Key Steps to Implementing Physical Activity into Health Professional Training Programs

Abstract

Physical Activity Promotion in Health Settings Health care providers are uniquely positioned to address the low levels of physical activity (PA) seen across our general population for the primary and secondary preventions of physical and mental health issues (1,2). However, research indicates that most health professionals lack self-efficacy and are inadequately prepared to provide guidance to their patients on becoming more physically active (3,4). This likely stems from the fact that few health professional training programs include any significant, well-defined academic preparation on PA (5–8). Efforts to offer this training are hindered by a lack of guidance on what topics should be covered and how to integrate them into an established curriculum. Providing standardized guidance to health professional training programs is critical to ensure that all health professionals receive a basic level of training on PA. Coming to a Consensus on PA Training — Results from an Expert Panel To address this gap, we engaged in a modified, electronic ("e") Delphi process, bringing together leaders across six clinical health professions (nurse practitioners, occupational therapists, physical therapists, physician assistants, physicians, registered dietitians) with established backgrounds in PA, along with clinical exercise physiologists, to come to a consensus on the key PA categories (broad headings) and topics (specific objectives) that should be covered in all health professional training programs. The findings from our work were first published in February 2020 (9). We were surprised to see that health behavior change clearly emerged as the most important category across our health professional fields. This speaks to a growing realization of the importance for improving evidence-based care and better patient-provider communication to empower patients to take charge of their own health decisions. Training in health behavior change is increasing in many health professional programs through instruction on motivational interviewing and other health behavior models (10–12). However, this training is still limited, tends to focus on other health behaviors, such as smoking cessation and substance use, and there is little evidence that case studies and live patient interactions based on PA topics are used in any programs (13,14). Ranked equally after health behavior change were two categories "clinical exercise physiology" and "PA and public health." The even matching of these categories shows the importance placed on understanding a spectrum of PA benefits from a physiological perspective to population health outcomes. Within the first of these categories, general PA assessment and prescription, and customized prescriptions for special/clinical populations, emerged as the two most important topics. Within PA and public health, understanding current PA recommendations and guidelines and having knowledge of PA programs and interventions arose as the top two topics. These outcomes align with previous calls for broad implementation of PA counseling and referral systems as clinical practice standard of care and highlight the growing recognitions that these practices have the potential to improve PA at the population level (15). Despite the consensus around these categories and topics, recent reports indicate that they are included only sporadically in medical school curricula (16–18), and details regarding the specific PA training of other health care professionals are even less well defined (7,19). With the information from our recent work in hand, now comes the hard part — bridging the "implementation gap" to ensure that these findings are translated into practice, and not left to collect dust on a bookshelf. Our immediate challenge is aligning academic training on the PA categories and topics highlighted in our work with real-world application in clinic settings, namely, assessing patient PA levels, providing patients with a PA prescription and/or brief PA counseling, and referring them to existing PA resources (i.e., programs, places, and professionals). A Vision Forward As health professional training programs reimagine their curricula, the consensus developed through our e-Delphi study can serve as a template for the inclusion of PA into training programs. Indeed, it is our hope that these results will catalyze a long overdue process analogous to the inclusion of nutrition in medical school curricula that began in 1985 (20–22). We concede that adding material to existing academic programs is a highly individualized process with many institutional challenges and limitations. Most notably, altering established curricula is often difficult because of the accreditation requirements of each health profession. However, we believe that these categories and topics can be gently woven into existing modules for all trainees and does not require wholesale reconstruction of each program. We foresee this integration occurring through two distinct processes. First, it is critical that as interprofessional, patient-centered practice becomes the norm, all trainees have a foundational knowledge of PA as a core professional competency. We believe that PA should not be taught in isolation, but that the categories and topics identified in our work be included throughout training programs, even in early curriculum units. When scaffolding units, there are places in modules where information from each of our categories can be logically added. Knowledge-based topics, such as cellular and systemic implications of exercise, can be integrated in existing units that provide didactic knowledge of health and disease, clinical exercise physiology can be incorporated during modules of skills application, while public health topics and health behavior change are suited toward units focused on patient care. This threading of material is key so that practitioners see the value of PA across the continuum of care and that patients receive consistent, integrated recommendations regarding PA, regardless of which practitioner is delivering the counseling. Second, the interpretation and utilization of the PA categories and topics identified in our work likely needs to be modified depending on the scope of practice for each health profession. Some professions are more suited to deliver specific elements of PA counseling with patients at differing points of care. For example, a physician may be the most logical care team member to complete a PA prescription while a nurse or dietitian is better positioned to provide referrals and connect patients to community resources before they leave the clinic setting. Roles may need to be further refined within specific care teams or clinics, depending on the resources available and personnel included. To better understand and define roles, one solution is to complete a job task analysis, or role delineation study (RDS), for all health professions to understand how they can enhance the promotion of PA in a clinic setting. The RDS is widely used in health care to determine the work behaviors necessary for practitioners to safely and effectively perform their role at a specified level of expertise and how to assess those skills (23–27). The RDS utilizes a survey method to verify the major domains of practice, guided by an advisory committee of subject matter experts (23). An RDS defines domains and identifies task statements that can help inform specific skills required of each future practitioner when planning to integrate PA into a specific health professional curriculum. This exercise would then determine where key PA categories and topics could be logically added and how trainees should be assessed. We can no longer overlook the glaring need for enhancing PA promotion as a part of clinical care. While the integration of PA will look different between health professional training programs, it is critical that all health care professionals receive targeted education on PA. This training, modifiable to teach knowledge and skills appropriate for each profession, should be included throughout didactic and clinical education, practiced with standardized patients, and incorporated into standardized testing. This multipronged approach is critical as we enter a new generation of education reform designed to improve the performance of health systems by adapting core professional competencies to optimize patient care.

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