To our knowledge, this is the first study to assess both PA and SB counselling among RDs. Guided by TPB, this study explored FHT RDs’ behaviour, behavioural intention, attitude, subjective norm, and perceived behavioural control (facilitators and barriers) related to PA and SB counselling. A main finding was that all participants counselled patients on PA, which is similar to results from previous quantitative research [17, 20, 25]. All participants in the current study used some strategies in motivational interviewing. Motivational interviewing is a multi-faceted, patient-centered, and goal-oriented form of counselling focused on increasing intrinsic motivation among patients and creating sustainable behaviour change [39,40,41]. This approach includes working with patients to assess their readiness to change, resolve their uncertainties, and ultimately allow ideas for change to come from the patient and not the counselor [39,40,41]. Patient-centered counselling is defined as providing optimal care for patients that is based on patients’ personal values, needs, and preferences and stresses the importance of involving patients in all decision-making processes regarding their care [42]. Regarding counselling strategies, George et al. [20] found that 30% of RDs assessed patient readiness when counselling patients on PA, a theme that was more prevalent in the current study (nearly half of participants addressed readiness). Furthermore, though other studies regarding RDs did not specifically discuss the prevalence of motivational interviewing for PA counselling, researchers found that the majority of RDs had training in motivational interviewing [20, 25]. Previous literature indicates that motivational interviewing can be effective when used in PA counselling or other health behaviour counselling [43,44,45,46], including dietary counselling by RDs [47]. Based on the main themes identified in the current study, one could posit that participants utilized a counselling style that is similar to the 5A framework (ask, advise, assess, assist, and arrange) [48] for PA counselling even though they did not use that term. To illustrate, each construct in this framework with possible corresponding themes from the present study is as follows: ask (establish a PA baseline), advise (general PA education), assess (assess readiness to change), assist (goal setting; guide patients to resources), and arrange (refer to other HCPs). This framework is widely used in counselling for other health behaviours, such as smoking cessation [49] and weight-loss counselling [50]. The amount of time that current participants spent counselling individual patients on PA was not discussed, but PA counselling should involve multiple sessions for sustained behaviour change. A systematic review of the effectiveness of PA counselling in primary care, specifically patient counselling by family physicians or teams, indicated that a single session focusing on a discussion of the patient’s motivation may increase PA 1 year later but follow-up counselling may sustain this PA level after 1 year [43].
More studies are needed to further understand SB counselling and prevalence. Most participants reported counselling patients on SB. In contrast, a previous study that assessed SB counselling among physicians found that, based on patients’ reports, 10% of patients were counselled by their physician to reduce sitting time [26]. The present study was the first to our knowledge to address RDs’ intention regarding their PA and SB counselling and therefore more research in this area is also needed.
More research is needed to further examine RDs’ attitude toward PA and SB counselling. While some participants had a positive attitude about the effectiveness of RD counselling on PA and SB (i.e., feeling that RD counselling in these areas is effective in increasing patients’ PA and decreasing their SB), their belief about effectiveness was contingent on a number of factors such as time frame for behaviour change. Consistent with the current findings, a systematic review found that primary care providers (including nurses, nurse practitioners, physicians, and physicians’ assistants) were unsure of the effectiveness of their PA counselling [51]. Focus group findings in the Spidel et al. [19] study indicated strong support from RDs for incorporating PA counselling into RDs’ daily practices, but RDs’ views on the effectiveness of their counselling were not discussed. To determine the effectiveness of PA and SB counselling, intervention research involving rigorous research designs are needed.
Results from the literature are mixed regarding injunctive normative beliefs among HCPs and HCPs in training. RDs in past studies agreed that PA counselling or promoting active living is part of their role as an RD [19, 20, 25], which is consistent with the current results. Participants in the current study felt that all HCPs, including RDs, should counsel patients on PA and SB. Similar to Spidel et al.’s [19] findings, participants in the present study felt that they should provide general counselling about PA only and that exercise prescription is outside their scope of practice. However, whereas many current participants felt that other HCPs expect them to counsel on PA, a study of primary care residents found that residents rated obesity, nutrition and PA counselling norms (including what was expected of them and the importance that their peers and profession placed on obesity, nutrition and PA counselling) as low [52]. Some current participants believed that other HCPs did not expect them to provide PA and SB counselling, which is similar to Spidel et al.’s [19] finding that RDs had concerns about how other HCPs (as well as the public) would perceive their counselling in this area.
Regarding descriptive normative beliefs, greater communication among HCPs is warranted. Although many participants had not asked other RDs about their practices, most believed that other RDs were counselling on PA, and many felt the same was true for SB. Past studies have not addressed communication among RDs regarding PA and SB counselling, though previous research suggested a need for increased communication and collaboration between RDs and PA specialists [19]. A study of the promotion of healthy eating among exercise specialists suggested that there was a need for increased collaboration between RDs and exercise specialists so that RDs could support exercise specialists in their role as healthy eating promoters as well [53].
Participants were divided in their opinion of what is expected of them by other HCPs. In order to improve support between HCPs, particularly in team-based settings, specific improvements in communication may be required. If RDs know what is expected of them pertaining to PA and SB counselling and also know what other RDs’ counselling practices are in these areas, they could feel more supported in their role regarding PA and SB counselling. This is important considering that previous research among primary HCPs revealed that subjective norm can have a meaningful influence on behavioural intention, and subsequently, behaviour [54]. Also, greater communication could elicit conversations regarding division of responsibility in terms of PA and SB counselling among RDs and other HCPs in FHTs.
Findings from the literature are mixed regarding HCPs’ perceived behavioural control. Perceived behavioural control is often considered comparable to self-efficacy [36]. Whereas almost all participants in the present study were confident in basic PA counselling only, a previous study found that self-efficacy related to PA counselling is relatively low among RDs [19] and a recent review found this to be true for other HCPs as well [54]. To our knowledge, there has been no previous research regarding HCPs’ self-efficacy related to SB counselling. The current research was the first of its kind to study RDs in FHTs and therefore participants identified facilitators that were likely unique to the FHT and articulated how the FHT setting (a collaborative team of HCPs with increased access to patients and patients’ health information) made it easier to provide PA counselling. Time was discussed as a facilitator to counselling in the present study but identified as a barrier in previous studies [19, 20]. Most participants in the present study stated that they had ample time with patients during appointments to cover PA counselling. The discrepancy in these findings could be attributed to the different practice settings for participants in the present study compared with past studies. In the studies that found time to be a barrier, RDs were working in a variety of practice settings [19] or in mostly clinical settings [20]. Perhaps RDs working in clinical settings have less time to counsel patients on PA, as it is likely that managing acute nutrition-related issues takes precedence.
Past studies addressing RDs’ PA counselling found that the main barriers to counselling included lack of protocol surrounding RDs’ PA counselling [20], time constraints [19, 20], concerns about public or other HCPs’ perceptions of RDs counselling on PA [19], and lack of knowledge or training in PA counselling [19, 25]. Also, to our knowledge, there are no previous studies addressing facilitators and barriers that influence HCPs’ SB counselling. Though participants in the present study did not mention the term “lack of protocol” when discussing barriers to PA counselling, RDs’ scope of practice was identified as a barrier. Some participants in the current study felt that PA assessment and exercise demonstration are outside their scope of practice. While RDs in a previous study reported PA monitoring to be outside their scope of practice or role [19], this was not mentioned by participants in the present study.
In particular, many current participants felt that exercise prescription is outside their scope of practice. This aligns with a recognised PA resource, specifically developed for RDs by both nutrition and exercise professionals. The resource suggests that RDs can provide general PA guidance (e.g., counsel about the PA recommendations; discuss goal setting related to PA), based on national PA guidelines, to patients but RDs require fitness certification to assess fitness and prescribe exercise [55]. In previous studies, it was found that out of the four domains of exercise prescription (frequency, intensity, duration, and type), RDs addressed frequency most often and intensity least often [20, 25]. Though the interview guide did not address these domains specifically, the current participants discussed that they were less comfortable counselling patients about higher intensity exercises, but they counselled patients using the PA guidelines, which includes intensity (i.e., 150 min of MVPA per week in at least 10-min bouts). George et al. [20] found that RDs felt that lack of protocol for PA counselling negatively affected their counselling. If RDs were to have a clear protocol to follow when counselling patients on PA, they may feel more confident that they are counselling patients within their scope of practice. Increased HCP self-efficacy has been found to have a positive influence on the level of PA counselling among RDs [54], and the same may be true for SB counselling. In terms of SB counselling and RDs’ scope of practice, though participants in the present study felt that most aspects of SB counselling fit within their scope of practice, there is no previous research in this area to compare these findings to.
The organisation of HCP roles in Canada influenced these RDs’ perceptions of PA and SB counselling. RDs in Canada are regulated by provincial legislation, while standards for education/training programs are national [56, 57]. Currently, the national competency standards do not include specific standards/competencies regarding PA and SB and counselling in these areas. Instead, they are quite general in terms of encouraging overall health, which would encompass basic PA counselling. In Ontario, the College of Dietitians of Ontario regulates practice through Controlled Acts and each health profession is under a different College [58]. Neither diet nor PA counselling fall under any of the Controlled Acts, so any HCP can counsel in these areas. If PA and SB interventions are considered to require specific skills, then further development of education and regulations within different health care systems to define scope of practice for different HCP groups will be needed.
Providing more education about PA and SB counselling to HCPs is warranted. Past studies consistently cited knowledge as a barrier to PA counselling among RDs [19, 25] and other HCPs [54]. In a study of PA counselling among RDs [20], knowledge was not explicitly stated as a barrier but nonetheless only a third of interviewed RDs received PA or PA counselling education in the last 5 years. Similarly, in the present study, participants discussed lack of PA and SB knowledge as an obstacle to counselling in these areas. Conversely, in a recent review, knowledge and training were facilitators to PA counselling among some HCPs [54]. Some participants in the current study intended to pursue further education in PA, SB, and counselling in these areas. There is some related past research regarding RDs’ perceived needs to facilitate further PA counselling. In a UK-based, survey study, McKenna et al. [25] found that almost all RDs wanted further education in PA and counselling in this area, preferably in the form of a day course. Similarly, in a focus-group-based study conducted in Alberta, Canada, Spidel et al. [19] found that RDs wanted more education about exercise physiology, PA assessment, and ways to monitor PA.
There are strengths and limitations of the present study. A qualitative approach was appropriately used to obtain a deeper understanding of the unexplored research topic regarding FHT RDs’ beliefs and behaviours related to counselling patients on PA and SB. There may have been selection bias in that RDs who are interested in PA and SB may have been more likely to volunteer to participate in the study. Also, the sample size was small (20 participants), though samples in qualitative research are often small. Nonetheless, theoretical saturation was reached during thematic analysis and some common themes were identified. Multiple authors identified themes from the audio-recorded and transcribed interviews to yield accurate results. However, the findings cannot be generalized to all RDs working in team-based primary care throughout Ontario. This exploratory study can provide direction for a subsequent qualitative study of FHT RDs sampled from across Ontario.
The issue of whether the research purpose was examined sufficiently by using TPB also warrants mention. TPB is a widely used theory that examines attitude, subjective norm, and perceived behavioral control, as key determinants of behavioural intention and ultimately behaviour. In addition to these three types of beliefs, other factors were examined in that subjective norm addressed the interpersonal component and perceived behavioural control addressed some environmental factors that made it easy or difficult to counsel patients on PA and SB. Also, utilizing theory when analyzing the qualitative data might initially appear as a limitation based on the premise that themes were not identified inductively. However, an inductive approach was actually used in that TPB informed which topics were addressed in the semi-structured interview guide (specifically, theoretical constructs that were of interest) and then, within that structure, themes for each TPB construct were identified inductively.
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