Introduction

Physical activity (PA) provides a multitude of physical, emotional, and mental benefits (U.S. Department of Health and Human Services [USDHHS], 2018). Not only does PA enhance a person's quality of life, but it also creates an avenue for disease prevention and management (Pedersen & Saltin, 2015; USDHHS, 2018). However, less than 20% of Americans are meeting the recommended PA guidelines for aerobic activity and muscle strengthening (Lauer et al., 2017), with physical distancing restrictions during the COVID-19 pandemic adversely affecting these numbers further. Physical inactivity can stem from many different reasons, such as lack of access to parks or fitness centers, unsafe environments, and other poor lifestyle habits (Booth et al., 2012). Concurrently, individuals are spending more time in sedentary behavior and engaging in screen time, decreasing the amount of time spent participating in PA behaviors (President's Council on Sports Fitness & Nutrition, 2017). These trends have led to a pressing need for more efforts to educate the public about the importance of regular PA.

Health care providers are trusted professionals that can play a crucial role in encouraging and guiding patients to effectively incorporate PA into their daily lives (Frank et al., 2008). Although providing long-term primary care, health care professionals can help patients set priorities and overcome PA barriers as a means of maintaining overall health, as well as addressing a wide array of physical and mental chronic diseases (Berra et al., 2015). Efforts to provide PA counseling are linked to increased PA levels in patients (Berra et al., 2015; Coom et al., 2020). Often the first point of contact for patients in providing effective and supportive care, nurse practitioners (NPs) play a major role in positively affecting their patients' PA levels because of repeated interactions over the lifespan in which NPs learn patient preferences and can develop tailored PA strategies (Richards, 2015; Woo et al., 2017).

Despite its importance in disease prevention and treatment, few health care providers counsel their patients on PA (Hillier et al., 2017). Although studies have documented health care providers' positive attitudes toward and willingness to promote PA (Happell et al., 2011; Hebert et al., 2012; Karvinen et al., 2012), previous research has also demonstrated a lack of knowledge, confidence, and training (Auyoung et al., 2016; Cardinal et al., 2015; Dirks-Naylor et al., 2016; Happell et al., 2011; Hebert et al., 2012; Kime et al., 2020). More than half of U.S. medical programs do not provide formal PA training (Cardinal et al., 2015) and that PA training for U.S. medical students, although gradually increasing, is still inadequate and often does not provide students with sufficient PA training (Stoutenberg et al., 2015). Consequently, as many as 75% of physicians feel ill prepared to give patients guidance on PA and diet regimens (Womersley & Ripullone, 2017).

Although calls to action and efforts to integrate PA training into health care provider curricula have focused largely on medical schools (Hill et al., 2015; Phillips et al., 2015; Sallis, 2009; Trilk & Phillips, 2014), the National Physical Activity Plan calls for a system approach that necessitates PA training for all health care professionals (National Physical Activity Plan Alliance, 2016). Despite the attention given to PA training in medical school curricula, there are no existing studies explicitly examining the level of PA training included in NP programs that we were able to find. With nearly 90% of NPs certified in an area of primary care and 69% delivering primary care, there is a need to better understand whether and how NPs are prepared during their professional training to promote their patients' PA behaviors (NP Fact Sheet, 2021). Therefore, the aim of this study was to broadly examine the amount and type of PA training offered across different primary care NP training programs in the United States, as well as future plans and barriers to integrating PA into the curriculum.

Methods

This cross-sectional study consisted of two phases. First, a broad overview of the inclusion of PA in NP training was assessed by extracting publicly available data from eligible NP program websites from October 2018 to September 2019. Second, a more in-depth assessment of programs was conducted via an online survey disseminated to NP program leaders from June 2019 to May 2020. Institutional review boards (IRBs) at the University of Tennessee-Chattanooga and the University of Miami provided an exemption for nonhuman participants' research, and IRB approval was secured from the University of Portland.

Eligible institutions and nurse practitioner programs

Institutions offering NP programs were considered eligible for the study if they were accredited by the Accreditation Commission for Education in Nursing (ACEN) or the Commission on Collegiate Nursing Education (CCNE). A master spreadsheet of all eligible institutions that had a primary care focus, including specializations in adult/gerontology, dual primary care/acute care, family, mental health/psychiatric, pediatric, or women's health/midwifery, was compiled. Excluded programs included those with a nonprimary care focus, such as specializations in acute care, anesthesia, clinical nurse leadership, emergency care, public health nursing, management/executive leadership, neonatal acute care, nursing education, or nursing research. Study staff reviewed institutions' websites to identify master, doctoral, and certificate NP programs offered at each institution. When there were overlapping programs at an institution, such as dual acute care/primary care programs and their standalone equivalents or, more generally, identical clinical courses across different program types (i.e., certificate, masters, doctoral), duplicate programs were excluded. Institutions that did not provide programmatic information were excluded from analysis. Overall, 1,067 NP programs across 373 institutions were deemed eligible.

Website review

Program- and PA-specific information was extracted from eligible NP programs' websites. Program-specific information included institution type (i.e., public or private), program type (e.g., master, doctoral, or certificate), program delivery (e.g., traditional, hybrid, or online), program specializations, program credit hours, availability of plans of study and course descriptions, and contact information for program representatives. Physical activity-specific information included whether website content included any mention of "general health promotion" and/or "PA-specific" keywords within program descriptions, plans of study, and course descriptions (Table 1).

Table 1. Keywords used during the review of nurse practitioner training program websites

Program leader surveys

Using information collected during the website review, representatives from eligible programs were contacted and asked to complete a survey about the PA content included in their NP curricula. A first email invitation was sent to the main program leader (i.e., program director). If they were nonresponsive, a follow-up email and a phone call were sent in successive weeks. Due to COVID-19, the follow-up phone calls were discontinued once institutions transitioned to online learning for the remainder of 2020. If efforts to contact the main program leader were unsuccessful, an email invitation to participate in the study was sent to a second program leader if their contact information was available, followed by a reminder email one week later if they were unresponsive. For institutions with more than one survey submission (n = 9), responses from only one survey were retained such that those reporting the inclusion of PA training superseded those that did not (n = 7), as well as surveys with more complete responses (n = 3).

The survey was modeled after previous work assessing PA training in medical schools (Stoutenberg et al., 2015). Survey items asked about the presence of and details regarding PA training within the NP program, such as discussion on aerobic activity and strength training guidelines, type and amount of training offered (e.g., number of dedicated hours, NP specializations offering training, methods of delivery [e.g., didactic, clinical], and the means by which training is offered [e.g., required courses, electives, or extracurricular opportunities]). Open-ended questions allowed program leaders to summarize the content of the PA training within their various offerings. Program leaders' perceptions of whether their institution was responsible for providing PA training and students' desire for PA training were assessed on a 5-point Likert scale (i.e., strongly agree to strongly disagree), whereas perceptions of how well students were prepared to counsel patients on PA basics and starting a PA program were assessed on a 4-point Likert scale (i.e., extremely well to slightly well). Program leaders were also surveyed on their future plans for integrating PA training and to describe barriers they experienced or anticipated experiencing when including PA training within their programs.

Statistical analysis

Coder reliability

Intrarater reliability and interrater reliability (IRR) were evaluated to ensure data collection accuracy. For intrarater reliability, a sample of five randomly selected institutions was rereviewed by each reviewer. Estimates of Cohen's Kappa suggested "almost perfect" levels of agreement between the initial reviews and rereviews for each reviewer (K₁ = 0.81, p < .006; K₂ = 0.90, p < .001; K₃ = 1, p < .001). For IRR, each reviewer also reexamined data for 10 institutions' websites previously collected by the other reviewers. Interrater reliability (IRR = 0.89, p < .001) was determined to be "almost perfect."

Website review

Descriptive statistics (frequencies and percentages) were calculated for all categorical quantitative variables. Chi-square and Fisher exact tests were used to compare differences in keywords within course titles and descriptions by institution type, program type, program specialty, and program delivery.

Program leader survey

Descriptive statistics (frequencies and percentages) were calculated for categorical, quantitative survey items. Median and interquartile range (IQR) were computed for the number of hours of PA training provided. The frequencies of common responses to open-ended survey questions (e.g., PA content, PA integration barriers) were tallied. Analyses were conducted using Statistical Package for the Social Sciences (SPSS), version 26.

Results

Website review

Data were extracted from the websites of 1,067 NP programs eligible for inclusion in this study. Institutions were predominately private (67.8%) and provided between 1 and 11 NP programs. A majority of programs included in the study were master level (50.7%), followed by doctoral level (43.0%) and certificate level (6.3%). The most common program specialization had a family focus (35.0%), followed by adult/gerontology (19.2%) and mental health/psychiatric care (16.4%). Programs were offered in in-person (34.4%), hybrid (30.3%), online (23.1%), and in mixed formats (12.2%).

Nearly one quarter of NP programs contained one or more general health promotion keywords in their program description. Of those programs with an available plan of study (86.5%, n = 920), 31.0% included general health promotion keywords within their course titles, most of which (69.0%) were not required courses. Of those programs with available course descriptions (30.4%, n = 322), 81.7% included one or more general health promotion keywords within their course descriptions. The most common general health promotion keywords included "health promotion," "disease prevention," and "chronic disease/illness." No PA-specific keywords were found within course titles, whereas only two mentions of PA (0.6%) were found in the course descriptions.

Chi-square tests revealed some relationships between program characteristics and the presence of general health promotion keywords. Programs most likely to include general health promotion keywords within their course titles were those offered in a hybrid format (p < .001) and with a family-focused specialization (p < .001). Programs more likely to include general health promotion keywords within their course descriptions were those offered at the master level (p = .029), in a traditional format (p = .005), and had a family-focused specialization (p < .001).

Program leader surveys

Of the 373 eligible institutions, representing 1,067 eligible NP programs, 200 completed an online survey (53.6%). Program leaders from four eligible institutions declined to participate (1.1%). Table 2 presents an overview of responses regarding the provision of PA training and perceptions of the program leaders. Of the 164 institutions that responded, a majority (84.8%; n = 139) of respondents strongly or somewhat agreed that it was the responsibility of the institution to provide PA training, whereas only 45.1% (n = 74) believed that their students desired PA training. A total of 45.0% (n = 90) of respondents reported no inclusion of PA training in their NP curricula. Of the institutions providing PA training, 54.2% (n = 58) reported formally including both aerobic activity and strength training recommendations, whereas 82.2% (n = 88) and 55.1% (n = 59) reported formally including aerobic activity and strength training recommendations, respectively. Sixty-two percent (n = 56) and 46.1% (n = 41) of respondents felt that their institution prepared students to effectively counsel patients on the basics of PA and to start a PA program, respectively.

Table 2. Overview of PA training in U.S. NP programs

A description of the NP specializations most commonly offering PA training and the format of the training is provided in Table 3. Physical activity content was integrated across all NP specializations, although it was most commonly included in family (67.3%), adult/gerontology (46.4%), and pediatric (35.5%) care. Physical activity content was delivered in various formats, with didactic lecture (75.5%) being the most common. The amount of time dedicated to PA training ranged from 10 minutes to 60 hours with a median of 2 hours (IQR = 4 hours). Thirty-four respondents were unable to provide an approximation of the time dedicated to PA training in their programs.

Table 3. Details regarding the inclusion of PA training for NP students (

Sixty-nine respondents (62.7%) provided details about the PA content covered within their NP core curricula. The most commonly reported content was instruction on the PA guidelines and recommendations in the context of disease prevention and/or health promotion (49.3%), followed by discussing PA in the context of patient education and care plan development (15.9%). Few respondents reported providing training on PA assessment (5.8%), prescription (8.7%), or behavioral counseling (1.5%). These findings were consistent with PA content reported in elective courses. Although some electives were available as offerings within NP programs, a small number of programs (n = 3) explicitly reported allowing students to take electives offered by other departments (e.g., kinesiology, exercise and sports science, and sports medicine). Thirty-one respondents (28.2%) provided details about PA content in extracurricular opportunities outside of the classroom. The different extracurricular activities offered consisted of grand round speakers, attending professional conferences, and volunteer opportunities, whereas activities outside the NP programs included personal wellness classes, access to gym facilities, club and intramural sports, and participation in PA-related student organizations.

Institutions providing PA training were most likely to report intentions to maintain the level of PA training currently offered (78.9%, n = 71), with 16.7% (n = 15) planning to increase their PA training in the future and 4.4% (n = 4) unsure. Among the institutions not currently offering PA training, 13.7% (n = 7) reported considering the addition of formal PA training into their curricula. Table 4 provides an overview of barriers to integrating PA training into NP programs. For institutions that currently provide PA training, the largest barrier was viewed as insufficient time (32.9%), followed by competing content taking priority (12.7%). Institutions that did not provide PA training reported that their primary barrier was competing content taking precedence (32.6%), with other barriers including program format (e.g., online, accelerated, executive model, and varied specializations) (21.7%) and insufficient time (15.2%). A total of 23 (29.1%) and 8 (17.4%) institutions that had and had not integrated PA training into their curricula, respectively, reported no barriers.

Table 4. Barriers to integrating PA education into NP programs

Discussion

This study was the first to assess the inclusion of PA training in primary care NP programs within the United States. Nearly three quarters (71.0%; n = 142) of responding institutions reported no or inadequate (i.e., teaching only aerobic or strength training recommendations) PA training in their curricula, despite most program leaders (84.8%) agreeing that their institution was responsible for providing this content. The level of PA training observed in this study (55.0%) was lower than that reported (78.0%) in U.S. medical schools by Stoutenberg et al. (2015). Given that only a third of adults in the United States receive PA counseling from a health care provider (Barnes & Schoenborn, 2012), this rate of PA inclusion in NP programs may translate into missed opportunities for adequately preparing NPs to provide future patients with PA guidance. This supports the notion that there are glaring deficiencies in the amount, type, or format of PA training currently provided to NP students.

Physical activity training content, dedicated time, and delivery

The inclusion of PA content was most likely to appear in NP programs with a family specialization (67.3%). Inclusion of PA is important for this specialization because a majority of students (65.4%) are trained as family NPs (NP Fact Sheet, 2021). Nevertheless, the wide-ranging health benefits of PA suggest the need for training across all specializations, especially those currently reporting lower levels of PA inclusion (e.g., mental health/psychiatric).

With a median of 2 hours of PA training reported across programs, NP students receive limited exposure to PA content, significantly less than that provided to U.S. medical students across 4 years (Stoutenberg et al., 2015). Although quantifying time spent on PA training can be challenging, the current median hours of PA training reported within NP programs are not likely adequate for addressing the role of PA in the prevention and treatment of the wide range of largely chronic conditions that affect patients' health. As a point of comparison, current recommendations for the inclusion of nutrition education in health care provider preparation suggest a minimum of 25 hours of training (National Research Council, 1985).

Beyond reported time spent on PA training, a look at reported PA content provides a clearer understanding of the state of NP preparation. The PA content delivered within NP programs emphasizes introductory information (e.g., PA guidelines and recommendations) over skill-based information (e.g., PA assessment, prescription, and behavioral counseling). Nonetheless, more consistent inclusion of introductory information is needed because nearly half (45.8%) of program leaders reported providing guidance for only aerobic activity or strength training national guidelines. Greater incorporation of national guidelines for aerobic activity (82.2%) over strength training guidelines (55.1%) in NP programs was a finding consistent with PA training in U.S. medical schools, albeit at lower levels of incorporation (61.0% for aerobic activity and 44.0% for strength training) (Stoutenberg et al., 2015), and parallels the lower rates of strength training observed among U.S. adults (Harris et al., 2013). Nurse practitioner programs should equally prepare students to provide strength training guidance for patients considering the many health benefits of strength training, including weight and chronic disease management (Singh et al., 2020). The predominance of didactic delivery (75.5%) of PA content over more hands-on and applied formats, e.g., clinical hours (34.5%) and simulation (15.5%), also suggests greater overall programmatic emphasis of introductory PA content over developing PA-related clinical skills. This finding may be problematic when considering a study of nursing students' attitudes toward health promotion by Mooney et al. (2011), in which the abstract teaching of a concept was found to be less effective than teaching embedded in clinical nursing needs (Mooney et al., 2011). Fewer than 10% of NP programs providing PA training mentioned teaching skills like PA assessment, prescription, or counseling that are used to promote patients' PA behaviors.

Future plans for physical activity inclusion

Reported intentions to increase (7.5%) or incorporate (3.5%) PA training into NP curricula were very low despite evidence that PA training interventions improve aspiring health care provider PA counseling attitudes, knowledge, and skills (Dacey et al., 2014). Although program leaders perceived that their institutions were responsible for preparing their students to promote patients' PA behaviors, they also felt that most NP students (54.9%) do not desire PA training. Previous research shows similar findings, demonstrating NP students' perceptions of health promotion as irrelevant, especially when their workload was perceived to be too great to afford time for health promotion (Mooney et al., 2011). Although lack of student interest in PA training was not a highly rated barrier in this study, such perceptions may impede overall efforts toward PA inclusion.

Barriers to physical activity inclusion in nurse practitioner programs

Insufficient time for PA inclusion and competing content, the two main barriers identified by program leaders, are similar to challenges previously reported for U.S. medical schools (Stoutenberg et al., 2015). These barriers may prove to be larger barriers for NP programs, given their shorter average of 3-year plans of study for Doctor of Nursing Practice relative to medical schools with a four-year plan of study. Innovative strategies tailored to these realities are needed, although current efforts being used for medical students may provide some guidance (Hill et al, 2015; Phillips et al., 2015; Trilk & Phillips, 2014). To begin with, PA content can be integrated into existing NP course modules, as opposed to modularized. Integration into existing skill-based opportunities (e.g., interprofessional development, simulation) can limit additional time commitments to NP curricula while introducing PA content in practical ways that demonstrate its relevance and utility across the continuum of care (Mooney et al., 2011; Pojednic & Stoutenberg, 2020). Existing resources, such as those generated by Exercise is Medicine, can be tailored and used to inform these efforts, thus minimizing additional time burdens for faculty (ACSM, 2021). As a complement to NP program course offerings, provision of PA content via elective courses is a promising and underused strategy for PA inclusion, although additional flexibility in NP program plans of study may be a prerequisite. Extracurricular opportunities were not widely reported by program leaders but may serve as an ideal means for providing NP students PA training opportunities when NP program plans of study do not. These supplemental experiences not only address time barriers but are an effective means of imparting PA content (Mooney et al., 2011) and increasing both NP students' personal PA behaviors and professional PA promotion practices (Lobelo & Garcia de Quevedo, 2016). Personal self-care promotion may be especially important for nursing students that have lower PA levels, perceive fewer benefits and more barriers to PA, and have less PA social support than medical students (Blake et al., 2017). Further, inclusion of faculty with PA expertise, whether housed directly within or outside of an NP program, may also afford opportunities to efficiently and effectively integrate PA training opportunities into NP curricula.

The identification of program format as a top barrier for institutions not currently providing PA training was novel and not previously seen in previous studies. Although online program delivery may present some challenges for how to effectively provide PA training, especially with regards to the provision of skill-developing formats like simulation, clinical virtual simulation has been shown to be an effective and acceptable means of delivering content (Padilha et al., 2018). Overall, efforts to increase the priority placed on PA training should be housed within larger efforts to promote a paradigm shift that more strongly emphasizes health promotion and disease prevention in nursing programs (Hicks, 2018; Levy et al., 2014).

Broader efforts to promote physical activity training in nurse practitioner programs

Widespread adoption of PA training in NP programs requires a multifaceted, multistakeholder approach that extends beyond actions by individual NP programs to include academic and professional partners who can help to facilitate the inclusion of PA training. Nursing professional organizations (e.g., Quality and Safety Education for Nurses, National Organization of Nurse Practitioner Faculties) and accrediting bodies (e.g., ACEN, CCNE) are instrumental in informing relevant paradigm shifts in the health care environment (Schumacher & Risco, 2017) and reinforcing curricular updates spearheaded by NP programs that more explicitly promote and integrate PA content. The American Association of Colleges of Nursing's (AACN) 2021 educational framework, "The Essentials: Core Competencies for Professional Nursing Education," includes self-care management competencies that align well with PA promotion clinical skills, suggesting that efforts by NP programs to more intentionally incorporate PA into existing NP curricula would be both feasible and acceptable (AACN, 2021). Boards of nursing that develop licensure examinations can further reinforce PA integration by directly assessing PA knowledge and skills relevant to these standards of education. Moreover, health care systems, that serve as clinical partners for training programs and employ NPs, can play an influential role in concert with academic partners (Hicks, 2018). Previous calls to action (e.g., making PA a vital sign, including PA assessments in electronic health records, reimbursement for PA counseling) for updating standards of medical care to promote PA are exemplars for system and policy level change that will complement NP program efforts and bolster a culture of health promotion in health care settings (Berra et al., 2015; Bowen at al., 2019; Levy et al., 2014; Sallis et al., 2016; Stoutenberg et al., 2018; Whitsel et al., 2020). Collectively, these initiatives would clarify and normalize the high priority of PA promotion within the NP scope of practice for students and faculty alike (Mooney et al., 2011).

Presented findings and recommendations should be viewed in the context of study limitations. The program leader survey response rate was 53.2%, leaving a large number of institutions and NP programs omitted from this analysis. This response rate, however, was greater than previous research assessing PA inclusion in U.S. medical schools (Stoutenberg et al., 2015) and achieved despite the recruitment challenges faced during the COVID-19 pandemic. The self-selective nature of survey participation may have led to an overestimation of the overall level of PA training provided with NP programs. The website review, however, most likely underestimates PA inclusion through inaccurate reporting of course content in course titles and descriptions, which makes the two-phase data collection approach for this study an overall strength. Nuance and variability in programmatic offerings, in general and within an institution, may have been lost with single program leaders providing responses for multiple NP programs. Moreover, program leaders less familiar with one or more of their NP programs may have been unaware of the presence or absence of PA training. Finally, program leaders' self-reported perceptions may not be accurate depictions or reflective of student, faculty or administration consensus; nonetheless, they shed light on important considerations linked to the provision and potential adoption of PA training in NP curricula. Future studies should work to address these limitations and further explore PA training differences by program format and level of PA integration across courses.

Conclusion

This study provides an overview of the state of PA training inclusion in primary care NP programs within the U.S. Findings suggest the need for greater levels of inclusion of PA content, with increased emphasis on skill development, so that NP students will be adequately prepared to assess PA and deliver PA guidance to future patients. Concerted efforts are needed by NP programs, as well as academic and professional partners, to reduce barriers to and facilitate widespread adoption of PA training in NP programs.

Acknowledgments: A. Falcon, A. Vermeesch, and M. Stoutenberg developed the project. E. Sampson, M. Bender-Stephanski, W. Webb, and Y. Woo collected data. A. Falcon analyzed all data. All authors contributed to the writing and revision of the manuscript. M. Stoutenberg is a consultant to Exercise is Medicine, a program of the American College of Sports Medicine.

References