Review ArticleNarrative Review

Underrepresentation of Respiratory Therapists as Experts in Delphi Studies on Respiratory Practices and Research Priorities

Shirley Quach, Alanna Veitch, Marco Zaccagnini, Andrew West and Mika L Nonoyama
Respiratory Care December 2022, 67 (12) 1609-1632; DOI: https://doi.org/10.4187/respcare.10012

Abstract

Delphi survey techniques are a common consensus method used to collect feedback from an expert panel to inform practices, establish guidelines, and identify research priorities. Collecting respiratory therapists’ (RT) expertise and experiences as part of consensus-building methodologies is one way to ensure that they align with RT practices and to better influence respiratory care practice. This narrative review aimed to report the RT representation in expert panels of Delphi studies focused on respiratory therapy practices and research priorities. The research question that guided this review is: to what extent are RTs included as expert participants among published Delphi studies relate to respiratory therapy and research topics? We conducted a structured search of the literature and identified 23 papers that reported Delphi studies related to respiratory care practices and 15 that reported on respiratory-related research priorities. Delphi studies that focused on reporting consensus on respiratory care practices included the following: (1) mechanical ventilation, (2) high-flow nasal cannula therapy, (3) COVID-19 respiratory management, (4) home oxygen therapy, (5) cardiopulmonary monitoring, and (6) disease-specific guidelines. Delphi studies that focused on establishing respiratory research priorities included the following: (1) theory and practice-orientated knowledge gaps, and (2) priority research topics for empirical investigation. The results of this review suggest that RTs were rarely included as expert participants and, when involved, were minimally represented (5% to 33%). Given RTs’ diverse and relevant experience in respiratory care, incorporating their perspectives to inform future education, respiratory care practices, and research priorities would allow evidence to better align with knowledge gaps deemed important for the respiratory therapy profession.

Introduction

Respiratory therapists (RT) are specialized health-care professionals who possess expertise in cardiorespiratory health.1-3 RTs’ clinical decisions should be evidence based and incorporate clinical experience, best available evidence, and patients’ experiences to ensure high-quality care.4-6 RTs must be informed of and remain engaged in emerging research that could impact and influence their practice.4 However, a notable amount of empirical research that guides evidence-informed respiratory care is conducted without including the perspectives of RTs.3,7-20 The knowledge and expertise that RTs possess should determine how respiratory care is practiced and influence how research is conducted, especially when the evidence generated from the empirical research directly relates to and changes how RTs deliver care to patients.21,22

Empirical research on respiratory care, conducted by other health disciplines might not reflect the specific knowledge gaps and practice limitations within the respiratory therapy profession.21,22 Furthermore, some authors identified distinct practice- and theory-oriented knowledge gaps that are unique to the respiratory therapy profession.23,24 They suggested that a professional and political imperative exists to produce empirical evidence that indicates how RTs contribute to better patient care and influence decisions made by health-care organizations, governments, and funding bodies.21,23-25 Collecting RTs’ expertise and experiences as part of consensus-building methodologies is one method to optimize the results of empirical research so that they align with RT practice and better influence respiratory care.24,25

Consensus methods are widely used in medical research as a structured approach to synthesize expert opinions on topics that have little empirical evidence to inform clinical decisions.26,27 The results garnered from consensus methods support a collective understanding of what is important for future work and allow members of a profession to emphasize the known gaps and set research priorities.28-30 Identifying priorities helps stakeholders (eg, funding bodies, health-care organizations) decide how to prioritize their investments (eg, effort, monetary) into research and practice.26,27,29 Many variations of consensus methodology exist; the 2 predominant types are the Delphi technique and the nominal group technique. The purpose of this paper is to provide a narrative review of Delphi consensus studies that developed respiratory practices and research priorities. The research question that guided this review was: to what extent are RTs included as expert participants among published Delphi studies related to respiratory therapy and research topics?

Methods

The Delphi Survey Technique

The Delphi consensus technique is the focus of this paper because it is the most common method with the intended purpose of generating ideas and establishing consensus on topics with scarce information.29,31-34 This technique has been applied across different health science topics with a variety of health professionals, including nurses, occupational therapists, physiotherapists, physicians, and basic science researchers12,17-20,35-41 Delphi studies have been used to establish consensus in respiratory care practice and research priorities in other healthcare professionals. Some examples include identifying, understanding, and establishing respiratory-related research agendas, guidelines, and priorities in specialty practices; predicting disease patterns; directing health education; and standardizing practices and policies.30,34,42,43

Participants included in the Delphi technique are considered experts, specific individuals with the relevant knowledge, experience, and skills related to the topic under investigation.44–46 Because a definitive definition of an expert does not exist, researchers must explicitly outline the criteria of their ideal experts,30,42,47,48 because less credible participants may provide feedback that will jeopardize the quality of results.30,49 Specific expert criteria may include scientific credibility, work experience, and theoretical and/or experiential knowledge in the field of study.46,48

Overall Delphi Technique Process

Delphi survey techniques have been used for several purposes: (1) to investigate and understand common practices and treatments, (2) to identify gaps in knowledge, and (3) to identify research priorities. Many organizations have also used the Delphi technique to create and publish guidelines and recommendations for specific practice areas.7,19,20,49 The basic methodology of the Delphi technique involves the expert panel providing anonymized responses on a specific topic, through multiple items on a survey, through multiple rounds. After each round, results are analyzed to update and finalize survey content for the subsequent rounds. Usually, there are 2 to 4 rounds, and a pre-established definition of consensus helps determine when the Delphi study may be terminated. The overall process of the modified and classical Delphi techniques are illustrated in Figure 1.

Fig. 1.
Fig. 1.

Generic process of the Delphi study technique; the modified and classical Delphi technique differ in their round 1, but subsequent rounds are similar. Data from References 28 and 30.

Round 1 focuses on identifying survey items for subsequent rounds.31,49 The classical Delphi technique (sometimes called e-Delphi if hosted online) uses open-ended survey questions to gather unstructured feedback and opinions in its round 1 to generate survey items that inform subsequent rounds.28,30 In comparison, round 1 in the modified Delphi technique might use the results of literature reviews, focus groups, or one-on-one interviews to develop survey items for the subsequent rounds.30,44 Researchers must choose the technique that is the most suitable to answer their research question because both versions of the Delphi technique have their advantages and disadvantages.28,32,50 For example, advantages of the classical Delphi allow for anonymity among participants in round 1, which encourages creative and balanced considerations of ideas from expert participants while being resourcefully conserving.28,31,51

A disadvantage of this would be the limited opportunity for discussions and debates among expert panelists that may be essential for clarifying survey content. In contrast, in the modified Delphi, round 1 provides an opportunity for experts to deliberate and formulate unique ideas with each other through focus groups.51 However, the format of the modified Delphi technique may allow for certain dominating participants to lead and influence the conversations and opinions of the overall group.28 Regardless of which version is used, the open feedback must be reviewed, analyzed, and summarized by the research team by using various methodology (eg, thematic analysis) and data analysis software (eg, NVivo [QSR International, Doncaster, Australia], Dedoose [SocioCultural Research Consultants, Los Angeles, California]).30,42,51

In round 2 and subsequent rounds, participants are asked to provide ranked feedback on survey items by using a Likert scale.28,42,46 Subsequent rounds are terminated once the pre-determined level of consensus is reached for all items on the survey.44,48 Consensus thresholds vary from 50% to 100%, with 70% to 75% consensus as the most common.30,44 The number of rounds will depend on the research objectives and the level of consensus; however, conducting 2 to 3 rounds is usually sufficient.28,30,31,44 Before deciding if the Delphi survey technique is the best approach for certain research objectives, researchers should consider their strengths48,49 and limitations.28,34,52 If the relevant participants are geographically dispersed with limited time and resources, data collection is still possible because participants can provide their feedback asynchronously and remotely.30,53 However, the drawback of not holding synchronous meetings may limit the exchange or evolution of ideas and opinions among the panelists.30,53 When the Delphi technique is deemed appropriate, a research team with a combination of strong communication, organization, problem-solving, and leadership skills will enhance the study’s success.30,31,53

This paper provides a generic overview of the classical and modified Delphi techniques because they are often used in health sciences research. In addition to the Delphi technique, there are other similar alternative consensus methods that may be used, including the nominal group technique, the RAND/UCLA Appropriateness Method, or traditional consensus conferences.29,30 There are many variations of the Delphi technique and alternative options are reported in the literature (eg, policy Delphi technique, real-time Delphi technique); however, an extensive explanation of these variations is beyond the scope of this paper. Researchers interested in using this method are strongly advised to learn the details of its methodology, processes, and assessments of methodological rigor.30,52 There are several resources available to become familiar with this method and its successful use.28,30,31

Citation Selection

To determine the extent in which RTs were included as expert participants among published Delphi studies, we conducted a literature review to identify Delphi studies on the topics of (1) respiratory clinical practices and (2) respiratory-related research priorities. We conducted a search of the literature simultaneously on both topics with the assistance of a health science librarian. For Delphi studies that describe respiratory practices, we used terms that included “respiratory care” or “respiratory therapy” and “Delphi study/technique” MeSH (medical subject headings) controlled vocabulary and key terms to search CINAHL, Embase, and PubMed from inception to June 2020, with an updated search to September 2021 without a date limit. To be included, articles must have used the Delphi technique (or a similar alternative, ie, the RAND/UCLA Appropriateness Method, nominal group technique) to formulate a consensus on the respiratory practices of their respective topics of choice, published in either English or French.

For Delphi studies that describe research priorities of respiratory interventions and/or practices, “respiratory therapy,” “research,” “health priorities,” “Delphi study/technique” MeSH and key terms were used to search Embase and MEDLINE from inception to March 2021 without a date limit. To be included for this review, articles must have used the Delphi technique (or a similar alternative, ie, the RAND/UCLA Appropriateness Method, nominal group technique) to establish the reported research priorities in their respective respiratory care topics, published in either English or French. Both searches were repeated in the databases from the last searched date to May 2022, and no new articles were identified for this review. See Supplementary Material File 1 (see the supplementary materials at http://www.rcjournal.com) for search strategies. All the articles were uploaded, de-duplicated, and screened by using Clarivate Endnote X9.1 (Philadelphia, Pennsylvania) Reference Manager. Only one reviewer screen articles for inclusion for each topic (SQ, respiratory practices; AV, research priorities) and a second person (MLN) provided second opinions on the articles that the primary reviewers were uncertain whether to include. After both literature searches, we reviewed the studies’ findings, extracted information relevant to the research questions, and provided a scholarly summary of the body of knowledge along with interpretation and critique.50

Results

The search for Delphi studies that describe respiratory practices yielded 933 articles (Embase, 389; PubMed, 346; CINAHL, 198). After eliminating 239 duplicates, 694 articles were screened for inclusion. A total of 23 studies were included for full review. The search for Delphi studies that describe research priorities of respiratory interventions and/or practices yielded 375 articles (Embase, 210; MEDLINE, 138; CINAHL, 27). After eliminating 23 duplicates, 352 articles were screened for inclusion and 8 studies were included for full review. The reference lists of those 8 studies were also searched; an additional 11 were identified and 4 were recommended from our professional network for inclusion screening (15). Eight studies were excluded, and the remaining 7 were included. A total of 15 Delphi studies on research priorities of respiratory care practices and interventions were included for review. The PRISMA flow diagram to illustrate this citation selection process are included in Figure 2. The relevant articles under (1) respiratory care practices and 2) respiratory research priorities, and their respective RT representation are listed in Table 1. For the full description of each study, the summary of findings are summarized in Tables 2 and 3.

Fig. 2.
Fig. 2.

Flow chart.

View this table:
Table 1.

Summary of the Number of Participants and RTs Involved

View this table:
Table 2.

Delphi Studies Establishing Respiratory Practices

View this table:
Table 3.

Delphi Studies Establishing Respiratory Research Priorities

Respiratory Care Practices

RTs were underrepresented in expert consensus panels after reviewing and summarizing studies that established guidelines related to respiratory care practice. Of the included 23 articles, the following paragraphs elaborate on specific respiratory care practices, with details of each study in listed the Table 2.

Mechanical Ventilation.

Several Delphi studies focused on different aspects of mechanical ventilation. Irajpour et al37 surveyed 20 participants (11 intensive care nurses and 9 physicians) in Iran to create a comprehensive tool to assess patients’ readiness for extubation. Similarly, Cho et al7 sought consensus on the mechanical ventilation strategies for patients with and without ARDS, from critical care physicians and methodologists in Korea. Blackwood et al54 determined important outcome measures in mechanical ventilation management studies by gathering feedback from RTs, nurses, physiotherapists, physicians, pharmaceutical representatives, research funding organizations, patient groups, and clinical trial groups and investigators. Young et al20 led an international Delphi study with experts from Europe and North America (practice areas unspecified) in 2019 and published consensus recommendations on lung-protective strategies in postoperative mechanical ventilation management.

In a Delphi study by Robba et al,14 an international panel of 29 clinician-scientists outlined consensus for mechanical ventilation management in patients with acute brain injury. Their recommendations included 7 practice domains (eg, airway management, noninvasive ventilation, target arterial blood gas values). Parhar et al55 used a modified Delphi technique that consisted of nurses, RTs, intensivists, and nurse practitioners from intensive care centers in Alberta, Canada, to develop a standardized pathway for managing mechanical ventilation in patients with hypoxemic respiratory failure and ARDS. Lastly, the Pediatric Acute Lung Injury Consensus Conference Group,56 which consists of 27 pediatric critical care experts, used the RAND/UCLA Appropriateness Method to establish 132 strongly agreed on mechanical ventilation recommendations in managing pediatric ARDS. Of these 6 studies, only Blackwood et al54 and Parhar et al55 included RTs as expert panelists (8/80 clinicians [10%] and 10/30 practitioners [33.3%], respectively).

High-Flow Nasal Cannula.

This review identified 2 Delphi studies that investigated high-flow nasal canula practices, neither of which included RTs as experts. In 2018, Eklund and Scott8 conducted a modified Delphi technique to investigate common practices and available guidelines for high-flow nasal canula across the United States, whereas Yoder et al19 outlined consensus guidelines in the use and management of high-flow nasal canula in neonatal ICUs from an international perspective. Despite developing these consensus recommendations, both studies mentioned the necessity of additional randomized studies to enhance scientific data on this mode of therapy.8,19

COVID-19 Practices.

We identified 6 Delphi studies with regard to the topic of respiratory practices during the COVID-19 pandemic.10,13,16,18,57,58 More specifically, Hou et al57 used the Delphi technique to survey physicians and nurses to identify key components for a training curriculum to manage patients with COVID-19. They reported 3 major domains to include the following: knowledge, technical, and behavioral skills for health-care professionals to adequately manage COVID-19. In 2 other Delphi studies, Stein et al16 and Nasa et al13 published consensus statements on COVID-19 pediatric airway and mechanical ventilation management, respectively. Stein et al16 recruited international anesthesiologists to reflect on their experiences and provide recommendations on the equipment and practices of managing children with COVID-19. Nasa et al13 published 27 clinical recommendations to manage COVID-19–related acute respiratory failure topics, including awake self-proning; noninvasive ventilation for mixed hypoxemic-hypercapnic respiratory failure, high-flow nasal canula oxygen therapy to reduce intubation, timing of intubation, closed suctioning systems, lung-protective strategies, and prone ventilation.

In another international Delphi study, Vitacca et al18 reported on 4 critical priorities to include in a decision making framework for clinicians to consider when providing pulmonary rehabilitation for people after COVID-19. The investigators of these Delphi studies emphasized the necessity to include experts in consensus-building research to provide practical guidance due to limited research.13,16,57 Despite this emphasis, no RTs were listed as experts in identifying these practice recommendations.13,16,57 For specific procedures, Wahidi et al58 and Lamb et al10 published guidelines for performing bronchoscopy and tracheostomy, respectively, during the COVID-19 pandemic. Wahidi et al58 recruited 14 experts in methodology, bronchoscopy, interventional pulmonology, infectious disease, and critical care from the United States, with 1 RT (7%) among them. Thirteen physicians from the United States with expertise in pulmonary and critical care made up the expert panel in the consensus study by Lamb et al.10 Both recommended further evaluation and refinement of these guidelines as the pandemic progressed and new evidence surfaces.10,58

Home Oxygen Therapy.

We identified 2 Delphi studies that focused on home oxygen therapy. The first was an American Thoracic Society’s clinical practice guideline that used a modified Delphi survey.59 Of the 22 experts included, only 1 (4.5%) was an RT; this group created consensus recommendations to address practices in delivering effective home oxygen therapy for patients with COPD and interstitial lung disease.59 The second study was an international 3-round modified Delphi survey conducted by Lim et al11 to build a consensus guideline on the goals, indications, and barriers of supplemental oxygen for patients with fibrotic interstitial lung disease. Of the 42 international experts from 17 countries, none were RTs.11

Cardiorespiratory Monitoring.

We identified 1 Delphi study about continuous cardiorespiratory and oxygen saturation monitoring outside the pediatric ICU.60 Schondelmeyer et al60 used the RAND/UCLA Appropriateness Method and recruited an interdisciplinary panel of 12 members to create monitoring recommendations. One RT (8%) was included within the expert group. The group gained consensus on 55 recommendations with regard to intermittent and continuous monitoring in children with common conditions and/or receiving common therapies (eg, intravenous medications, respiratory support).

Disease-Specific Practices.

There were 5 articles that reported consensus on the respiratory management of certain chronic lung diseases, none included RTs.9,12,15,17,61 Burgess Kelleher et al61 conducted a modified e-Delphi survey with medical, nursing, and health-care professionals (no RTs were listed) in Ireland to develop educational guidelines for advanced care planning and palliative care for people with COPD. Korpershoek et al9 used the RAND/UCLA Appropriateness Method to identify 17 specific self-management behaviors (important for reducing exacerbations in patients with COPD) from the perspectives of respiratory clinicians and researchers. In another COPD-focused study, a modified consensus method was used to determine the important physical therapy outcome measures in primary care.17 Similarly, Shelley et al15 identified 3 themes for the physical rehabilitation priorities in treating patients with cystic fibrosis: (1) patient-related issues, (2) clinical practice issues, and (3) research issues. By using a modified Delphi technique, Massie et al12 acquired feedback from nurses, neonatologists, neuro-developmental and feeding specialists to create the proxy-reported pulmonary outcomes scale, an evaluation tool to determine the severity of bronchopulmonary dysplasia in preterm infants who require oxygen.

Respiratory Research Priorities

There are many Delphi studies that reported generic respiratory research priorities,62 and specific priorities in primary care,63,64 intensive and/or critical care,65-68 and respiratory nursing.65,69-72 We categorized these studies into 2 broad categories: (1) theory and practice-oriented knowledge gaps, and (2) priority research topics for empirical investigation. A single study included 1 RT as an expert participant to identify respiratory research priorities.74 In addition, Larson et al71 and Wewers et al72 acknowledged the necessity of including RTs’ perspectives to establish team-based research and overall practical approaches to treat respiratory patients. Below, we describe the included studies, with details of each study in Table 3.

Theory and Practice-Oriented Knowledge Gaps in Respiratory Research

Theory and practice-oriented knowledge gaps included disparities that incorporated patients’ perspectives to tailor practices, therapies to specific disease subgroups, and the necessity to identify and/or improve communication approaches between patients and clinicians to optimize the patient experience and their ability to participate in their care.

Inclusion of the Patient Perspective and Sensitivity to Patient Subgroups.

In many studies that assessed different aspects of respiratory care, the patient and the caregiver and/or family member perspective and experience were not included (but were recommended for inclusion in future research).62-64,68-73 Many investigators emphasized the necessity to integrate these perspectives into theory and practice models across respiratory professions to develop culturally sensitive and age-specific approaches to facilitate joint decision making in both respiratory research and care planning to improve patient outcomes.62,64,68,69,71,72 One identified study specifically focused on patients’ perspectives: Fiest et al74 conducted a cross-Canada modified Delphi study on the topic of restricted ICU visitation policies for families and caregivers. Their study included 94 expert stakeholders with 12 of them (12.8%) who practiced as RTs. Their results formulated evidence-informed consensus statements informed by diverse expert participants to enhance patient and family-centered care during a pandemic.

Improving Communication.

Improving communication between clinicians and patients and/or caregivers was identified as a necessity to understand the patient experience better and encourage joint decision-making in respiratory care. We identified 3 studies that emphasized the need to identify, develop, and/or evaluate communication approaches (eg, how best to communicate with patients who are on long-term mechanical ventilation),69 how best to deliver sensitive information to patients and/or family members,65 and to identify and evaluate communication approaches that encourage the participation of patients and caregivers.71 None of these Delphi studies included an RT on their expert panel.

Priority Topics for Empirical Investigation in Respiratory Research

We identified 15 Delphi studies that focused on identifying priority research topics for empirical investigation in the discipline of respiratory care.62-76 One included Delphi study had RTs as expert participants.74 We describe these studies below.

Disease Assessment and Diagnosis.

We identified 9 studies that focused on the priorities of identifying, assessing, and diagnosing respiratory illnesses across care settings.62–65,67-69,71,73 Topics included early assessment and diagnosis for conditions such as asthma, COPD, and dyspnea in both ICU and primary care settings,63,64,69,75 evaluating the efficacy of diagnostic questionnaires (eg, medical history, age, spirometry scores, and symptoms),62,63,65,67 and examining the use of technologies to aid diagnoses.65,68,71 Other topics include differentiating between common co-occurring symptoms in various respiratory diagnoses and evaluating the relationship between biologic and behavioral risk factors for respiratory illness.62,69,71,73

Respiratory Disease and Symptom Management.

Acute Care Management

Most of the literature lists respiratory research priorities within the critical care setting.65–67,69,72 The main topics for research included identifying what measurements should be used to assess patients who are critically ill (eg, spirometry, dyspnea scores, quality-of-life questionnaires);65,69 the ideal frequency of lung function tests; and optimal approaches to blood and fluid management, oxygen therapy, and mechanical ventilation.66 Other research priorities included identifying and testing interventions that improve recovery in acute care,67,68 evaluating tools to assess sleep during critical illness,65 assessing common symptoms among patients who are critically ill (eg, thirst, anxiety, depression, dyspnea, and fatigue),69 and, finally, determining the role of pulmonary rehabilitation in critical care.67,72

Chronic Care Management

Seven Delphi studies discussed the complexity of managing patients who are chronically ill with asthma, COPD, lung fibrosis, and/or tobacco dependence.62-65,69-73,76 The research topics included identifying the optimal pharmacologic and non-pharmacologic strategies for patients with poorly controlled symptoms64,73 and to understand the impact of chronic respiratory diseases on patients’ cognitive function, psychosocial development, and family functioning and interactions.62,65,70,71 Other topics for future research included the following: identifying or developing optimum treatment regimens for people with co-morbidities;72,73 describing the role of pulmonary rehabilitation in symptom management, functional status, and health-related quality of life;71,72 and identifying the unique needs of children, older adults, women, and underrepresented minorities with respiratory illness.63,70,73

Furthermore, it was emphasized that more research on respiratory patients’ adherence and compliance to therapies (pharmacologic and non-pharmacologic) are needed.63-65,71-73 The authors suggest that researchers should investigate the ways to improve and support patients’ self-management of their pulmonary condition and/or disease.62–64,69,70,72,73 For example, developing and evaluating ways to assist patients to better monitor and respond to their pulmonary symptoms, understand preferences for therapy and/or device use63,70 motivating health-seeking behaviors,69,71,72 developing technologies to support self-care and better sleep health,64,65 tailoring and individualizing care,68 and evaluating education programs to enhance patients’ and caregivers’ understanding of their respiratory condition.65,70

Prevention and Treatment of Pulmonary Complications.

Investigators from 10 studies prioritized research with regard to strategies to predict, prevent, and safely treat pulmonary complications and/or infections.62–67,69–72 The research topics included preventing and treating iatrogenic harm caused by pulmonary technologies and therapies (eg, mechanical ventilation and pain medication);63,67,72 testing alternative methods of delivering oxygen and patient positioning;66,67 and examining issues related to mechanical ventilation initiation, maintenance, suctioning, and weaning.69,70 Other topics included methods to prevent respiratory tract infections (eg, pneumonia), the development of ARDS, and evaluating the safety of antibiotic prescription practices.62–64,66 Also, some investigators included the need to develop or identify ways to prevent and treat delirium (ie, cognitive dysfunction) among respiratory patients in intensive care was identified as an important priority.65-67,71

Organization, Delivery, and Access to Medical Care.

Investigators from 7 Delphi studies emphasized the need to empirically study the process in which respiratory-related care is organized, delivered, and accessed.62,65,66,68,70–72 Specifically, identifying and developing cost-effective approaches to deliver respiratory care to resource-poor areas, atypical settings, or populations with limited access.62,68,72 In addition, there is a need to evaluate the factors that influence patients’ decisions and ability to access care and to determine feasible interventions and delivery systems for chronic care after hospital discharge.65,66,70,71

Discussion

The aim of this narrative review was to determine the extent to which RTs are included as expert participants among published Delphi studies related to respiratory care practices and respiratory research priorities. We identified 23 articles related to respiratory care practices, and 22% of the articles had RTs included as expert participants.54,55,58-60 We also identified 15 articles with respiratory research priorities, which had only 1% seeking RTs’ feedback.62-76 Based on the results from this narrative review, we believe that RTs were underrepresented in expert panels of respiratory-related Delphi consensus studies, despite having a primary role in respiratory procedures and therapies.2,3,10,58,77 No consensus exists for the definition of an “expert” in consensus-building research, which provides the research team flexibility when selecting experts for their study.47

Often, experts are chosen because they possess a high degree of knowledge about the topic under study and can provide an in-depth contextual understanding of the subject matter.30,47,53 RTs possess a high degree of knowledge and a contextual understanding of each research topic of study in the included Delphi articles but their perspectives were not included. Consensus research that describes respiratory practices and research priorities were often conducted by other disciplines and included disciplines other than RTs as expert panelists (eg, respiratory nursing or physicians). Our goal in providing this scholarly summary of the literature is to inform the structure and process of future Delphi studies that investigate topics related to the respiratory care profession and encourage RTs to advocate to be included as expert participants.

Delphi Studies Establishing Respiratory Practices

RTs were not included in the expert panels of several studies that focused on mechanical ventilation management,13,14,37 even though RTs’ practice is largely based on daily mechanical ventilation initiation, management, and severance.2,3 Previous research demonstrated that RT-directed mechanical ventilation weaning protocols (compared with physician-directed protocols) significantly lowered duration of mechanical ventilation and hospital length of stay, which highlights that RTs possess expertise in this area of clinical practice.78 Furthermore, a recent survey of nurses and physicians reported that they felt confident in RTs’ ability to assess and manage mechanical ventilation in ICUs.79 High-flow nasal cannula is another therapy primarily managed by RTs; however, both Delphi studies on this topic did not seek practice feedback from them.8,19

More recently, the COVID-19 pandemic has emphasized the role and importance of RTs in providing respiratory care to patients.80,81 However, Delphi studies of establishing airway or respiratory care management priorities during COVID-19 did not include RTs.13,16 Lamb et al10 did not include any RTs in their expert panel for tracheostomy use during COVID-19. In the study by Hou et al,57 the perspectives of RTs were not included when evaluating the educational and preparational needs of health-care professionals involved in caring for patients with COVID-19. Because RTs have such an integral role in this pandemic, it may have been beneficial to consider their contextual knowledge and needs to inform this educational framework.

Some Delphi studies did include RTs, but they were the least represented in the panel. Of the included studies, Jacobs et al59 included 1 RT of 18 panelists (5.5%), and Schondelmeyer et al60 included 1 RT of 12 panelists (8.3%) to determine the best recommendations for home oxygen use and continuous monitoring, respectively. In the study by Blackwood et al54 in determining the important mechanical ventilation outcome measures, 161 clinicians participated, of whom, only 8 were RTs (4.9%). The Delphi study by Wahidi et al58 conducted in the United States included 1 RT of 7 panelists (14%) for their COVID-19 bronchoscopy expert panel. The study with the best RT representation was by Parhar et al55 in Alberta, Canada, where 10 RTs were included in a group of 30 clinicians (33.3%) to determine the essential components in managing hypoxemic respiratory failure and respiratory distress syndrome in intensive care.

Delphi Studies Establishing Respiratory Research Priorities

RTs play an integral role in the interprofessional team and are heavily involved in managing respiratory therapies and treatments in various practice settings;2,77 however, they were not included in most Delphi studies that identified respiratory research priorities,62–73 except for one.74 A recent modified Delphi study in Canada determined strategies to help improve care practices when ICU visitations were limited during COVID-19.74 Along with patients and family members, RTs were involved during all Delphi rounds, with a relatively good RT representation (12 RTs [12.8%] of 94 participants were involved).74 Another recent Delphi study from Saudi Arabia sought feedback from health-care professionals and community volunteers to determine the research priorities in tobacco and substance use.76 However, the experts included were respiratory care staff and did not specify whether RTs were part of this subgroup classification.

Most of the included studies recruited experts from different practice areas, including respiratory nursing, primary care, intensive care, respiratory physiotherapy, and/or respiratory research. Some studies included patients and caregivers and/or patient representatives as experts to assist in identifying and prioritizing a respiratory-related research agenda (eg, in intensive care).65-67 Moreover, the role of RTs was only mentioned by 2 groups of investigators,71,72 who emphasized the importance of establishing team-based approaches and collaboration to address therapy adherence among respiratory patients. This narrative review revealed that RTs are uncommonly solicited to provide their expertise to identify respiratory research priorities, which suggests that emerging priorities may not identify knowledge gaps deemed important for the respiratory therapy profession.

Future Directions

Delphi studies are well suited for identifying respiratory care core outcomes in treatment plans, for testing the feasibility of clinical tools, and for establishing research priorities.12,54,82,83 From our review, there are many published Delphi studies that could have benefited from RTs contributing their knowledge and contextual understanding of various topics.9,11,12 One example that shows the success and benefits of RT engagement in a Delphi study was completed in 2021, with an exclusive RT expert panel from 15 different Canadian pediatric acute care institutes.84 The result was a pediatric mechanical ventilation consensus document on 59 specific practices, organized into 10 subsections (eg, noninvasive ventilation, tidal volumes and inspiratory pressures, advanced mechanical ventilation, weaning, monitoring, equipment adjuncts).84 This Delphi study was the first to provide RT-specific perspectives and consensus on their own respiratory care practices. This consensus document may help inform standardized and RT-specific mechanical ventilation management across Canada and be used as a foundation for other health-care disciplines who are heavily involved in pediatric mechanical ventilation management.

We acknowledge the limitations of our conclusions, given we did not define thresholds of health profession underrepresentativeness; we were not able to find definitions in the literature. Future studies could investigate representativeness of health professions for respiratory care practices, especially in jurisdictions where RTs practice. Given most included articles (19 of the 23 studies)8-14,16,18-20,37,54-60 included countries where RTs are primary respiratory care practitioners, and only 5 studies54,55,58-60 (a total of 21 RTs of 1,884 health professionals across all studies) included them as experts, we believe the threshold for underrepresentativeness in these studies was reached. Similarly, in the 15 included studies 62-76 that investigated research priorities for respiratory care, there were 2194 healthcare professionals included as participants and only 1 study clearly indicated that they had 12 RT participants.74 We also acknowledge the possibility that RTs were sought for study participation but were unsuccessfully recruited, which resulted in the poor representation in the literature. In such cases, further investigation into why RTs might not choose to agree to participate in such research is needed.

The range of clinical tasks that RTs perform, combined with their knowledge and expertise in cardiorespiratory health, suggests that RTs can provide contextual knowledge and valuable insight into a range of health science topics.58-60,85,86 RTs require critical thinking and should base their clinical decision-making on the most up-to-date evidence while incorporating patients’ values and clinical experience. To do this, RTs need to contribute to the growth of their own practices.21,24 The minimum representation of RTs in the Delphi studies focused on the respiratory care profession suggests that RTs should encourage their engagement in future research to ensure that emerging empirical research includes their perspective. Improving RTs representation in future studies is necessary and may require education, guidance, and elimination of barriers associated with their involvement in research.22,87

Summary

The Delphi technique is a common, well-accepted, and flexible consensus gathering method for developing practice guidelines and prioritizing areas for future research. The Delphi method aims to collect feedback from an expert panel through a series of rounds, each informing the next.30,44 Many health-care professionals are well represented in the expert panels of different respiratory-related Delphi studies.62-73 However, the results from this narrative literature review suggest that RTs have sparse representation on expert panels for respiratory-related practices and research priorities despite their extensive knowledge and experience.8,10,19,37,58,85,86,88 RTs possess specialized knowledge, experience, and expertise that are valuable in research focused on respiratory care topics. RTs can use the Delphi technique to enhance their respiratory care practices and contribute to the growing pool of empirical evidence. Research specific to RT practice is warranted because of the lack of literature informed by and directed toward respiratory therapy as a profession. The findings of this narrative review can inform an overarching respiratory therapy research agenda and provide guidance on specific areas that require particular attention.

Footnotes

  • Correspondence: Mika L Nonoyama RRT PhD, Department of Respiratory Therapy, Hospital for Sick Children, 555 University Ave, Toronto, Ontario, M5G 1X8. E-mail: mika.nonoyama{at}sickkids.ca

  • Ms Quach and Ms Veitch are shared first authors.

  • Supplementary material related to this paper is available at http://www.rcjournal.com.

  • Mr. Zaccagnini is an editorial board member of RESPIRATORY CARE and was not involved in any decision regarding this manuscript.

  • There are no conflicts of interest from any authors to disclose.

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