year Masters program. The implementation of this program structure at RMIT in 2002 represented a major shift from the primarily teaching college approach used since 1986. This shift resulted in a decrease of emphasis on didactic teaching to a greater emphasis on student directed and problem-based learning. The effects of this period of transition, as students adapted to this new approach, should be taken into consideration when reading of their reported experiences. Over the five years students are required to undertake an intensive and extensive range of health science and osteopathic medicine subjects to prepare them for osteopathic practice. The RMIT osteopathic teaching clinic provides an environment for senior students to develop these skills under the supervision of qualified osteopaths. The investigators, (JKH, RAM, LMP) had previously observed that students express an array of emotions in response to their experiences throughout the journey. They appreciated that these responses are significant and often shared amongst the student body, however are seldom acknowledged or documented. The desire to gain insight into the experiences of these students was the motivator for this study. This study has the potential to create awareness of the osteopathic student lived experience, in order to give recognition to its importance and to provide current and prospective osteopathic students with a resource to relate to and reflect upon, to better understand their own lived experience. This study has the potential to invite further inquiry into the lived world of the osteopathic student and perhaps the impact of the structure of the osteopathic university programs on this experience, which may be an essential consideration for an osteopathic program to evolve.14,15 2. Methods Ethics approval was granted by the RMIT Human Research Ethics Committee. 2.1. Approach, setting and sampling The purpose of this study was to understand the meaning and significance of the phenomenon of being an osteopathic student, based on the experiences of those living it. Therefore phenomenology was the method of choice, as it focuses on the essence of the lived experience, without attempting to predict or control the phenomenon. Colaizzi’s (1978) description of the practice of descriptive research involves the phenomenologist ‘‘contacting that phenomenon as people experience it.’’.2 This then is the basis for forming the appropriate set of research questions and examining the researcher’s pre-suppositions. As the investigators were current osteopathic students during the implementation of this study, they have an insight into the investigated phenomenon and, although essential, it creates the potential for bias to exist and this is discussed below. Purposeful sampling was used to attain maximal diversity amongst participants across all year levels. It was initially proposed that four to five students from each of the five year levels would be chosen to participate in the study, however if saturation were to occur due to the in-depth exploratory nature of this research method, the interviewing of further participants would cease. In order to participate in this study subjects must be volunteers, over the age of 18 years, current RMIT osteopathic student and available for two separate interviews.
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2.2. Information collection and analysis Prior to the actual information gathering process each of the investigators conducted a pilot interview supervised by an experienced researcher in the qualitative field, to ensure that the correct procedure for interviewing was followed. Employing Colaizzi’s approach to enquiry,2 one on one in-depth interviews lasting between 30 and 50 min were conducted, after informed consent was obtained from the participant. The semistructured interview was undertaken in a relaxed, welcoming environment at the beginning of the academic year. Interviews began with the open-ended question: ‘‘Tell me about your experience of being an osteopathic student.’’ In order to elicit the depth and essence of the participant’s experience, this was followed by prompting questions such as: ‘‘Tell me about your thoughts and feelings related to these experiences’’ ‘‘Can you give me an example of when you felt this way?’’ Each interview was tape recorded and later transcribed by the investigators. A second interview with each participant was conducted to provide the participant with the opportunity to clarify, confirm or refute any part of the interview transcript or the researcher’s interpretation. It also provided the opportunity to add any other thoughts and feelings they wished to convey. The transcribed interviews were analysed using a technique articulated by Colaizzi involving the following seven steps2: 1. Read all participants’ narratives several times to achieve a thorough understanding of their experience. 2. Extract significant statements – reviewing participants’ transcripts and taking from them phrases or sentences that directly pertain to the phenomenon. 3. Formulate meanings for significant statements – spelling out the meaning of each significant statement. The researcher needs to capture the depth of the students’ lived experience not just by what they say but how they say it, taking into account their tone, body language and general demeanor. 4. Arrange formulated meanings into theme clusters – scrutinising significant statements and formulated meanings, grouping these into common themes. 5. Write exhaustive descriptions of the investigated phenomenon – integrate all of the results from the steps above into a narrative description of the phenomenon. 6. Identify the fundamental structure of the phenomenon – drawing together the exhaustive descriptions of the phenomenon ‘‘in as unequivocal a statement of identification of its fundamental structure as possible’’. 7. Return to participants for validation – ensuring a true representation of their student experience has been presented.
Lincoln and Guba outlined a set of criteria to identify the trustworthiness of a phenomenon; credibility, transferability, dependability and confirm-ability, and achieving these criteria gives a study rigour and validity.16 Credibility (internal validity), refers to the overall methodological quality of the study.17–19 It was important to maintain credibility whilst developing formulated meanings from significant statements in taking what the participants had said and interpreting this to form a meaning. Credibility is improved through having the three investigators come to agreed formulated meanings as well as returning these formulated meanings to the participant to allow for clarification.
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Transferability of the study (external validity) refers to the concept of generalisation found in quantitative research. The investigators selected a range of osteopathic students to create diversity within the results to facilitate transferability.17 Dependability was achieved through rigorously following Colaizzi’s seven step information analysis process. To obtain confirm-ability the investigators demonstrated that the information used within this project was not a product of their imagination, but came from an external source, by having a clear format of each step and by referencing the participants’ statements whereby data could be tracked to its source.17 There is a notion of bias compounding when working in a group environment as investigators may encourage one another’s views or beliefs, forgetting to be impartial, therefore strategies were required to limit this. As previously mentioned open-ended questions were used during interviews, so as not to lead participants towards an answer the investigators expected to hear. Directed questioning such as: ‘‘can you elaborate on how that made you feel?’’ were used, avoiding leading questions such as ‘‘did that make you feel angry?’’ When identifying significant statements from transcripts of the participants’ interviews, investigators took care to keep an open mind and to not disregard a statement simply because it did not mirror their own experience. 3. Results 3.1. Findings During the interview process it was found that three to four students per year level provided sufficient material for a saturation of themes to be reached, so the original notion of interviewing four to five students became redundant. Of the nineteen participants, seven males and twelve females formed the cohort of the study. The participants were from each of the five-year levels, including students from Melbourne and interstate, as well as students who had entered the program directly from secondary school and those who had undertaken previous higher education studies. Following Colaizzi’s seven step approach to analysis, significant statements were drawn from participants’ interviews, which were then integrated into common themes and a collective formulated meaning. Examples of one significant statement and one formulated meaning from each theme, in order of the most common to least common theme, are given in Table 1. The next step in the process of analysis involved combining all formulated meanings per theme into an exhaustive description, presented in Table 2. In terms of the analysis of themes, participants described their experiences in relation to five distinct stages throughout the osteopathic program. Those identified were: 1. 2. 3. 4. 5.
Acceptance into and Commencement of the Program; Progression through the Program; Clinical Experience; The Masters Program; and Looking Beyond Graduation to the Future.
To be consistent with the participants’ experience the investigators exhaustively investigated the themes associated with each stage. Due to the large volume of findings within each stage of the program, this article focuses on ‘Progression through the Program’ only, as it captures a wide range of themes and is applicable to all current osteopathic students.
3.2. Progression through the program As students progress through each year of the osteopathic program they are presented with a wide scope of new challenges and experiences, all of which stir a vast array of emotions. Participants enjoy the constant stimulation of learning and describe it as motivating and inspiring, knowing they will apply this education in clinical practice. However such constant stimulation has been perceived at times as a constant overwhelming bombardment of information. Participants emphasised that the amount of knowledge to retain not only compounds throughout the semester but also as the years progress. ‘‘You’re basically chucked in at the deep end, you get this hundred or two hundred pages of notes, and if you flick through it your head spins.’’ If participants did not form a coping mechanism, this perceived colossal workload led to feelings of extreme self-doubt or to breaking point. For those students who did develop coping mechanisms they still experienced times of near absolute exhaustion. During particularly high times of stress some participants reported behavioural and physical manifestations of their stress such as decreased level of tolerance, subconscious eye twitches, stomach upsets, depression, panic attacks and heart palpitations, all of which emphasise that stress is not just a state of mind. The high expectations of staff and also those which participants place upon themselves provoke feelings of frustration, anger and resentment, as they feel incapable of living up to these constantly growing expectations: ‘‘we are expected to know so much when it really takes a lifetime to learn.it’s just like 10,000 kilos of information being pounded on top of me, ‘now retain all of that.’ It feels drowning, like I can’t cope, like I cannot have anything else in my life because so much is expected of us.’’ One of the most significant challenges described was that of attempting to establish and maintain a balance between commitment to osteopathic study and outside life. Frustration surfaced as participants tried to balance university hours, study, work, family, friends, partners, sports and hobbies and social life. Due to the intense workload and constant demands, participants feel as though every spare moment should be dedicated to studying. Feelings of guilt and frustration would then arise when they wished to or actually did partake in any activity unrelated to the program, leading to anger as such constant guilt felt like it was taking over their life. ‘‘I just didn’t have enough time. And then if I did have time, I had the guilt because the group was meeting regardless. With the guilt, it was mixed in with anger. I felt guilty because I felt like I wasn’t sacrificing enough.’’ An element of sadness also emerged when participants felt they were unable to spend enough time with important people in their lives due to study commitments. Even though it is difficult to make time and enjoy an outside life, away from study, participants recognised the importance of having other outlets, for balance in their life: ‘‘You’ve got to be focused, but you’ve also got to do the things you want. Uni is a part of your life, but it’s not your whole life!’’ Some participants experienced self-doubt and frustration in regards to certain subjects, in particular osteopathic palpatory diagnosis class. The major qualm was with the level of palpatory skill required to form such diagnoses in class, and the inadequate level most participants felt they had at this time. Although they
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Table 1 Themes, significant statements and formulated meaning. Theme 1 Significant Statement Related Formulated Meaning Theme 2 Significant Statement Related Formulated Meaning Theme 3 Significant Statement
Related Formulated Meaning Theme 4 Significant Statement Related Formulated Meaning Theme 5 Significant Statement
Related Formulated Meaning Theme 6 Significant Statement Related Formulated Meaning Theme7 Significant Statement Related Formulated Meaning Theme 8 Significant Statement Related Formulated Meaning Theme 9 Significant Statement Related Formulated Meaning Theme 10 Significant Statement Related Formulated Meaning
Stress And Anxiety ‘‘It was like being thrown out of cold water into hot boiling water, it really physically and mentally felt like a massive shift and I think by the end of the second week I was just delirious and I thought ‘how on earth am I ever going to get through this?’’. Settling into the osteopathic program was a time full of stress and anxiety, as I was trying to establish my life whilst developing new friendships and becoming accustomed to everything required of me to commit to this program Happiness And Excitement ‘‘[Upon acceptance into Osteopathy] I felt like I was looking at this whole new horizon that I’d never considered before. a whole new world open to me, so many opportunities.’’ I felt tremendous excitement about starting this new journey of osteopathic study and the opportunity it would bring. Contentment ‘‘I started to feel an unconscious kind of deep ease. knowing that I’d found something that I really loved, and realising that this is what I’m meant to be doing. Having searched for the answers to the big question ‘What are you going to do with yourself?’ The search was over!’’ Knowing that Osteopathy is the right direction for me at this point gives me a sense of deep ease and contentment. Self-satisfaction ‘‘I am so passionate about it [Osteopathy] and I love what it can do for people, and what I can feel underneath my fingers and. the changes that I can make.’’ Making a positive difference to my patients’ wellbeing is rewarding and makes all the hard work worthwhile. Frustration ‘‘You feel that you can’t get balance because you’ve got to spend time at uni studying and then out of uni you’ve also got to worry about work and. you want to do other things but you unfortunately can’t.I’m always struggling to get that balance, and it gets frustrating when you can’t do everything.’’ Constantly trying to manage my time between study and life outside of uni is very frustrating as it is extremely hard to find a balance, let alone maintain it. Fear of Failure And Self-doubt ‘‘[Overwhelmed by] the amount that we are expected to know as a student to pass our exams and to qualify. The amount of knowledge is massive and that is intimidating, it makes me feel inadequate.’’ The pressure that escalates during the exam period leads to feelings of extreme self-doubt. Sense of Support ‘‘It’s a very close-knit group, it’s kind of a family atmosphere. it makes you realise that other people are going through the same sort of things. There’s always going to be somebody else there to guide you. it’s just a really welcoming environment.’’ The family atmosphere amongst fellow students continues to grow as you progress through the program, making me feel comfortable and supported as we face our challenges together. Anger And Resentment ‘‘With the guilt, it was mixed in with anger. I felt guilty because I felt like I wasn’t sacrificing enough. but I was also angry to think that if I did sacrifice that little bit more, I probably would have just lost-it!’’ The constant feeling of guilt if I0 m not studying makes me angry because it prevents me from enjoying the things that once brought pleasure to my life. Fear of the Unknown ‘‘[Looking to the future] That makes me feel excited yet anxious, and also nervous about what the next journey in this whole process of life is going to bring.’’ Fear of the unknown associated with graduating from the program, although exciting, is also worrying and daunting. Sadness ‘‘[Fitting life with uni] sometimes I feel like I’d be much happier, much better if I didn’t spread myself out so much.it causes a lot of stress.sadness, just that I’m even putting myself in this situation.’’ There is some sadness felt when I0 m unable to spend enough time with important people in my life because of study commitments.
realised that such skills take time and practice to develop, it was frustrating in the meantime;
Although cramming is often resorted to, some participants admitted that:
‘‘I guess it’s learning patience, but you want it now, people are trying to get you to diagnose something and it’s hard’’.
‘‘if you do a little bit each week rather than a lot at the end, it works much better in the long run. and you retain the knowledge rather than just remembering it for the exam.’’
The osteopathic examination period was commonly described as a time when stress and frustration became most apparent. As the pressure escalated, so did these emotions. With practical and theoretical components of most subjects, students have to prepare for a large number of examinations each semester. Participants realised that in order to get through the exam period they needed to keep their thoughts and emotions in perspective. In order to distract themselves from the fear of failure many described various methods of procrastination for example overeating or socialising. If participants were not organised throughout the entire semester, ‘cramming’ the huge amount of content became their only option to get through the exam period. One participant reflected on this: ‘‘my body just doesn’t want to do that anymore, if you build up that much stress then you [have to] deal with it, you get your get lack of sleep, you get sick, you get cranky and I can’t see the point.’’
As this is such a challenging time, participants felt extremely proud, empowered and more confident as they got through each semester, making it all seem worthwhile; ‘‘. it’s made me a stronger person if nothing else.’’ All participants remarked upon the supportive environment within the osteopathic program, which not only came from within their own year level, but extended across all years; ‘‘There’s always going to be somebody else there to guide you. the year levels above are really good in the way they interact with the younger year levels, befriending and helping them.’’ The faculty also play a role in supporting the students, as one participant noted: ‘‘I feel pretty good [knowing] there are some really great lecturers and organisers out there that are looking after us.
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Table 2 Formulated meanings. Theme
Exhaustive description
Stress and Anxiety
Although students recognise that being in a state of stress does not accomplish anything, feelings of stress and anxiety continually arise throughout the osteopathic program and are not only reflected in the mind but also in the physical body. The intense workload, struggling to find and maintain a balance between osteopathic study and outside life, and not being in control of all aspects of the program are the major contributors to the stressful state. Sustaining this stressful state diminishes the enjoyment of the student experience and other aspects of life. Undertaking osteopathic study provokes significant feelings of happiness and excitement, whether it stems from beginning a new journey, the experiences and milestones throughout the journey or the prospect of applying this education and personal growth as an Osteopath in the future. Underlying this feeling is a strong passion for Osteopathy, which represents a life of never-ending learning accompanied by endless opportunity. Osteopathy represents not only a career but a lifestyle, a pathway of self-discovery and continual growth. Being on this pathway with a passion for osteopathy makes students feel content and at ease. Remembering this passion and maintaining balance allows contentment to remain constant by keeping emotions in perspective during difficult times. A deep sense of self-satisfaction comes with acceptance into this program for which students have a strong passion and feel is the right path for them. This feeling resurfaces as they progress successfully through each year and is magnified in the clinical setting as students integrate all they have learnt and apply this to make a difference to their patients’ lives. Many facets of the program bring about feelings of frustration such as; palpation takes time to develop but is a vital skill in the learning and practice of Osteopathy; time restraints related to inefficient timetabling, Masters group work or balance with outside life; living the ‘‘student life’’ while others not studying appear not to have the same restraints; being subjected to some staff members closed-minded unwavering bias. The pressure associated with exam periods, clinical practicum and constant influx of information leads to feeling of self-doubt, which in turn holds students back from willingly putting forth their ideas. Procrastination is a common method used by osteopathic students in order to distract themselves from the fear of failure. There is a strong family atmosphere within the osteopathic program, not only within the student body but also within the faculty, provoking a strong sense of support and comfort, which only gets stronger as the years progress. However, should problems arise within the group setting of the Masters program or from lack of guidance from the faculty, students can feel as though some of that support is lost. Feelings of stress, guilt and frustration due to the intense workload, the struggle to enjoy a life outside of uni and the feeling of a lack of support within in the faculty lead to anger and resentment compounded by the high expectations placed upon students. In the instance of entering into the unknown, such as beginning the osteopathic program or nearing the end, facing the future, a sense of fear arises. Even though this fear of the unknown can be daunting, trying to hold on to a positive outlook transforms the fear into excitement of the unknown enabling the fear to be outweighed. If moving away from home, and support base, is required to begin the osteopathic program, sadness can arise as one phase of life ends and another begins. This reoccurs at the completion of the program as students go their separate ways and again one phase ends whilst another begins. In another context, sadness arises throughout the program when students are unable to share quality time with those they wish to due to study commitments.
Happiness and Excitement
Contentment
Self-satisfaction
Frustration
Fear of Failure and Self-doubt
Sense of Support
Anger and Resentment
Fear of the Unknown
Sadness
[I have] a positive outlook on the fact that they are trying to change stuff and [the program] is constantly evolving.’’ Many reported on the importance of friendship amongst the students as a means to face and overcome the challenges of the program together. ‘‘I think your friends are a very important part of uni, and I don’t know how people get through without them. Probably that’d be the most special thing I’ve taken from uni.’’ The support of those at university is very important, as participants explained, it is only those in the program who truly understand the hardships involved in being an osteopathic student. The osteopathic program involves high contact hours, many exams and assessments, and a heavy volume of information to tackle. Students recognise that while this is required to complete the qualification, this recognition does not make the journey any easier. Remembering their passion for osteopathy helped to make the journey smoother and the respondents stated passion for Osteopathy underpinned the contentment theme; ‘‘you definitely go back to that hope, and that feeling of deep down knowing that it’ll be alright’’. ‘‘ . it reassures you to know that people are as passionate as you are, and you’re able to rely on people .’’ Participants realised that excessive stress achieves nothing, and when they stepped back from this stress they felt a deep sense of ease and contentment, which was also present when participants reflected on their own self-growth and discovery throughout the osteopathic student journey;
‘‘It’s self- discovery through discovery of a discipline’’. Facing the demands of this program forces students to mature on many levels, learning how to cope with constant high demands and responsibility; ‘‘I think I’ve matured a lot. my understanding of life in general has grown. I0 m just open to learning new things, it is that excitement of learning and growing as a person that gets me through and keeps me going’’. A student’s perspective shapes their experience; a positive outlook improves their ability to cope with the demands of the program; ‘‘Life will always throw you obstacles; you’ve just got to work out the best way to get through them. Uni is exactly the same, it’s just another obstacle, you’ve just got to find your own path.’’ 4. Discussion The students’ experience of the osteopathic program was found to be divided into five main stages; Acceptance into and Commencement of the Program, Progression Through the Program, The Clinical Experience, The Masters Program and Looking Beyond Graduation to the Future. Each provoked varied emotional responses forming the major themes; Stress and Anxiety, Happiness and Excitement, Contentment, Self-Satisfaction, Frustration, Fear of Failure and Self-Doubt, Sense of Support, Anger and Resentment, Fear of the Unknown and Sadness.
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The investigators concluded from this study that, while fear of failure was a strong motivator, a student’s underlying passion for Osteopathy and strong friendships formed within the program are what enable the student to get through the challenges and difficulties associated with undertaking this program. Nearly twice as many references were made to their passion for osteopathy than to their fear of failure as a motivator. Certain strengths and limitations of the study arose as a result of the investigators being osteopathic students. They found it difficult at times to put aside their own bias and remain impartial, particularly during the interview process if participants struggled to describe their experience in terms of emotions, the investigators found themselves wanting to offer suggestions. It was also difficult to accept an experience as being valid when a negative viewpoint was raised by a participant, when the investigators did not feel the same way. Having three investigators reviewing the material should lessen the impact of this potential bias but may not eliminate it completely. However strength also came from the investigators’ closeness to the topic, as they had an insight into being an osteopathic student and hence were able to understand the participants’ experience to accurately convey this phenomenon. 5. Conclusions This research provides insight into the lived experience of being an osteopathic student at RMIT University, a phenomenon that has previously not been investigated in Australia. The investigators felt it important to give recognition to the osteopathic student journey for the benefit of students, staff and the program. By providing current and prospective osteopathic students with such a resource, there is the potential for students to better understand their own lived experience through relating to others’. This may be of benefit to staff by not only recalling their own osteopathic student journey but also in better understanding the challenges and emotions of today’s students who are now undertaking a different program structure. Findings of the research have indicated areas of the osteopathic program in which changes could be considered, for example the timing and volume of assessments. Such improvements may help in the advancement of the osteopathic program. The findings of this research have the potential to invite further inquiry into the lived experience of the osteopathic student. Each theme cluster that emerged could be individually explored to provide a greater insight into this emotional experience, for example stress. Each of the five stages of the program could be further researched individually, in order to obtain a more detailed understanding, for example clinical experience or the Masters program. Other areas that could be investigated in greater depth include: 1. the lived experience of mature age students as compared to that of the secondary school graduate; 2. the students’ experience of developing palpatory or diagnostic skills; 3. interactions between students and their teachers, clinicians or patients; 4. the transition from student to practicing osteopath; 5. the lived experience of the staff, who are responsible for the organisation of the osteopathic program.
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One of the metaphors offered by a participant to summarise their journey through the osteopathic training was: ‘‘You’re walking along the sand, you see your goal yet it’s so far ahead. It can get tough walking in the sand and your goal still seems so far ahead, but then you look back and you realise how far you’ve come.’’ Competing interests None declared. Authors’ contributions JKH, RAM and LMP contributed equally to this work through performing the interviews analysis and prepared the manuscript. RGM conceived of the study and supervised the project, edited and reviewed the manuscript. All authors reviewed and approved the manuscript. Acknowledgements We wish to thank Dr Anthony Welch for his guidance and advice on qualitative research methods. References 1. Still AT. Autobiography of Andrew T. Still: with a history of the discovery and development of the science of osteopathy. Medicine & society in America. New York: Arno Press; 1972 [460 pp.]. 2. Colaizzi PF. Psychological research as the phenomenologist views. In: Vale R, King M, editors. Existential-phenomenological alternatives for psychology. New York: Oxford University Press; 1978. p. 48–71. 3. Griffin A, Sweet S. Undergraduate osteopathic medical education: addressing the impact of college growth on the applicant pool and student enrolment. J Am Osteopath Assoc 2006;106:51–7. 4. Sweet S. Undergraduate osteopathic medical education. J Am Osteopath Assoc 2003;103:507–12. 5. Crapse F, Hudgins P, Baker H. Lifestyle changes associated with osteopathic medical education. J Am Osteopath Assoc 1993 Oct;93:1051–4. 6. Kurtz M, Paulsen R, Ferguson D. How effectively are osteopathic medical students coping with a stressful life-style? J Am Osteopath Assoc 1991 Jul;90:613–22. 7. Dornan T, Bundy C. What can experience add to early medical education? Consensus survey. Br Med J 2004 Oct;329:834. 8. Beck C. Burnout in undergraduate nursing students. Nurs Educ Today 1995;20:19–23. 9. Brown H, Edelmann R. Project 2000: a study of expected and experienced stressors and support reported by students and qualified nurses. J Adv Nurs 2000;31:857–64. 10. Hammil C. The phenomenon of stress as perceived by project 2000 student nurses: a case study. J Adv Nurs 1995;21:528–36. 11. Jones M, Johnston D. Reducing distress in first level and student nurses: a review of the applied stress management literature. J Adv Nurs 1997; 32:66–74. 12. Lauder W, Cuthbertson P. Course-related family and financial problems of mature nursing students. Nurs Educ Today 1998;18:419–25. 13. Ogunsiji O, Wilkes L. Managing family life while studying: single mothers’ lived experience of being students in a nursing program. Contemp Nurse 2004;8: 108–23. 14. Obradovic JL, Beaudry SW, Winslow-Falbo P. Osteopathic graduate medical education. J Am Osteopath Assoc 2006;106:59–68. 15. Shannon SC. Osteopathic medical education in 2006: charting a course for the future. J Am Osteopath Assoc 2006 Feb;106:48–9. 16. Lincoln Y, Guba E. Naturalistic enquiry. Nebury Park Ca: Sage; 1985. 17. Coˆte´ L, Turgeon J. Appraising qualitative research articles in medicine and medical education. Med Teach 2005;27:71–5. 18. Devers KJ. How will we know ‘‘good’’ qualitative research when we see it? beginning the dialogue in health services research. Health Serv Res 1999;34: 1153–88. 19. Frankel RM. Standards of qualitative research. In: Crabtree B, Miller W, editors. Doing qualitative research. Thousand Oaks CA: Sage Publications; 1999. p. 333.
Contents lists available at ScienceDirect
International Journal of Osteopathic Medicine journal homepage: www.elsevier.com/ijos
Research report
Progression through osteopathic training in Australia: The student experience Jessica K. Hartup, Rachel A. Murphy, Loretta M. Plowman, Ray Myers* Division of Osteopathy, School of Health Sciences, RMIT University, PO Box 71, Bundoora 3083, Australia
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 December 2008 Received in revised form 27 April 2009 Accepted 21 January 2010
Background: The objective of this study was to explore the lived experience of being an osteopathic student. The paucity of published material on the experience of osteopathic students highlighted the need for such research to record the nature of this aspect of osteopathic culture in Australia. Methods: One on one in-depth interviews with participants were conducted and explored employing a phenomenological approach to information gathering and analysis. Setting: Students undertaking the five-year osteopathic program at RMIT University, Melbourne, Australia. Analysis: Colaizzi’s seven step approach to phenomenological analysis was utilised. Subjects: Purposeful sampling was used to select nineteen participants across all year levels to form the cohort of the study. Results: The RMIT osteopathic program was found to be described in relation to five main stages; Acceptance into and Commencement of the Program, Progression through the Program, The Clinical Experience, The Masters Program and Looking Beyond Graduation to the Future. Each stage provoked significant and varied emotional responses forming the major themes of the study; Stress and Anxiety, Happiness and Excitement, Contentment, Self-Satisfaction, Frustration, Fear of Failure and Self-Doubt, Anger and Resentment, Sense of Support, Fear of the Unknown and Sadness. Conclusions: The most prevalent emotional experience reported was that of stress and anxiety within the student’s journey. While this was of great significance, it was concluded that a student’s underlying passion for osteopathy and strong friendships formed within the program are what enable the student to get through the challenges and difficulties associated with undertaking the osteopathic program. Ó 2010 Elsevier Ltd. All rights reserved.
Keywords: Osteopathic medicine Education Lived experience Phenomenology
1. Background The profession of osteopathy was founded by an American pioneer, Doctor Andrew Taylor Still (1828–1917) in 1874.1 The practice of osteopathy has developed into two distinct forms, one the osteopathic physician with full medical practice rights, as seen in the USA, and the other as osteopaths with a scope of practice limited to manual therapy, as seen in Australia and the UK. The aim of this study was to explore the lived experience of being an osteopathic student throughout the full-time five-year program at RMIT University, Melbourne, Australia. For the purpose of this study the term ‘lived experience’ is used to denote the day-to-day feelings and emotions2 associated with being an osteopathic student. In the literature, there was no direct reflection on the notion of the osteopathic students’ lived experience per se. Quantitative
* Corresponding author. E-mail addresses: [email protected] (J.K. Hartup), rachel.murphy@ optusnet.com.au (R.A. Murphy), [email protected] (L.M. Plowman), ray. [email protected] (R. Myers). 1746-0689/$ – see front matter Ó 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijosm.2010.01.003
studies generally measured student experience with regards to academic performance,3,4 and qualitative studies on students’ lived experience were most commonly from the field of nursing. Quantitative studies included those by Kurtz et al. (1991) and Crapse et al. (1993), who reported on how osteopathic students cope with their stressful lifestyle. They found the primary coping behaviours students used in response to stress included humour, leisure, exercise, and social activity.5,6 From a qualitative perspective, a study on medical students’ clinical experience by Dornan and Bundy (2004) reported on medical education as being vocationally driven and emotionally laden; students described entering the clinical environment as ‘‘being thrown in the deep end,’’ with the fear of being inadequate, but also exciting at the same time.7 Other studies8–13 investigated nursing students’ learning experiences and related emotional experiences. Factors identified as stressors for students were: difficulty balancing home and study demands, time pressure, financial concerns, feelings of distance from faculty and staff in the clinical setting, stress associated with feeling unprepared for clinical practice and feeling incompetent in clinical skills.
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In Australia, the osteopathic student’s journey spans five years of full-time study, comprising of a three-year Bachelor program followed by a two-year Masters program. The implementation of this program structure at RMIT in 2002 represented a major shift from the primarily teaching college approach used since 1986. This shift resulted in a decrease of emphasis on didactic teaching to a greater emphasis on student directed and problem-based learning. The effects of this period of transition, as students adapted to this new approach, should be taken into consideration when reading of their reported experiences. Over the five years students are required to undertake an intensive and extensive range of health science and osteopathic medicine subjects to prepare them for osteopathic practice. The RMIT osteopathic teaching clinic provides an environment for senior students to develop these skills under the supervision of qualified osteopaths. The investigators, (JKH, RAM, LMP) had previously observed that students express an array of emotions in response to their experiences throughout the journey. They appreciated that these responses are significant and often shared amongst the student body, however are seldom acknowledged or documented. The desire to gain insight into the experiences of these students was the motivator for this study. This study has the potential to create awareness of the osteopathic student lived experience, in order to give recognition to its importance and to provide current and prospective osteopathic students with a resource to relate to and reflect upon, to better understand their own lived experience. This study has the potential to invite further inquiry into the lived world of the osteopathic student and perhaps the impact of the structure of the osteopathic university programs on this experience, which may be an essential consideration for an osteopathic program to evolve.14,15 2. Methods Ethics approval was granted by the RMIT Human Research Ethics Committee. 2.1. Approach, setting and sampling The purpose of this study was to understand the meaning and significance of the phenomenon of being an osteopathic student, based on the experiences of those living it. Therefore phenomenology was the method of choice, as it focuses on the essence of the lived experience, without attempting to predict or control the phenomenon. Colaizzi’s (1978) description of the practice of descriptive research involves the phenomenologist ‘‘contacting that phenomenon as people experience it.’’.2 This then is the basis for forming the appropriate set of research questions and examining the researcher’s pre-suppositions. As the investigators were current osteopathic students during the implementation of this study, they have an insight into the investigated phenomenon and, although essential, it creates the potential for bias to exist and this is discussed below. Purposeful sampling was used to attain maximal diversity amongst participants across all year levels. It was initially proposed that four to five students from each of the five year levels would be chosen to participate in the study, however if saturation were to occur due to the in-depth exploratory nature of this research method, the interviewing of further participants would cease. In order to participate in this study subjects must be volunteers, over the age of 18 years, current RMIT osteopathic student and available for two separate interviews.
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2.2. Information collection and analysis Prior to the actual information gathering process each of the investigators conducted a pilot interview supervised by an experienced researcher in the qualitative field, to ensure that the correct procedure for interviewing was followed. Employing Colaizzi’s approach to enquiry,2 one on one in-depth interviews lasting between 30 and 50 min were conducted, after informed consent was obtained from the participant. The semistructured interview was undertaken in a relaxed, welcoming environment at the beginning of the academic year. Interviews began with the open-ended question: ‘‘Tell me about your experience of being an osteopathic student.’’ In order to elicit the depth and essence of the participant’s experience, this was followed by prompting questions such as: ‘‘Tell me about your thoughts and feelings related to these experiences’’ ‘‘Can you give me an example of when you felt this way?’’ Each interview was tape recorded and later transcribed by the investigators. A second interview with each participant was conducted to provide the participant with the opportunity to clarify, confirm or refute any part of the interview transcript or the researcher’s interpretation. It also provided the opportunity to add any other thoughts and feelings they wished to convey. The transcribed interviews were analysed using a technique articulated by Colaizzi involving the following seven steps2: 1. Read all participants’ narratives several times to achieve a thorough understanding of their experience. 2. Extract significant statements – reviewing participants’ transcripts and taking from them phrases or sentences that directly pertain to the phenomenon. 3. Formulate meanings for significant statements – spelling out the meaning of each significant statement. The researcher needs to capture the depth of the students’ lived experience not just by what they say but how they say it, taking into account their tone, body language and general demeanor. 4. Arrange formulated meanings into theme clusters – scrutinising significant statements and formulated meanings, grouping these into common themes. 5. Write exhaustive descriptions of the investigated phenomenon – integrate all of the results from the steps above into a narrative description of the phenomenon. 6. Identify the fundamental structure of the phenomenon – drawing together the exhaustive descriptions of the phenomenon ‘‘in as unequivocal a statement of identification of its fundamental structure as possible’’. 7. Return to participants for validation – ensuring a true representation of their student experience has been presented.
Lincoln and Guba outlined a set of criteria to identify the trustworthiness of a phenomenon; credibility, transferability, dependability and confirm-ability, and achieving these criteria gives a study rigour and validity.16 Credibility (internal validity), refers to the overall methodological quality of the study.17–19 It was important to maintain credibility whilst developing formulated meanings from significant statements in taking what the participants had said and interpreting this to form a meaning. Credibility is improved through having the three investigators come to agreed formulated meanings as well as returning these formulated meanings to the participant to allow for clarification.
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Transferability of the study (external validity) refers to the concept of generalisation found in quantitative research. The investigators selected a range of osteopathic students to create diversity within the results to facilitate transferability.17 Dependability was achieved through rigorously following Colaizzi’s seven step information analysis process. To obtain confirm-ability the investigators demonstrated that the information used within this project was not a product of their imagination, but came from an external source, by having a clear format of each step and by referencing the participants’ statements whereby data could be tracked to its source.17 There is a notion of bias compounding when working in a group environment as investigators may encourage one another’s views or beliefs, forgetting to be impartial, therefore strategies were required to limit this. As previously mentioned open-ended questions were used during interviews, so as not to lead participants towards an answer the investigators expected to hear. Directed questioning such as: ‘‘can you elaborate on how that made you feel?’’ were used, avoiding leading questions such as ‘‘did that make you feel angry?’’ When identifying significant statements from transcripts of the participants’ interviews, investigators took care to keep an open mind and to not disregard a statement simply because it did not mirror their own experience. 3. Results 3.1. Findings During the interview process it was found that three to four students per year level provided sufficient material for a saturation of themes to be reached, so the original notion of interviewing four to five students became redundant. Of the nineteen participants, seven males and twelve females formed the cohort of the study. The participants were from each of the five-year levels, including students from Melbourne and interstate, as well as students who had entered the program directly from secondary school and those who had undertaken previous higher education studies. Following Colaizzi’s seven step approach to analysis, significant statements were drawn from participants’ interviews, which were then integrated into common themes and a collective formulated meaning. Examples of one significant statement and one formulated meaning from each theme, in order of the most common to least common theme, are given in Table 1. The next step in the process of analysis involved combining all formulated meanings per theme into an exhaustive description, presented in Table 2. In terms of the analysis of themes, participants described their experiences in relation to five distinct stages throughout the osteopathic program. Those identified were: 1. 2. 3. 4. 5.
Acceptance into and Commencement of the Program; Progression through the Program; Clinical Experience; The Masters Program; and Looking Beyond Graduation to the Future.
To be consistent with the participants’ experience the investigators exhaustively investigated the themes associated with each stage. Due to the large volume of findings within each stage of the program, this article focuses on ‘Progression through the Program’ only, as it captures a wide range of themes and is applicable to all current osteopathic students.
3.2. Progression through the program As students progress through each year of the osteopathic program they are presented with a wide scope of new challenges and experiences, all of which stir a vast array of emotions. Participants enjoy the constant stimulation of learning and describe it as motivating and inspiring, knowing they will apply this education in clinical practice. However such constant stimulation has been perceived at times as a constant overwhelming bombardment of information. Participants emphasised that the amount of knowledge to retain not only compounds throughout the semester but also as the years progress. ‘‘You’re basically chucked in at the deep end, you get this hundred or two hundred pages of notes, and if you flick through it your head spins.’’ If participants did not form a coping mechanism, this perceived colossal workload led to feelings of extreme self-doubt or to breaking point. For those students who did develop coping mechanisms they still experienced times of near absolute exhaustion. During particularly high times of stress some participants reported behavioural and physical manifestations of their stress such as decreased level of tolerance, subconscious eye twitches, stomach upsets, depression, panic attacks and heart palpitations, all of which emphasise that stress is not just a state of mind. The high expectations of staff and also those which participants place upon themselves provoke feelings of frustration, anger and resentment, as they feel incapable of living up to these constantly growing expectations: ‘‘we are expected to know so much when it really takes a lifetime to learn.it’s just like 10,000 kilos of information being pounded on top of me, ‘now retain all of that.’ It feels drowning, like I can’t cope, like I cannot have anything else in my life because so much is expected of us.’’ One of the most significant challenges described was that of attempting to establish and maintain a balance between commitment to osteopathic study and outside life. Frustration surfaced as participants tried to balance university hours, study, work, family, friends, partners, sports and hobbies and social life. Due to the intense workload and constant demands, participants feel as though every spare moment should be dedicated to studying. Feelings of guilt and frustration would then arise when they wished to or actually did partake in any activity unrelated to the program, leading to anger as such constant guilt felt like it was taking over their life. ‘‘I just didn’t have enough time. And then if I did have time, I had the guilt because the group was meeting regardless. With the guilt, it was mixed in with anger. I felt guilty because I felt like I wasn’t sacrificing enough.’’ An element of sadness also emerged when participants felt they were unable to spend enough time with important people in their lives due to study commitments. Even though it is difficult to make time and enjoy an outside life, away from study, participants recognised the importance of having other outlets, for balance in their life: ‘‘You’ve got to be focused, but you’ve also got to do the things you want. Uni is a part of your life, but it’s not your whole life!’’ Some participants experienced self-doubt and frustration in regards to certain subjects, in particular osteopathic palpatory diagnosis class. The major qualm was with the level of palpatory skill required to form such diagnoses in class, and the inadequate level most participants felt they had at this time. Although they
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Table 1 Themes, significant statements and formulated meaning. Theme 1 Significant Statement Related Formulated Meaning Theme 2 Significant Statement Related Formulated Meaning Theme 3 Significant Statement
Related Formulated Meaning Theme 4 Significant Statement Related Formulated Meaning Theme 5 Significant Statement
Related Formulated Meaning Theme 6 Significant Statement Related Formulated Meaning Theme7 Significant Statement Related Formulated Meaning Theme 8 Significant Statement Related Formulated Meaning Theme 9 Significant Statement Related Formulated Meaning Theme 10 Significant Statement Related Formulated Meaning
Stress And Anxiety ‘‘It was like being thrown out of cold water into hot boiling water, it really physically and mentally felt like a massive shift and I think by the end of the second week I was just delirious and I thought ‘how on earth am I ever going to get through this?’’. Settling into the osteopathic program was a time full of stress and anxiety, as I was trying to establish my life whilst developing new friendships and becoming accustomed to everything required of me to commit to this program Happiness And Excitement ‘‘[Upon acceptance into Osteopathy] I felt like I was looking at this whole new horizon that I’d never considered before. a whole new world open to me, so many opportunities.’’ I felt tremendous excitement about starting this new journey of osteopathic study and the opportunity it would bring. Contentment ‘‘I started to feel an unconscious kind of deep ease. knowing that I’d found something that I really loved, and realising that this is what I’m meant to be doing. Having searched for the answers to the big question ‘What are you going to do with yourself?’ The search was over!’’ Knowing that Osteopathy is the right direction for me at this point gives me a sense of deep ease and contentment. Self-satisfaction ‘‘I am so passionate about it [Osteopathy] and I love what it can do for people, and what I can feel underneath my fingers and. the changes that I can make.’’ Making a positive difference to my patients’ wellbeing is rewarding and makes all the hard work worthwhile. Frustration ‘‘You feel that you can’t get balance because you’ve got to spend time at uni studying and then out of uni you’ve also got to worry about work and. you want to do other things but you unfortunately can’t.I’m always struggling to get that balance, and it gets frustrating when you can’t do everything.’’ Constantly trying to manage my time between study and life outside of uni is very frustrating as it is extremely hard to find a balance, let alone maintain it. Fear of Failure And Self-doubt ‘‘[Overwhelmed by] the amount that we are expected to know as a student to pass our exams and to qualify. The amount of knowledge is massive and that is intimidating, it makes me feel inadequate.’’ The pressure that escalates during the exam period leads to feelings of extreme self-doubt. Sense of Support ‘‘It’s a very close-knit group, it’s kind of a family atmosphere. it makes you realise that other people are going through the same sort of things. There’s always going to be somebody else there to guide you. it’s just a really welcoming environment.’’ The family atmosphere amongst fellow students continues to grow as you progress through the program, making me feel comfortable and supported as we face our challenges together. Anger And Resentment ‘‘With the guilt, it was mixed in with anger. I felt guilty because I felt like I wasn’t sacrificing enough. but I was also angry to think that if I did sacrifice that little bit more, I probably would have just lost-it!’’ The constant feeling of guilt if I0 m not studying makes me angry because it prevents me from enjoying the things that once brought pleasure to my life. Fear of the Unknown ‘‘[Looking to the future] That makes me feel excited yet anxious, and also nervous about what the next journey in this whole process of life is going to bring.’’ Fear of the unknown associated with graduating from the program, although exciting, is also worrying and daunting. Sadness ‘‘[Fitting life with uni] sometimes I feel like I’d be much happier, much better if I didn’t spread myself out so much.it causes a lot of stress.sadness, just that I’m even putting myself in this situation.’’ There is some sadness felt when I0 m unable to spend enough time with important people in my life because of study commitments.
realised that such skills take time and practice to develop, it was frustrating in the meantime;
Although cramming is often resorted to, some participants admitted that:
‘‘I guess it’s learning patience, but you want it now, people are trying to get you to diagnose something and it’s hard’’.
‘‘if you do a little bit each week rather than a lot at the end, it works much better in the long run. and you retain the knowledge rather than just remembering it for the exam.’’
The osteopathic examination period was commonly described as a time when stress and frustration became most apparent. As the pressure escalated, so did these emotions. With practical and theoretical components of most subjects, students have to prepare for a large number of examinations each semester. Participants realised that in order to get through the exam period they needed to keep their thoughts and emotions in perspective. In order to distract themselves from the fear of failure many described various methods of procrastination for example overeating or socialising. If participants were not organised throughout the entire semester, ‘cramming’ the huge amount of content became their only option to get through the exam period. One participant reflected on this: ‘‘my body just doesn’t want to do that anymore, if you build up that much stress then you [have to] deal with it, you get your get lack of sleep, you get sick, you get cranky and I can’t see the point.’’
As this is such a challenging time, participants felt extremely proud, empowered and more confident as they got through each semester, making it all seem worthwhile; ‘‘. it’s made me a stronger person if nothing else.’’ All participants remarked upon the supportive environment within the osteopathic program, which not only came from within their own year level, but extended across all years; ‘‘There’s always going to be somebody else there to guide you. the year levels above are really good in the way they interact with the younger year levels, befriending and helping them.’’ The faculty also play a role in supporting the students, as one participant noted: ‘‘I feel pretty good [knowing] there are some really great lecturers and organisers out there that are looking after us.
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Table 2 Formulated meanings. Theme
Exhaustive description
Stress and Anxiety
Although students recognise that being in a state of stress does not accomplish anything, feelings of stress and anxiety continually arise throughout the osteopathic program and are not only reflected in the mind but also in the physical body. The intense workload, struggling to find and maintain a balance between osteopathic study and outside life, and not being in control of all aspects of the program are the major contributors to the stressful state. Sustaining this stressful state diminishes the enjoyment of the student experience and other aspects of life. Undertaking osteopathic study provokes significant feelings of happiness and excitement, whether it stems from beginning a new journey, the experiences and milestones throughout the journey or the prospect of applying this education and personal growth as an Osteopath in the future. Underlying this feeling is a strong passion for Osteopathy, which represents a life of never-ending learning accompanied by endless opportunity. Osteopathy represents not only a career but a lifestyle, a pathway of self-discovery and continual growth. Being on this pathway with a passion for osteopathy makes students feel content and at ease. Remembering this passion and maintaining balance allows contentment to remain constant by keeping emotions in perspective during difficult times. A deep sense of self-satisfaction comes with acceptance into this program for which students have a strong passion and feel is the right path for them. This feeling resurfaces as they progress successfully through each year and is magnified in the clinical setting as students integrate all they have learnt and apply this to make a difference to their patients’ lives. Many facets of the program bring about feelings of frustration such as; palpation takes time to develop but is a vital skill in the learning and practice of Osteopathy; time restraints related to inefficient timetabling, Masters group work or balance with outside life; living the ‘‘student life’’ while others not studying appear not to have the same restraints; being subjected to some staff members closed-minded unwavering bias. The pressure associated with exam periods, clinical practicum and constant influx of information leads to feeling of self-doubt, which in turn holds students back from willingly putting forth their ideas. Procrastination is a common method used by osteopathic students in order to distract themselves from the fear of failure. There is a strong family atmosphere within the osteopathic program, not only within the student body but also within the faculty, provoking a strong sense of support and comfort, which only gets stronger as the years progress. However, should problems arise within the group setting of the Masters program or from lack of guidance from the faculty, students can feel as though some of that support is lost. Feelings of stress, guilt and frustration due to the intense workload, the struggle to enjoy a life outside of uni and the feeling of a lack of support within in the faculty lead to anger and resentment compounded by the high expectations placed upon students. In the instance of entering into the unknown, such as beginning the osteopathic program or nearing the end, facing the future, a sense of fear arises. Even though this fear of the unknown can be daunting, trying to hold on to a positive outlook transforms the fear into excitement of the unknown enabling the fear to be outweighed. If moving away from home, and support base, is required to begin the osteopathic program, sadness can arise as one phase of life ends and another begins. This reoccurs at the completion of the program as students go their separate ways and again one phase ends whilst another begins. In another context, sadness arises throughout the program when students are unable to share quality time with those they wish to due to study commitments.
Happiness and Excitement
Contentment
Self-satisfaction
Frustration
Fear of Failure and Self-doubt
Sense of Support
Anger and Resentment
Fear of the Unknown
Sadness
[I have] a positive outlook on the fact that they are trying to change stuff and [the program] is constantly evolving.’’ Many reported on the importance of friendship amongst the students as a means to face and overcome the challenges of the program together. ‘‘I think your friends are a very important part of uni, and I don’t know how people get through without them. Probably that’d be the most special thing I’ve taken from uni.’’ The support of those at university is very important, as participants explained, it is only those in the program who truly understand the hardships involved in being an osteopathic student. The osteopathic program involves high contact hours, many exams and assessments, and a heavy volume of information to tackle. Students recognise that while this is required to complete the qualification, this recognition does not make the journey any easier. Remembering their passion for osteopathy helped to make the journey smoother and the respondents stated passion for Osteopathy underpinned the contentment theme; ‘‘you definitely go back to that hope, and that feeling of deep down knowing that it’ll be alright’’. ‘‘ . it reassures you to know that people are as passionate as you are, and you’re able to rely on people .’’ Participants realised that excessive stress achieves nothing, and when they stepped back from this stress they felt a deep sense of ease and contentment, which was also present when participants reflected on their own self-growth and discovery throughout the osteopathic student journey;
‘‘It’s self- discovery through discovery of a discipline’’. Facing the demands of this program forces students to mature on many levels, learning how to cope with constant high demands and responsibility; ‘‘I think I’ve matured a lot. my understanding of life in general has grown. I0 m just open to learning new things, it is that excitement of learning and growing as a person that gets me through and keeps me going’’. A student’s perspective shapes their experience; a positive outlook improves their ability to cope with the demands of the program; ‘‘Life will always throw you obstacles; you’ve just got to work out the best way to get through them. Uni is exactly the same, it’s just another obstacle, you’ve just got to find your own path.’’ 4. Discussion The students’ experience of the osteopathic program was found to be divided into five main stages; Acceptance into and Commencement of the Program, Progression Through the Program, The Clinical Experience, The Masters Program and Looking Beyond Graduation to the Future. Each provoked varied emotional responses forming the major themes; Stress and Anxiety, Happiness and Excitement, Contentment, Self-Satisfaction, Frustration, Fear of Failure and Self-Doubt, Sense of Support, Anger and Resentment, Fear of the Unknown and Sadness.
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The investigators concluded from this study that, while fear of failure was a strong motivator, a student’s underlying passion for Osteopathy and strong friendships formed within the program are what enable the student to get through the challenges and difficulties associated with undertaking this program. Nearly twice as many references were made to their passion for osteopathy than to their fear of failure as a motivator. Certain strengths and limitations of the study arose as a result of the investigators being osteopathic students. They found it difficult at times to put aside their own bias and remain impartial, particularly during the interview process if participants struggled to describe their experience in terms of emotions, the investigators found themselves wanting to offer suggestions. It was also difficult to accept an experience as being valid when a negative viewpoint was raised by a participant, when the investigators did not feel the same way. Having three investigators reviewing the material should lessen the impact of this potential bias but may not eliminate it completely. However strength also came from the investigators’ closeness to the topic, as they had an insight into being an osteopathic student and hence were able to understand the participants’ experience to accurately convey this phenomenon. 5. Conclusions This research provides insight into the lived experience of being an osteopathic student at RMIT University, a phenomenon that has previously not been investigated in Australia. The investigators felt it important to give recognition to the osteopathic student journey for the benefit of students, staff and the program. By providing current and prospective osteopathic students with such a resource, there is the potential for students to better understand their own lived experience through relating to others’. This may be of benefit to staff by not only recalling their own osteopathic student journey but also in better understanding the challenges and emotions of today’s students who are now undertaking a different program structure. Findings of the research have indicated areas of the osteopathic program in which changes could be considered, for example the timing and volume of assessments. Such improvements may help in the advancement of the osteopathic program. The findings of this research have the potential to invite further inquiry into the lived experience of the osteopathic student. Each theme cluster that emerged could be individually explored to provide a greater insight into this emotional experience, for example stress. Each of the five stages of the program could be further researched individually, in order to obtain a more detailed understanding, for example clinical experience or the Masters program. Other areas that could be investigated in greater depth include: 1. the lived experience of mature age students as compared to that of the secondary school graduate; 2. the students’ experience of developing palpatory or diagnostic skills; 3. interactions between students and their teachers, clinicians or patients; 4. the transition from student to practicing osteopath; 5. the lived experience of the staff, who are responsible for the organisation of the osteopathic program.
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One of the metaphors offered by a participant to summarise their journey through the osteopathic training was: ‘‘You’re walking along the sand, you see your goal yet it’s so far ahead. It can get tough walking in the sand and your goal still seems so far ahead, but then you look back and you realise how far you’ve come.’’ Competing interests None declared. Authors’ contributions JKH, RAM and LMP contributed equally to this work through performing the interviews analysis and prepared the manuscript. RGM conceived of the study and supervised the project, edited and reviewed the manuscript. All authors reviewed and approved the manuscript. Acknowledgements We wish to thank Dr Anthony Welch for his guidance and advice on qualitative research methods. References 1. Still AT. Autobiography of Andrew T. Still: with a history of the discovery and development of the science of osteopathy. Medicine & society in America. New York: Arno Press; 1972 [460 pp.]. 2. Colaizzi PF. Psychological research as the phenomenologist views. In: Vale R, King M, editors. Existential-phenomenological alternatives for psychology. New York: Oxford University Press; 1978. p. 48–71. 3. Griffin A, Sweet S. Undergraduate osteopathic medical education: addressing the impact of college growth on the applicant pool and student enrolment. J Am Osteopath Assoc 2006;106:51–7. 4. Sweet S. Undergraduate osteopathic medical education. J Am Osteopath Assoc 2003;103:507–12. 5. Crapse F, Hudgins P, Baker H. Lifestyle changes associated with osteopathic medical education. J Am Osteopath Assoc 1993 Oct;93:1051–4. 6. Kurtz M, Paulsen R, Ferguson D. How effectively are osteopathic medical students coping with a stressful life-style? J Am Osteopath Assoc 1991 Jul;90:613–22. 7. Dornan T, Bundy C. What can experience add to early medical education? Consensus survey. Br Med J 2004 Oct;329:834. 8. Beck C. Burnout in undergraduate nursing students. Nurs Educ Today 1995;20:19–23. 9. Brown H, Edelmann R. Project 2000: a study of expected and experienced stressors and support reported by students and qualified nurses. J Adv Nurs 2000;31:857–64. 10. Hammil C. The phenomenon of stress as perceived by project 2000 student nurses: a case study. J Adv Nurs 1995;21:528–36. 11. Jones M, Johnston D. Reducing distress in first level and student nurses: a review of the applied stress management literature. J Adv Nurs 1997; 32:66–74. 12. Lauder W, Cuthbertson P. Course-related family and financial problems of mature nursing students. Nurs Educ Today 1998;18:419–25. 13. Ogunsiji O, Wilkes L. Managing family life while studying: single mothers’ lived experience of being students in a nursing program. Contemp Nurse 2004;8: 108–23. 14. Obradovic JL, Beaudry SW, Winslow-Falbo P. Osteopathic graduate medical education. J Am Osteopath Assoc 2006;106:59–68. 15. Shannon SC. Osteopathic medical education in 2006: charting a course for the future. J Am Osteopath Assoc 2006 Feb;106:48–9. 16. Lincoln Y, Guba E. Naturalistic enquiry. Nebury Park Ca: Sage; 1985. 17. Coˆte´ L, Turgeon J. Appraising qualitative research articles in medicine and medical education. Med Teach 2005;27:71–5. 18. Devers KJ. How will we know ‘‘good’’ qualitative research when we see it? beginning the dialogue in health services research. Health Serv Res 1999;34: 1153–88. 19. Frankel RM. Standards of qualitative research. In: Crabtree B, Miller W, editors. Doing qualitative research. Thousand Oaks CA: Sage Publications; 1999. p. 333.