In Ontario, Canada, kinesiology is governed by a regulatory college, and its scope of practice is defined as “the assessment of human movement and performance and its rehabilitation and management to maintain, rehabilitate or enhance movement and performance” (Kinesiology Act, 2007). Although broad, the registered kinesiologist's (RKin) scope of practice can include delivering physical interventions for persons with chronic diseases, performance testing and training in elite athletes, assessing and prescribing exercise programs in the general population, providing rehabilitation for patients with brain injuries, conducting ergonomic assessments and delivering work readiness programs, or providing healthy behavior change interventions. Comparable designations in terms of scope of practice include those among the Exercise is Medicine Canada Level 2 Professional Recognition Program (exerciseismedicine.org/Canada), such as the American College of Sports Medicine Clinical Exercise Physiologist and the Canadian Society for Exercise Physiology Certified Exercise Physiologist. However, professional regulation requires oversight by a professional college to protect public interests and well-being and represents a common standard across health care professionals, such as nurses, physicians, and physical therapists. As such, the regulation of kinesiologists has advanced the role exercise professionals toward wider acceptance and compatibility with existing health care teams. Irrespective of the specific area of professional practice, optimal delivery of health care services by the RKin requires an evidence-based approach.
With regulation and increased integration in the health service setting, there is a concurrent need to demonstrate and advance evidence-informed practice in kinesiology. Although research has provided the theoretical framework to underscore the relevant role of RKins (i.e., the value of appropriately designed exercise programming across populations), there has been a lack of strategic direction with respect to research related to their professional practice. Consulting with the providers and relevant stakeholders is a fundamental component of the research agenda building process as it draws on professional expertise when identifying the areas of research requirements, ensuring that the research priorities yielded by the consultation process are relevant to the needs of the health care providers. In more established areas of clinical practice, research priorities have been empirically developed and grounded in contemporary professional opinion and used to inform clinical research. Empirically developed research agendas often use a consultative and consensus building process known as the Delphi method of consensus building (9) and are the foundation for strategic prioritization of research resources in a given discipline. Health care professions that have undertaken this activity include emergency medical services (11,12), physiotherapy (18,22), chiropractic (21), and osteopathy (23) among others. Identifying research priorities ensures the best possible use of available resources and directs research efforts to clinically and socially relevant areas (15).
Given that RKins are currently without a research agenda, the aim of this study was to engage this professional group to determine key research priorities that will inform strategic direction of future research in kinesiology in Ontario. Accordingly, a Delphi methodology was used that provided a robust process to yield a list of consensus-based research priorities that will reflect the clinical needs of the profession.
This study used a modified Delphi method for consensus building approach that spanned four rounds: (9) the development of baseline research priorities identified through qualitative analysis of semistructured focus groups (11,12,18) and three rounds of online quantitative Delphi consensus surveys. The Queen's University Research Ethics Board approved this study protocol. All participants completed informed consent before each round of this study.
Qualitative Baseline Study
Ten focus groups, each comprising of six to eight RKins, were convened at a professional association's (Ontario Kinesiology Association [OKA]) annual conference on June 2, 2015. Each 90-min focus group was led by a designated facilitator that guided discussions toward identifying and describing topics that participants felt needed more research. All group facilitators followed the same prepared script and were trained to ascertain the detail required to design appropriate research questions from discussion topics. Training of group facilitators was done by NW, who has experience leading focus groups and qualitative research methods. Focus group discussions were audio-recorded and transcribed verbatim. Transcripts were analyzed in NVivo 10.0 (QSR International, 2014) using thematic analysis (2) by two independent researchers (NW and RA) and reviewed by the research team to generate the foundational group of research questions.
Online Delphi Survey
Three rounds of online surveys were sent to the professional association (OKA) membership via e-mail listserv in November 2015 (round 1), January 2016 (round 2), and finally April 2016 (round 3). Respondents were asked to rate the importance of the research questions generated from the previous rounds and add new questions. Participants were also encouraged to forward the online survey link (Survey Monkey, Palo Alto, CA) to other RKins not on the OKA listserv (snowball sampling) (26). Participants were incentivized to participate with raffle entries for OKA prize packs with additional entries provided to those who participated in multiple rounds. Each round of surveys was accessible online for 2 wk, and three invitation/reminder e-mails were sent. For each round, participants were asked to provide demographic information, including gender, age, education, credentials and certifications, geographic area of practice, and primary patient population. Participants were given the opportunity to provide feedback on the survey experience at the conclusion of each round.
In the first online round, participants were asked to rate each research question identified from the focus groups on a Likert scale from 1 to 5 (1 = not important, 2 = not very important, 3 = possibly important, 4 = important, and 5 = very important). Questions were worded in a similar fashion to “How important do you feel it is to have more research on…” Participants were invited to provide comments on each question that would be available to respondents in subsequent rounds, as well as add new questions to the pool of identified research topics for further consideration.
In the second online round, questions from the first round (including those added by respondents) were presented back to participants for the opportunity to review the average ratings and respondents' comments for each question. Participants were invited to either accept the ratings from round 1 or rerate questions on the same Likert scale should they wish to increase or decrease a question's average score. Participants were informed that all questions that failed to achieve the a priori consensus mean of at least 4 out of 5 (i.e., “important”), as well as a median of 4, would be removed from the list in subsequent rounds of surveys (7). Upon completion of this round, questions that achieved at least 4 out of 5 were reviewed by the research team for clarity and redundancy, whereas questions that did not achieve this threshold were removed from the subsequent round.
In the final round, research questions that met rating criteria were presented back to participants who were then asked to choose their top 10 research questions and rank order them in terms of their perceived importance. In the case where participants chose more than 10 questions, their 10 highest rated questions were recorded.
A priori, it was determined that a potential research question would be considered “important” if it received an mean rating of 4 out of 5 and rated as “important” or “very important” by at least 70% of participants who answered the question (22). Ratings were combined from rounds 2 and 3 to determine consensus regarding the importance of research questions which were then advanced into the final round for ranking.
In the fourth round, respondents' top 10 research questions were assigned points to yield a total score per question. The most important question was given a value of 10, the second most important question was given a value of nine, and so on. Questions identified as not being in the respondent's top 10 received a score of zero. Kendall's coefficient of concordance (Kendall's W), a nonparametric statistic, was used to determine agreement among respondents' final 10 research priorities whereby 0 represented no agreement and 1 represented complete agreement (25).
Sixty-seven RKins participated in 10 focus groups. Demographic information for participants in the focus groups is presented in Table 1. One audio recording was lost due to a defective recording device identified after the meeting. A total of 264 research questions were developed and categorized into themes and subthemes by two independent researchers (NW and RA). Themes and subthemes are presented in Table 2. These research questions were reviewed by the research team to remove redundant questions and to provide editorial revision for clarity while maintaining the essence of the original question. The final baseline list was composed of seven unique research questions.
Delphi Survey Rounds
Three rounds of online surveys were administered. Demographic information for each round is presented in Table 1. In the first online round, n = 104 participants completed the survey. Upon completion, 45 of 217 questions achieved an average rating of at least 4 out of 5. In the second online round, n = 102 participants reviewed average ratings and comments from the previous round and rerated questions, reducing the number that achieved a score of 4 or greater to 32 questions. These 32 research questions were then reviewed by the research team, edited, and reworded to improve clarity and to further reduce redundancy resulting in a short list of n = 24 research questions. In the last online round, n = 102 participants reviewed the final 24 questions and selected and rated their 10 most important research questions (Table 3; and see Table, Supplemental Digital Content 1, http://links.lww.com/TJACSM/A15, Round Three Question Scores and Rankings). Kendall's coefficient of concordance indicated moderate consensus was reached for the final 10 most important questions (W = 0.44, P < 0.001).
To our knowledge, this is the first attempt to formalize consensus around research priorities for the profession of kinesiology. Of the 217 potential research questions generated from focus groups, 24 were identified as concordant (i.e., agreed upon by respondents), with 10 identified as the most important areas needing more evidence to help advance the profession.
The research priorities cover a variety of topic areas relevant to expanding the knowledge base of kinesiology services and facilitating the integration of providers into health care settings. In particular, several questions relate to professional existentialism within the health care setting. The qualitative analysis appeared to indicate frustration due to a perceived lack of acknowledgment and opportunity of this new profession within the context of interprofessional health care teams (1,5,19,20,24). Accordingly, research questions that emerged in our study focus on generating further evidence to justify the role and meaningful contributions of RKins to comprehensive health service delivery. For example, the research questions “How do the outcomes of exercise interventions led by kinesiologists compare to those offered by other health service providers, such as personal trainers, physiotherapists, occupational therapists, or physicians?”(rank 2); “How would the kinesiologist optimally function within a family health team that delivers rehabilitation and chronic disease prevention and management services?” (rank 3); and “What communication strategies optimally inform the public about the roles kinesiologists can play in health care that are distinct from other health care providers?” (rank 4) provide a palpable sentiment of the existential curiosity and quandary of the profession. It is worth noting that the identification of these questions as top priorities in the inaugural research agenda for professional kinesiology affirms current anecdotal attitudes in the field.
Questions related to cost savings attributable to the inclusion of RKins in chronic disease management strategies were also identified as a priority for future research. Cost savings questions included “What is the cost effectiveness of providing kinesiologist-delivered service for the management of chronic diseases, such as diabetes, obesity, cancer, arthritis, cardiovascular disease?” (rank 1) and “What is the cost/benefit of Kinesiology services within a multidisciplinary team to treat or prevent chronic disease?” (rank 10). There is indirect evidence to suggest that the inclusion of RKins in the health care system would lead to cost savings because: they provide exercise counseling; physical inactivity is estimated to cost the Canadian health system approximately Can $6.8 billion (10), and physical inactivity is the fourth leading underlying cause of mortality worldwide (17). Such reports demonstrate the potential for cost savings to publically funded health care systems that invest in physical activity and lifestyle counseling that the RKin (and comparable professionals) are ideally suited to deliver. Furthermore, evidence is growing describing cost-effectiveness and utility in the secondary prevention/rehabilitation setting associated with clinical exercise programs, particularly in cardiac care, provides a foundation for further exploration in terms who is most qualified and economically feasible to deliver related care (4,6,13).
Respondents also identified the prospective issue that physicians may not be aware of the RKins' scope of practice, illustrated in the following prioritized research question “What communication strategies optimally inform physicians about the roles kinesiologists can play in health care that are distinct from other health care providers?” (rank 4). This relates to knowledge translation strategies directed toward physicians about the benefits and safety of exercise for clinical populations as well as information on who is qualified to deliver exercise care. Steps toward facilitating better comprehension of exercise professionals' scopes of practice have been initiated by Exercise is Medicine Canada that have attempted to simplify credential interpretation for physicians and patients using two levels to encompass most common exercise credentials where level 1 provides exercise services to healthy and/or medically cleared clients and level 2 can extend such services to those with chronic disease and other clinical conditions. Additional interprofessional education opportunities are warranted to enhance physician familiarity with the evidence about exercise and the clinicians that deliver it in an effort to create rapport between physicians and kinesiologists toward improved collaborative practice (14).
Our study sought to identify research priorities for RKins and in so doing identified issues related to knowledge translation strategies about the scope and value exercise professionals may bring to health care teams and the clients they serve. However, our study also illuminates the need for internal strategies for knowledge translation relative to the professional membership about various areas of practice that have been empirically studied. More specifically, our aim was to identify the perceived research needs of RKins that may include better communication of research that addresses the questions identified by participants. As such, although research initiatives should consider the priorities identified in this study, the profession must reflect on strategies to disseminate evidence intra-professionally in addition to acquiring novel evidence.
There were several strengths of this study. Compared with similar research (18,21,22), participation in each round of the online Delphi survey was well received by potential participants and has demonstrated demographic consistency (just over n = 100 participants per online round). Second, several participants indicated positive experiences related to providing direction to the future of professional kinesiology, such as “very long survey but in general, questions were excellent” and “I feel that the important aspects have all been identified.” Third, our sample was generally representative of the College of Kinesiologist of Ontario members (>60% female, predominantly between the ages of 20 and 40 yr and with a baccalaureate degree as highest level of education). Finally, this was an opportunity for kinesiology academics across universities in Ontario to connect and collaborate with the profession in an effort to expand kinesiology research in ways that are relevant to practitioners. The merging of academia and professional practice for the profession of kinesiology is nascent by virtue of the recent regulation of RKins and opens the door for greater depth in collaboration.
It is also important to recognize several limitations of this study. First, at the time of this survey, there were 1400 RKins. Our samples therefore represent only approximately 7% of the target population per round. It is not mandatory for RKins to be a member of the OKA; therefore, we could not approach all licensed RKins. Although snowball sampling was used as a recruitment technique, being unable to directly contact all RKins may have led to a biased sample. Unfortunately, we were unable to use the College of Kinesiologists mailing list, which would have ensured the invitation to participate was sent to all RKins. However, it is worth noting that our experience is similar to others where participation is from a small subset of the practicing professionals (12,21). Second, the inclusion of original research questions from the focus groups in round 1 was based on interpretation by investigators of the recorded dialogue and could have missed important areas not captured in the n = 217 questions that moved into phase two. The expertise of two independent researchers was used to mitigate this risk, but bias is still possible. Third, it is possible that participants misinterpreted the purpose of the study and rated the importance of the research for their specific practice rather than a generalized need for evidence in the field to guide the profession. This is reflected in questions such as “What are the most effective exercise routines for managing a chronic health condition, such as cancer, cardiovascular disease, diabetes, and paraplegia?” where substantial research is available. This demonstrates a need for greater knowledge dissemination to practicing kinesiologists. Fourth, although the Delphi method is an often-used tool for gathering consensus, this methodology has criticisms. For example, the approach may lead to a diluted version of the best opinion and that the anonymity provided by the approach may lead to a lack of accountability and encourage hasty decisions (16). As well, although there is evidence that clinical care across health care providers has improved due to the identification and investigation of research priorities, there is some evidence that the research does not always reflect these priorities (3). When constructing the methodology of this trial, decisions were made to best apply the process of a modified Delphi study (9). We attempted to maximize the reliability and validity of the approach using guidelines outlined in previous literature (8) and ensuring a transparent and thorough consultative process.
This is the first formal and systematic attempt to establish a research agenda for RKins. We recommend the distribution of this list to academic institution and research funding agencies to help inform future research to advance the profession of kinesiology by targeting specific areas identified by current practitioners in need of further evidence. To ensure relevancy to clinical practice, this study should be repeated routinely, especially in the early years to capture the evolution of research needs for the professional kinesiologist.
The authors thank all participants in the study.
Funding for this research was received from the Ontario Kinesiology Association in the form of a Post-Doctoral Fellowship Award for NW. SL, LS, CL, ST, CS, JS, and DSM are members of the Ontario Kinesiology Association Academic Advisory Committee. DSM and SF are members of the Ontario Kinesiology Association Board of Directors (as of January 1, 2017).
The results of the present study do not constitute endorsement by the American College of Sports Medicine.
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