2.1 Design

This consensus statement project used a modified e-Delphi model, combining online surveys distributed via email and focus groups conducted via videoconference to establish an expert consensus. The participants (expert working group) were asked their opinions on what attributes should be included in entry-level professional standards for clinical exercise physiology practice to inform the global standards. The professional standards were made up of 'Professional Standard Domains', which describe the overarching themes in the professional standards, and 'Elements' that list discrete descriptors of attributes in the standard domain. Ethics approval to conduct this project was obtained from Griffith University Human Research Ethics Committee (GU Ref No: 2024/066).

2.2 Steering Committee

A steering committee was established prior to the commencement of this research project to provide oversight of the research. Members of the steering committee (n = 4) had all previously been involved in the development of clinical exercise physiology professional standards in their respective countries, served as members of professional associations whose membership included clinical exercise physiology professionals and had extensive experience teaching clinical exercise physiology professional competencies in university level education programs. Each member of the steering committee was a board director of the International Confederation of Sport and Exercise Science Practice (ICSESP) which is committed to the promotion of international professional standards for sport and exercise science professionals [6].

2.3 Participants

A panel of experts, referred to as the ‘Expert Working Group,’ was recruited for the consensus development process based on content-specific expertise and experience as outlined below and aligned with themes consistent with those established in the literature as ‘expert’ [23, 24]. Recruitment of the expert working group occurred internationally via direct and indirect methods. The direct recruitment process involved members of the ICSESP utilising their networks to identify and invite individuals with recognised knowledge of and experience in the field of clinical exercise physiology. Indirect recruitment involved a process whereby individuals could self-nominate their interest to be in the working group. All direct and indirect working group nominations self-selected for the working group based on meeting the minimum requirement of an ‘expert’ in the field of clinical exercise physiology professional standards. For this project an expert was defined as someone who meet at least one and ideally more than one of the following criteria:

A university qualification and extensive experience in applying the knowledge and skills of clinical exercise physiology practice (greater than 10 years)

Experience in developing or reviewing clinical exercise physiology professional standards

Development of a clinical exercise physiology curriculum across multiple domains of knowledge and skills at the postgraduate university level (or equivalent, i.e. 4-year bachelor degree)

Consistent with recognised features of e-Delphi studies [25, 26], the target expert working group sample size was 15–30, with representation sought from all countries with existing clinical exercise physiology national standards; those countries where clinical exercise physiology national standards were an active aspiration; and all countries where there was an existing clinical exercise physiology workforce. No more than two representatives from any individual country were permitted, except for the USA which was allowed a maximum of three representatives, owing to the variety of professional associations that represent clinical exercise physiology practice.

Expert working group members were provided with a Participant Information Sheet and a Consent to Participate Form at the commencement of the project and responses to all surveys remained anonymous and confidential and only accessible to the steering committee. Each item was put through up to two rounds of voting. The specific stages in the consensus process were as follows: initial voting of previously established standards (1a), identification of additional relevant elements (1b), review of non-consensus items and addition of rationale for decision (2a), voting on additional elements (2b), consensus meeting and final voting on all elements (3), final steering committee deliberations and an external stakeholder review. A consensus threshold was defined a priori as 80% of expert working group members voting for the importance of any individual item above a 7 on a 9-point Likert scale, in accordance with previously published approaches in this field [27, 28]. In addition to the Likert rating, expert working group members were asked to also consider if they viewed an element as ‘core’ or should still be included, but as ‘non-core.’ This allowed them to consider an element to be important for practice as a clinical exercise physiologist but not necessarily essential in the global context for any reason. For this purpose, ‘core’ was defined as ‘cornerstone or an essential part of the professional standard domain of professional practice in all countries and regions’ and ‘non-core’ was defined as ‘an important but not cornerstone or an essential part of the professional standard domain of professional practice in all countries and regions.’ Elements that reached consensus were not voted on in subsequent rounds. One author (NR) thematically coded the survey free text responses in rounds 1b and 2a. All online surveys were conducted using Microsoft Forms with access links sent to the expert working group members via email. Meetings of the expert working group were completed online using the Microsoft Teams videoconference platform.

2.4 Round 1a Survey: Initial Ranking of Elements from Audit

Prior to opening the round 1a survey, expert working group members were asked to review the list of standards identified in an audit of existing clinical exercise physiology standards internationally [7]. The expert working group members were emailed links to four online surveys, one for each of the professional standard domains identified in the audit findings (Professional Practice, Foundational Knowledge, Assessment & Client Management and Design & Delivery of Exercise-Based Interventions). Expert working group members were asked to independently review the elements within the standard domain and rank them on a 9-point Likert scale (see Fig. 1), indicating their level of agreement that the element should be part of the international professional standards.

Fig. 1

Nine-point Likert scale to rate agreement on the element being included as part of the standard domain

In Part 2 of the same survey, expert working group members were asked to rate each of the elements as core, non-core, or unsure (Fig. 2).

Fig. 2

Rating of element as core, non-core or unsure

A ranking of ‘core’ was reflective of the expert working group members indicating that the element should be part of the international professional standards, ‘non-core’ was reflective of the expert working group members indicating that the element should not be part of the international professional standards, and an ‘unsure’ ranking was reflective of the expert working group members indicating that it was unclear to them if the element should be part of the international professional standards.

2.5 Round 1b Survey: Identification of Additional Elements

In round 1b, expert working group members were provided with the list of elements identified in the audit in each of the professional standard domains and asked to consider if there were any elements not yet included that should be. Expert working group members were encouraged not to identify any regionally specific elements (i.e. those elements that would only be relevant at a local level), but rather elements that would have global relevance. A single online survey was used to share the list of existing elements and for collecting expert working group member responses. The survey responses collected were thematically clustered and a draft element was agreed by the steering committee in preparation for round 2b.

2.6 Round 2a Survey: Ranking Rationale

In round 2a, expert working group members were provided with the list of elements from round 1a that did not reach consensus for being part of the international professional standards and/or for not being identified as core. Expert working group members were asked to describe why they rated the element on the 9-point Likert scale the way they did, and/or why they rated the element as core, non-core, or unsure. A single online survey was used to share the list of elements for collecting expert working group member responses.

2.7 Round 2b Survey: Ranking of Additional Elements

In round 2b, expert working group members were provided with the list of new elements identified in round 1b and asked to rank them on a 9-point Likert scale indicating their level of agreement that the element should be part of the international professional standards, and if it should be core, non-core or unsure. To assist the expert working group members in ranking the element they were provided with a list of elements across the four professional standard domains that were considered in the round 1a survey. As occurred in the round 1a survey, responses to each of the elements were summed to determine the level of consensus for each element in relation to agreement that the element should be part of the international professional standards, and if so, should it be core or non-core. Consensus was set as ≥ 80% of agree (scores of 7–9) and core (scores of core and unsure).

2.8 Round 3 Survey: Consensus Meeting and Re-voting of All Items

In round 3, expert working group members attended an online focus group to discuss the elements that had not met the consensus threshold to be part of the international professional standards and/or core in round 1b and 2b. Group discussion was followed by expert working group members using an online survey to indicate their agreement on a 9-point Likert scale that the element should be part of the international professional standards, and if it should be core or non-core. In addition, during the discussion groups the expert working group members were asked to declare if they wanted to revise the wording of any of the elements (including those elements that had achieved consensus and those that had not). Prior to the focus group, expert working group members were provided with the round 2a survey responses to aid their preparation. Three discussion groups were scheduled over a 24-h period, 6 h apart to ensure expert working group members in various time zones could attend. Expert working group members were invited to attend one of the focus groups.

2.9 Steering Committee Recommendations

The steering committee reviewed the consensus outcomes captured in the round 1a and 3 surveys for each of the original and additional elements. The steering committee was also presented with expert working group member feedback on alternative wording for the elements. Using open discussion and collective decision-making, the steering committee subsequently agreed upon the first draft of the international clinical exercise physiology professional standards. At this stage, the steering committee discussed the precise wording of each element and whether elements receiving < 80% expert working group consensus for being included should still be included, given their importance to international practice as a professional clinical exercise physiologist, and no further decisions were required.

2.9.1 External Stakeholder Feedback

External stakeholder feedback was sought on the draft international clinical exercise physiology professional standards over a 6-week period. Recruitment of external stakeholders was both targeted (i.e. direct invitations to people with similar experience to the working group) and broad (i.e. email invitations sent to founding partners of the ICSESP to disseminate to their membership). Background on the work completed (including preface, project governance, project contributors, and references) and the draft professional standards was made available via the ICSESP website. A link to an online Microsoft Forms survey was provided on the website for feedback to be provided. Steering committee members forwarded website links to individuals as part of the targeted recruitment.

Comments from external stakeholders were analysed using an inductive framework approach to identify naturally emerging themes. The initial themes were identified by N.R. and K.L. and then reviewed and agreed upon by the other co-authors, after which the remaining comments were systematically coded [29]. This summary was presented to the steering committee for review. Using open discussion and collective decision-making, the committee decided if the feedback warranted a modification of the draft professional standards. A revised version of the draft professional standards was developed.

The expert working group were emailed a copy of the updated draft of the international clinical exercise physiology professional standards and asked to provide feedback. A total of seven email responses were received from the expert working group which were summarised and presented to the steering committee for review. Using open discussion and collective decision-making, the steering committee decided if the feedback warranted a modification to the draft professional standards. A final version of the draft professional standards was developed.