Using Expert Consensus to Develop a Tool to Assess Physical Therapists’ Knowledge, Skills, and Judgement in Performing Airway Suctioning

Abstract

Purpose: The aim of this study was to develop a tool to assess physical therapists’ knowledge, skills, and judgement in performing airway suctioning with intubated and non-intubated adults. Method: A modified Delphi methodology was used to develop the tool and to evaluate its sensibility (i.e., common-sense nature). Participants were experienced cardiorespiratory physical therapists who perform airway suctioning and physical therapists employed in academic positions related to cardiorespiratory physical therapy at Canadian universities. Round 1 focused on refining which items to include in the tool, Round 2 focused on finalizing the items, and Round 3 focused on evaluating a preliminary version of the tool. Results: A total of 34 individuals participated in Round 1, 30 participated in Round 2, and 25 participated in Round 3. A literature review identified 11 relevant domains and 69 supporting competencies. In Round 1, consensus was achieved for all domains; however, it was borderline for the professionalism domain. Multiple participants suggested that it was redundant because it is a global requirement for all physical therapists. Consensus was also achieved for 64 of the 69 supporting competencies; however, it was borderline for 5 of these items, and 5 achieved no consensus. In Round 2, participants rated a series of recommendations related to items requiring further consideration, as well as 9 new items suggested by the participants in Round 1. In Round 3, the preliminary tool was found to be globally sensible, but concerns were expressed about the inclusion of redundant factors and the tool’s length. The tool was revised, resulting in a tool with 4 domains, 6 sub-domains and 43 supporting competencies, as well as an item rating the individual’s overall performance. Conclusions: The final-round sensibility questionnaire provided preliminary evidence of the tool’s face and content validity. We will investigate the tool’s measurement properties in a future study.

The inability to effectively clear pulmonary secretions can impair ventilation and adequate oxygenation. Suctioning is one technique that health care professionals use to help individuals manage secretion retention and maintain the integrity of their airways. For the purpose of this study, the term suctioning is used to describe multiple approaches to removing secretions from the trachea using a suction catheter, including open and closed system suctioning via an endotracheal or tracheostomy tube, as well as orotracheal and nasotracheal suctioning. Because suctioning has the potential to cause serious adverse effects,¹ restrictions are in place to limit who can perform it.² Physical therapists are among those health care professionals authorized to perform suctioning.³

In Ontario, physical therapists who perform suctioning are required to roster (i.e., register) with the College of Physiotherapists of Ontario (the provincial regulatory body for the profession), indicating that they have sufficient training and experience to perform this technique in a safe manner.⁴ This training must include an evaluative component assessing the physical therapist’s knowledge, practical skills, and judgement to perform suctioning competently.⁵ Although professional competence assessments are an important process because they help to protect the public, they also provide individual feedback and help institutions identify health care professionals in need of further training.⁶ Despite their importance, professional competence assessments have been reported to be limited beyond initial licensure for many health care professionals.⁷

Particular importance has been placed on assessing competence for both high-risk and low-volume health care activities.⁸ On a survey conducted by Brooks and colleagues,⁹ all the participants reported that nurses, respiratory therapists, and physical therapists performed suctioning in their health care settings; however, nurses were identified as the health care professional group who performed suctioning most often, and respiratory therapists were identified as the health care professional group consulted most often when expertise related to suctioning was required. Assessing competence for suctioning may therefore be of additional importance for physical therapists, who may have fewer opportunities to perform suctioning in clinical practice than other health care professionals.

A number of tools have been developed to assess competence in performing suctioning. A recent scoping review identified 36 articles and resources that described or implemented tools for assessing the competence of health care professionals who perform suctioning with adults.¹⁰ The majority of these tools were designed to be used with nurses and nursing-related professions, such as nurse technicians, and all but two were developed outside the Canadian health care context.¹⁰ To our knowledge, the appropriateness of these tools for use with physical therapists in the Canadian health care context has not been formally evaluated.

Rather than further exploring the utility of an existing tool for use with Canadian physical therapists, we chose to create a new tool. There were three reasons for this. First, most existing tools focus on endotracheal suctioning and suctioning performed in intensive care units or other critical care environments.¹⁰ Their broad applicability to current practice is therefore limited because they do not reflect the range of suctioning approaches that are used and the variety of environments in which suctioning is performed. Second, more than a third of the articles and resources provided insufficient detail to discern how the assessment tools were developed, which detracted from the credibility of these tools as valid assessment measures.¹¹ Finally, many of the existing tools predate the release of more recent peer-reviewed clinical practice guidelines for suctioning and therefore do not consider more recent evidence and recommended practices^1,12 (e.g., newer evidence about indications for suctioning, open versus closed system suctioning, and infection control procedures).¹²

The objective of this study was to develop a comprehensive, up-to-date tool to assess physical therapists’ knowledge, skills, and judgement in performing airway suctioning with both intubated and non-intubated adults that would be relevant to the Canadian practice context. We intended this tool to apply across different health care settings and with the suctioning approaches used by physical therapists working with adults.

In assessing competence, we selected knowledge, skills, and judgement as the primary components under consideration given the College of Physiotherapists of Ontario’s requirement to evaluate these three factors in relation to the performance of controlled acts.⁵ We defined knowledge as the theoretical or practical understanding of a concept, skills as the ability to perform a discrete or observable act, and judgement as the ability to form valuable opinions and make good decisions.^13–15

Methods

We used a modified Delphi method to reach consensus about which elements to include in the tool and guide its development. The Delphi method is frequently used to achieve agreement among a group of experts in a given area using a structured multi-round survey process.^16,17 Participants are not given the opportunity to physically meet because this reduces the potential for one participant to exert dominance over others in the opinion-building process.¹⁸ We followed the six stages of the Delphi method reported by Humphrey-Murto and colleagues,¹⁹ modified to include a structured first-round questionnaire and a final-round sensibility questionnaire.^16,20

Developing the questionnaire

To establish an initial set of items to include in the first-round questionnaire, we conducted a literature search. We searched four scientific electronic databases: MEDLINE, EMBASE, the CINAHL, and the Cochrane Library from inception to March 9, 2018, using both database-specific search headings – for example, suction/ and (lung/ or trachea/) and (practice guidelines/ or clinical competence/ or professional standard/) – and key word searching – such as suction* and (endotrachea* or nasopharyngea* or oropharyngea*) and (competenc* or knowledge or educat*). We considered evidence and recommendations identified in relevant systematic reviews, a meta-analysis, and clinical practice guidelines, as well as items commonly occurring in existing tools that assess competence for suctioning for health care professionals working with adults.^1,12,21–26

We then generated a list of items relevant to the knowledge, skills, and judgement required to perform suctioning with adults that was based on our literature search findings. This list of items was included in the first-round questionnaire, with the items grouped according to domains and supporting competencies. Domains were defined as distinct components of the overall act of suctioning, and supporting competencies were defined as the essential subcomponents of a domain.²⁷ The initial questionnaire was piloted with two experienced physical therapists and, on the basis of their feedback, we made minor wording changes to improve clarity.

Participants and the recruitment process

Recruitment for this study was purposeful, targeting experienced cardiorespiratory physical therapists from across Canada. This included a mix of practising physical therapists and physical therapists employed in academic positions related to cardiorespiratory practice. To ensure that respondents had adequate knowledge, practising physical therapists were eligible to participate if they had current independent practice registration with a provincial or territorial physical therapy regulator, had 2 or more years of physical therapy practice experience in a setting in which individuals with cardiorespiratory conditions made up at least 25% of their caseload, and had performed suctioning at least once in the previous 6 months.

Physical therapists employed in academic positions were eligible to participate if they held a current academic position at a Canadian university and identified cardiorespiratory physical therapy as one of their primary teaching areas. They were not required to have performed suctioning at least once in the previous 6 months. Individuals not registered to practise physical therapy in Canada and individuals under provisional or supervised practice were excluded.

A lack of agreement exists about the optimal sample size when using the Delphi method in health care.²⁸ With a relatively homogeneous participant group, 10–15 experts has been suggested.²⁹ Given that this study aimed to represent a national perspective and included two related yet distinct expert types, a larger group of 20–25 study participants was targeted. A recruitment email for the study was sent out through the Canadian Physiotherapy Association Cardiorespiratory Division to its members. We also sent out a recruitment email to faculty members in physical therapy programmes at Canadian universities. Finally, snowball sampling was used, whereby individuals who received the recruitment email were asked to forward the study information to other physical therapists who might be interested.

To administer the questionnaires, we used the online survey platform SurveyMonkey (SurveyMonkey, San Mateo, CA). Anonymized data were exported to Microsoft Excel 2016 (Microsoft Corporation, Redmond, WA) for analysis. Descriptive statistics included the response rate and the frequency of distribution for each item. Ethics approval was obtained from the Health Sciences Research Ethics Board at the University of Toronto, and informed consent was obtained from all participants.

Questionnaire rounds

We selected a target of three rounds in an attempt to avoid the potential for the false consensus phenomenon, whereby fatigued participants agree in an effort to end their participation in a study.³⁰

Round 1

This round focused on refining the list of items to include in the tool. Participants were asked to rate their level of agreement about including each item (domains and supporting competencies) using a 5-point Likert-type scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree). Text boxes on the questionnaire enabled the participants to explain their ratings. Consensus was defined a priori as having at least 70% of respondents agree or strongly agree or having at least 70% of respondents disagree or strongly disagree with an item. This definition was selected because it is a fairly typical definition of agreement and disagreement in consensus studies.³⁰

A decision made in advance was to include items in the draft tool about which we had reached consensus of agreement and to exclude items about which we had reached consensus of disagreement, with the exception of items that achieved only borderline consensus (70%–79% agree or strongly agree or 70%–79% disagree or strongly disagree, with written comments suggesting the need for further consideration). These items were included in the next round, as were items about which consensus was not reached. Participants were also given the opportunity to suggest additional items that may have been missed in the literature review.

Participants were also asked to express their opinion about five rating scales that could potentially be used in the tool (e.g., not observed, partially observed, observed; poor, fair, good, very good, excellent). For each rating scale, participants selected one of three choices: 1 = this would not be a suitable scale, 2 = neutral, 3 = this would be a suitable scale. Finally, demographic information was collected about the participants to provide insight into the breadth of their relevant experience and representation across geographical areas. If participants did not respond to the questionnaire within 1 week, we sent out a reminder email; we followed this same reminder process in all rounds.

Round 2

The focus of this round was to finalize the items to include in the tool and select a final rating scale for the tool. Only individuals who had participated in Round 1 were invited to participate. We gave them the results from Round 1 in aggregate form along with a summary of anonymized comments to help them make their decisions.¹⁸ The participants rated the new items proposed in Round 1 and expressed their opinions on a series of recommendations about any items requiring further consideration. Round 2 used the same Likert-type scale as Round 1, and text boxes were again provided for responses. The participants were also asked to rate or re-rate the rating scales moved forward from Round 1; these included the two rating scales that had received the highest mean scores in Round 1 and one new scale proposed by a study participant. Additional questions posed about the rating scale for the tool are included in Figure 1; the complete Round 1 and 2 questionnaires are available on request from the authors.

Figure 1.

Additional Rating Scale Questions

Note: Examples provided under each supporting competency have been omitted.

Round 3

This round focused on evaluating the preliminary version of the tool that we created on the basis of the responses in Rounds 1 and 2. We shared the preliminary tool with an Expert Advisory Committee (EAC) made up of four regulated health care professionals (two physical therapists, one respiratory therapist, and one registered nurse) with expertise in suctioning or developing health-care-related assessment measures. We then participated in a round-table discussion with the EAC, followed by an anonymous majority-rules vote to reach consensus on items still under consideration after Round 2. The EAC also provided feedback on the preliminary tool before we shared it with the participants.

Only those individuals who had participated in Round 2 were invited to participate in Round 3. They evaluated the preliminary tool by completing a sensibility questionnaire adapted from Duong and colleagues, who had based their work on a questionnaire originally developed by Rowe and Oxman, using the dimensions of sensibility outlined by Feinstein.^20,31,32 In this context, sensibility refers to the tool’s level of common sense, which is tied to its face and content validity.³¹ The questionnaire was answered using the same five-point Likert-type scale as in the previous rounds and included text boxes to allow participants to explain their ratings and provide additional feedback about the tool. As determined a priori, individual items in the sensibility questionnaire were considered sensible if they achieved a mean score of at least 4 out of 5, and we used a combined mean score of at least 4 out of 5 to determine the tool’s global sensibility.

Modified Delphi rounds concluded after Round 3. We used the responses from the Round 3 questionnaire to revise the preliminary tool and then emailed the revised tool to all the final-round participants.

Results

A total of 34 individuals participated in Round 1, 30 of 34 participated in Round 2, and 25 of 30 participated in Round 3. The participants’ characteristics are presented in Table 1. Round 1 remained open for 3 weeks: an initial 2-week period followed by a 1-week extension; the round was re-opened after a number of new participants expressed interest in the study. Rounds 2 and 3 remained open for 2 weeks each, separated by a 2-week period.

Table 1.

Delphi Participants’ Characteristics

Characteristic	Round, no. (%)*
	1 (n = 34)	2 (n = 30)	3 (n = 25)
Employment status
Practising physical therapist	22 (64.7)	19 (63.3)	15 (60.0)
Teaching position in physical therapy	4 (11.8)	4 (13.3)	4 (16.0)
Both	8 (23.5)	7 (23.3)	6 (24.0)
Province or territory of employment
British Columbia	2 (5.9)	1 (3.3)	1 (4.0)
Alberta	4 (11.8)	3 (10.0)	2 (8.0)
Saskatchewan	4 (11.8)	3 (10.0)	3 (12.0)
Ontario	20 (58.8)	19 (63.3)	17 (68.0)
Quebec	3 (8.8)	3 (10.0)	1 (4.0)
Nova Scotia	1 (2.9)	1 (3.3)	1 (4.0)
Physical therapy related practice, y
Range, min–max	4–41	4–41	4–41
Median	13	18	19
Primary practice setting
Acute care (including intensive and critical care)	28 (82.4)	25 (83.3)	20 (80.0)
Educational or academic setting	5 (14.7)	5 (16.7)	5 (20.0)
Outpatient setting	1 (2.9)	0 (0)	0 (0)
Suctioning procedures, past 6 mo
None†	5 (14.7)	4 (13.3)	4 (16.0)
< 1×/mo	4 (11.8)	4 (13.3)	3 (12.0)
≥ 1×/mo	3 (8.8)	3 (10.0)	3 (12.0)
≥ 1×/wk	3 (8.8)	2 (6.7)	1 (4.0)
1×/d	8 (23.5)	6 (20.0)	5 (20.0)
> 1×/d	11 (32.4)	11 (36.7)	9 (36.0)

Note: Percentages may not total 100 because of rounding.

^*Unless otherwise indicated.

^†Physical therapists employed in academic positions were eligible to participate in the study even if they had not performed suctioning at least once in the previous 6 months.

Round 1

On the basis of the literature review, we identified 11 domains (distinct components of suctioning) – baseline assessment, access to appropriate equipment, equipment preparation, patient preparation, suctioning procedure, patient monitoring, post-suctioning care, post-suctioning assessment, infection control, communication with the health care team, and professionalism – and 69 supporting competencies (essential subcomponents). Consensus was achieved for all domains; however, it was borderline for the professionalism domain (79% agreed or strongly agreed that it should be included). Multiple participants suggested that it was redundant given that it is a global requirement for all physical therapists and is not specific to suctioning. Consensus was also achieved for 64 of the 69 supporting competencies; however, it was borderline for 5 of these items, and 5 achieved no consensus. Table 2 provides a summary of the results for the supporting competencies that achieved borderline or no consensus.

Table 2.

Items That Achieved Borderline or No Consensus in Round 1

Domain and supporting competencies	Percentage			Consensus
	SD+D	N	A+SA
Access to appropriate equipment (ensures that it is accessible and in working order)
Mask and goggles or face shield	3	18	79	Borderline
Sterile gloves for open-system suctioning	21	18	62	Not achieved
Gown	21	30	48	Not achieved
A nasal–pharyngeal airway if frequent nasotracheal suctioning is being performed	6	21	74	Borderline
Patient preparation
Has informed consent for suctioning	12	15	74	Borderline
If not contraindicated, positions the patient in Fowler’s or semi-Fowler’s position	12	29	59	Not achieved
Does not routinely perform hyper-inflation	9	41	50	Not achieved
Suctioning procedure
Continuous suction is used during withdrawal of suction catheter for patients with an artificial airway	0	21	79	Borderline
Does not routinely instill saline	3	24	74	Borderline
Domain: Post-suctioning care
If hyper-oxygenation is performed, it is done for at least 1 min	3	29	68	Not achieved

Note: Percentages may not total 100 because of rounding.

SD+D = strongly disagree and disagree; N = neutral; A+SA = agree and strongly agree.

Round 2

The participants’ comments and responses from Round 1 were used to generate 39 recommendations for the participants to consider in Round 2. These recommendations included adding new examples under the supporting competencies (4 instances), rewording or modifying the content of the supporting competencies (10 instances), removing the supporting competencies (9 instances), removing the professionalism domain and its supporting competencies, and combining or replacing multiple supporting competencies with a single supporting competency (7 instances). Renaming the baseline assessment domain and combining a number of domains and organizing them according to sub-headings was also proposed.

In addition, nine new supporting competencies suggested by participants in Round 1 were rated. The rating scale does not meet expectations, meets expectations, exceeds expectations received the highest mean score (2.4 of 3); 83% of the participants preferred a tool that enabled the rater to rate a physical therapist’s performance on each of the individual supporting competencies, and 87% wanted a tool to include an item rating the individual’s overall performance. A summary of the results for all Round 1 and 2 items is available from the authors on request.

Round 3

After Round 2, 11 outstanding items were brought forward to the EAC for a final decision. The Round 2 results for these items, as well as the decisions from the EAC, are provided in Table 3. The participants then rated the preliminary tool, and the results from the sensibility questionnaire are shown in Table 4. Seven of those 10 items had a mean score of 4 or more out of 5 and were therefore deemed to be sensible; the remaining 3 items had a mean score of less than 4 out of 5. Overall, the preliminary tool was deemed to be globally sensible with a combined mean score for all items of 4 out of 5. The participants’ comments suggested that although the participants thought that the tool would be useful, they were concerned that it was a little long and included a number of redundant items.

Table 3.

Summary of Items Presented to EAC after Round 2

Item	Percentage			Consensus	EAC’s decision
	SD+D	N	A+SA
“Verifies the identity of the patient” should be included as a supporting competency.	13	17	70	Borderline	Exclude
“Ensures that hand sanitizer and soap/water are accessible” should be included as a supporting competency.	20	23	57	Not achieved	Exclude
“Verifies the expiration date on the package of the sterile suction catheter (for open system suctioning only)” should be included as a supporting competency.	37	43	20	Not achieved	Exclude
“Sets the suction pressure to 150 mmHg or less” should be replaced by “Sets the suction pressure to 120 mmHg or less.”	10	20	70	Borderline	Re-word
“If not contraindicated, the patient’s head is in a slightly extended position” should be included as a supporting competency.	24	45	31	Not achieved	Exclude
“Has informed consent for suctioning” should be excluded.	27	30	43	Not achieved	Exclude
“If not contraindicated, positions the patient in Fowler’s or semi-Fowler’s position” should be excluded.	7	30	63	Not achieved	Exclude
“Does not routinely perform hyper-inflation” should be excluded.	3	37	60	Not achieved	Exclude
“Post-suctioning care: if hyper-oxygenation is performed, it is done for at least 1 minute” should be excluded.	3	27	70	Borderline	Exclude
“Is able to demonstrate reflective thinking about the encounter” should be included as a supporting competency.	13	23	63	Not achieved	Exclude
The professionalism domain and its supporting competencies should be excluded.	3	33	63	Not achieved	Exclude

Note: Percentages may not total 100 because of rounding.

EAC = Expert Advisory Committee; SD+D = strongly disagree and disagree; N = neutral; A+SA = agree and strongly agree.

Table 4.

Round 3 Sensibility Questionnaire

Item	Mean (max score of 5)
1. The tool is clear.	4.04
2. The tool would be easy to use.	4.12
3. The tool has identified all necessary related factors.	4.22
4. The tool does not include any redundant factors.	3.60
5. The tool is appropriate for assessing knowledge related to tracheal suctioning.	4.04
6. The tool is appropriate for assessing skills related to tracheal suctioning.	4.08
7. The tool is appropriate for assessing judgement related to tracheal suctioning.	3.92
8. The tool is acceptable in terms of its comprehensiveness and the amount of time it would take to complete.	3.80
9. You would use this tool as a resource for clinical practice or teaching.	4.16
10. Overall, this tool would be useful for physical therapists.	4.16
Overall mean	4.01

Developing the final tool

In an effort to make the tool clearer and more concise, we revised the instructions for the tool, made minor wording changes, moved examples under the supporting competencies to a glossary, collapsed three supporting competencies into other similar items, and removed three supporting competencies identified by the participants as being redundant. These revisions resulted in a tool with four domains, six sub-domains, and 43 supporting competencies, as well as a final item rating the individual’s overall performance and a comments box. The revised tool is included as the online Appendix.

Discussion

We have described the development of a new tool to assess physical therapists’ competence for performing suctioning with adults. Using consensus methods is not a novel approach for developing assessment tools in physical therapy.^33–35 The Delphi method is particularly useful in cases in which the information about a topic is incomplete,²⁹ which is the case for the evidence on the optimal performance of suctioning. Early clinical practice guidelines for suctioning found a complete absence of studies on issues such as the optimal suctioning approach and using an artificial airway (e.g., an oral airway or a nasal-pharyngeal airway) for non-intubated patients, suction catheter diameter, suctioning frequency, optimal suction pressure, the depth at which to apply suction pressure, use of continuous versus intermittent suction, catheter rotation, and use of lubricating gel or water.²⁶

More recently, the evidence base for suctioning adults has improved; however, evidence to inform suctioning practices on non-intubated individuals has remained scarce, and the majority of studies have had small sample sizes.¹² Relevant clinical practice guidelines from the American Association of Respiratory Care and Chaseling and colleagues continue to highlight ongoing gaps in the literature, providing mainly weaker strength practice recommendations.^1,25 In the current study, we systematically gathered and consolidated expert opinion to supplement the existing relevant literature as we developed the tool.

Checklists and global rating scales (GRSs) are two common assessment methods. When using checklists, clinicians evaluate individuals against a list of specific predefined behaviours, using a binary scale to indicate whether they are at or below the standard.⁸ In contrast, GRSs provide a more global impression of an individual’s overall performance or performance on relevant sub-tasks.³⁶ Checklists have been criticized for rewarding thoroughness rather than expertise, and the psychometric properties of GRSs are commonly thought to be more robust.^37–39 A recent systematic review of the validity evidence for checklists compared with GRSs in simulation-based assessments in health care generally supported both, but the authors did convey the additional important benefits of GRSs, including the fact that they potentially applied across multiple tasks and could better capture subtle differences in performance expertise.³⁶

During Round 2, the majority of our participants indicated a preference for a tool that would enable a rater to rate performance on each supporting competency. Although this preference aligns more closely with a checklist-based approach, the participants did support including an item at the end of the tool that would provide a more global assessment of performance. Moreover, a three-level rating scale was selected, allowing for a greater appreciation of variation in performance compared with a binary scale.

Of note is the fact that the scale included in the tool is a modification of the scale selected by the study participants. In consultation with the EAC, we realized that the scale initially selected did not align well with a number of items in the tool. For example, it would not be possible for an individual to exceed expectations on items in the equipment domain. The not applicable option was also added to recognize that the appropriate suctioning procedure may vary according to the individual case, as well as the type of suctioning approach used and the practice context. This is in line with our goal to create a tool that will apply in the different practice settings in which suctioning is performed (e.g., the intensive care unit, critical and acute care environments, long-term care, home care), as well as across suctioning approaches (e.g., endotracheal, orotracheal, nasotracheal, using a tracheostomy).

Van Der Vleuten identified five variables to consider with regard to the utility of assessment methods for professional competence: reliability, validity, educational impact, acceptability, and cost.⁴⁰ Acceptance of the tool is critical.^40,41 For that reason, our participants included physical therapists who were likely to use the tool in the future (e.g., practising clinicians and educators). Overall, the preliminary tool was deemed to be globally sensible, and this assessment provides preliminary evidence of its face and content validity. Future studies will explore the utility of the revised tool, including an assessment of its reliability and validity for use with physical therapists in the Canadian health care context.

The assessment tool we developed represents only one possible method of assessment. A single assessment method is likely not sufficient to capture the complex array of information needed to make an informed judgement about successfully delivering services in health care.⁴² This tool is also not intended to replace the judgement of skilled evaluators or provide a definitive or stand-alone judgement of a physical therapist’s clinical competence for suctioning. Individuals using this tool in the future should consider how it fits within broader assessment frameworks, including multiple assessment approaches and assessments across multiple points in time.

This study had several limitations. Although we met or exceeded our target sample size in all rounds and the sample included participants from six Canadian provinces, experts from Ontario accounted for the majority of the study participants. In addition, nearly all the practising physical therapists who participated identified their primary practice setting as acute care. The results may therefore have been biased to more strongly reflect the relevant opinions and practices of Ontario-based physical therapists and those working in acute care environments, as opposed to reflecting a broader national perspective. Finally, although our study questionnaires were available only in English, we attempted to partially mitigate this issue by allowing participants to provide written comments in French when they requested it.

Conclusions

Using a modified Delphi methodology, we developed a new tool to assess physical therapists’ clinical competence for performing airway suctioning with adults. The final-round sensibility questionnaire provided initial evidence of the tool’s face and content validity, but the participants expressed concerns that the tool included redundant factors and was a little long. The tool was revised accordingly, and in the next phase of developing the tool, we will further assess its utility.

Key Messages

What is already known on this topic

Airway suctioning is an important but potentially dangerous intervention performed by health care professionals, including physical therapists. Given the high-risk nature of this technique, it is important to assess the clinical competence of the health care professionals who perform it. Previous tools have been developed for this purpose, but they are not relevant to current physical therapy practice.

What this study adds

This study describes how we used expert consensus to develop a comprehensive up-to-date tool to guide the objective assessment of physical therapists performing airway suctioning. This process resulted in the creation of a tool that study participants thought would be useful to physical therapists. The revised tool is provided in the online Appendix, and we plan to conduct further studies to assess its utility.