Research Design

This study used a mixed-methods, multiphase approach involving surveys and focus groups to establish a set of core clinical learning competencies (10). Figure 1 illustrates the phases used in this study. The study was approved by the University of Sydney Human Research Ethics Committee (Protocol No. 14555).

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Participants

Across all phases of this study, participants were recruited from the following groups:

• AEPs, and/or

• university academic staff members with a teaching role related to clinical exercise practice, and/or

• university clinical/practicum coordinators who were responsible for clinical education of EP students undertaking practicum in environments related to clinical exercise practice.

Recruitment methods included an item in the electronic newsletter of the professional association, ESSA, and an e-mail to the department heads of all universities in Australia that offered a relevant degree. The e-mail requested distribution of the study information to potential participants who met the above criteria.

Framework for Competencies

There is no agreed framework for describing competencies (11). For this project, we used the integrated approach proposed originally by the Australian National Office of Overseas Skills Recognition and as outlined by Gonczi et al. (12). This integrated approach to describing competencies has been used or adapted by other allied health professions in Australia, including speech pathology, podiatry, physiotherapy (i.e., physical therapy in the United States), and dietetics (13).

The integrated approach “views competence in terms of knowledge, abilities, skills, and attitudes displayed in the context of a carefully chosen set of realistic professional tasks which are of an appropriate level of generality” (14, p. 405). The knowledge, abilities, skills, and attitudes are collectively referred to by Gonczi and Hager (14) as attributes required for competent performance. Furthermore, “the integrated view of competence is holistic in that it situates attributes in the kinds of contexts in which they are employed in the practice of the occupation” (14, p. 405). The integrated approach allows for flexibility in the competencies in that they can be applied to a broad range of workplace situations without favoring one situation over another (15). This approach is therefore well suited to any future use of the competencies for assessment purposes in that one set of competencies can be used in a range of clinical placement settings.

The competencies are articulated across several levels (the reader is referred to [16] for an overview of the definitions of these levels). Briefly, the first level, the unit of competency, describes major professional tasks or activities that describe practice. Underneath each unit lies a set of elements that more specifically describes what a person must be able to do to successfully undertake these tasks or activities. Underlying each element are performance criteria that describe the observable behaviors from which it can be inferred that a person has achieved entry-level competency in each element (16). Underneath the performance criteria is a range of variables, statements, and evidence guides, although these are considered optional when describing competency standards (12).

Methodological Approach

Phase 2

An electronic survey hosted by SurveyMonkey, Inc. (Palo Alto, California) was used to determine the attributes considered essential for an entry-level EP graduate at the beginning of his or her professional career who is client-centered and able to practice safely and effectively. Ninety-one participants responded to the survey (see Appendix S2 for participant details of entire sample). Because indirect and third-party recruitment methods were used, a return rate cannot be established. Participants were most often aged 21–29 years (45%; followed by 30–39 years, 34%) and were most often currently AEPs operating mainly in a clinical role (37.4%; followed by university academics, 23.1%). Seventy-two participants identified as an AEP with experience (either presently or in the past) in clinical exercise practice (median: 5 years; range: 1–30 years). Forty-four participants indicated having experience as a university academic (median: 5 years; range: 1–30 years). Twenty-one participants indicated having experience as a practicum coordinator (median: 3 years; range: 1–18 years). Seventy percent of participants had supervised students undertaking placements in the area of clinical EP, with a median of 5 years of experience.

Participants were provided with the list of attributes from Phase 1 and asked to indicate for each whether they considered it critical; not critical, but still important; or not critical and not important with regard to an entry-level EP graduate at the beginning of his or her professional career who is client-centered and able to practice safely and effectively. Attributes that at least 40% of participants classified as critical were taken through to Phase 3. A conservative agreement threshold was selected (40%) to avoid loss of attributes that might later be considered critical by participants.

Phase 2

Forty-five attributes from the original list of 49 were considered critical for an entry-level EP graduate by at least 40% of participants. The 4 items eliminated were as follows:

1. Applies contemporary forms of information management to relevant areas of practice.

2. Demonstrates a level of skill in the use of information technology appropriate to their practice.

3. Participates in quality improvement processes.

4. Facilitates an individual's access to appropriate health and community services.

Phase 3

The first draft of competencies (Appendix S3) developed by the project team based on the output of Phase 2 included 6 units of competency with 19 underlying elements. The 6 units of competency were (i) communication, (ii) operating in a professional environment, (iii) professional behavior, (iv) assessment and interpretation, (v) planning and delivery of an intervention, and (vi) client-centered practice.

Phase 4

Competency units were modified and reorganized after feedback by the participants in the first 2 focus groups questioned the linkage of the elements to the respective competency units proposed in Phase 3. First, participants were concerned by the generic nature of the competencies, as demonstrated by the following quotes:

“I wonder how far do you have to read between these competencies before it was clear that it was about EPs rather than about any health professional” (participant 1 from Focus Group 1).

“. . . it sort of just read like anyone, any allied health professional” (participant 2 from Focus Group 2, made in reference to the original planning and delivery unit).

Second, the lack of emphasis on clinical reasoning and insufficient detail around risk management were also noted:

“Clinical reasoning is implicit in selecting assessments and delivering an intervention, but doesn't come through in the document” (participant 2 from Focus Group 1).

“patient safety. . . did not come across strongly enough. . . needs to jump out more” (participant 1 from Focus Group 2).

The changes made to the Phase 3 draft included a reorganization of elements into a different set of competency units. The revised draft included 6 units. Four of these, assessment and interpretation, design and delivery of exercise programs, lifestyle modification, and risk management, were considered by participants to be essential areas of practice that needed to be highlighted to make the competencies more clearly and uniquely relevant to EP. The 2 units from the Phase 3 draft, operating in a professional environment and professional behavior, were consolidated into 1 unit on professionalism; the unit on client-centered practice was removed, and the concept of client-centeredness threaded throughout the other competency units, for example, in elements 1 and 2 of Unit 4 (see Figure 2). A similar approach was preferred by the participants for evidence-based practice; that is, rather than having evidence-based practice as a separate competency unit or element, it was threaded throughout. Although participants considered that there was a lack of emphasis on clinical reasoning in the Phase 3 draft, the preferred way of handling this attribute was to thread elements of clinical reasoning explicitly into the risk management unit and implicitly into other units.

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Thereafter, changes made in response to participant feedback included the addition of 2 new elements, eliminating redundancies, rewording to increase the emphasis on a client-centered approach, and changes to the performance criteria (additions, deletions, editing). Figure 2 shows the final set of competencies, described as 19 elements organized into 6 units of competency.

Phase 5

The majority of participants considered each unit of competency as being important to practicing successfully as an entry-level practitioner (Table 1). Furthermore, the majority of participants considered each element underpinning a unit of competency to be important to that unit of competency (Table 2).

TABLE 1. Percentage of participants who considered each unit of competency as unimportant or important to practice successfully as an entry-level exercise physiologist.

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TABLE 2. Percentage of participants who considered each element as unimportant or important.

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The majority of the subgroup who identified as new to the profession considered themselves competent in each unit of competency (Table 3). Furthermore, the majority of this subgroup believed they demonstrated all elements underpinning each competency unit to a standard that would at least be consistent with an entry-level practitioner (Table 4).

TABLE 3. Percentage of new accredited exercise physiologists' beliefs of their competence with each competency unit.

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TABLE 4. Percentage of new accredited exercise physiologists who believe they do or do not demonstrate each element at a level consistent with an entry-level exercise physiologist.

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Limitations of the Study

In the process of refining the competencies, we sought input from AEPs, academics, and practicum coordinators in both metropolitan and regional locations across two Australian states. We acknowledge, though, that the final set of competencies may be influenced by areas of practice that are unique to these locations and may not fully capture the unique areas of practice in other states of Australia. Additionally, it is possible that the competencies may have been influenced by the setting in which participants worked and the types of clients with whom those in a clinical role had experience; however, we cannot determine this influence with the data collected in this study. It is also possible that the views of those who played the biggest role in refining the competencies (focus group participants and individual consultations in Phase 4) may not be consistent with all AEPs, academics, and practicum coordinators; however, the widespread view in the final survey of the importance of all competency units and elements suggests this may not have been the case.