Amanda Baskwill, PhD, MSc, BEd, RMT1*, Bryn Sumpton, BScN2, Stacey Shipwright, BA(Hons), RMT3, Lynda Atack, PhD4, Janet Maher, PhD4
1Faculty of Health Sciences and Wellness, Humber College, Etobicoke, ON, Canada
2College of Massage Therapists of Ontario, Toronto, ON, Canada
3Massage Therapy Program, School of Community and Health Studies, Centennial College, Toronto, ON, Canada
4Applied Research Centre, Centennial College, Toronto, ON, Canada
Background:
Massage therapists have been a part of Canadian’s health care since 1919. The profession has gone through great change over the past 100 years including adjustments to entry-to-practice education. An important recent change was the implementation of massage therapy (MT) education program accreditation. In light of the likely disruption as a result of programs becoming accredited, a scan of the current state of MT education in Canada was undertaken.
Methods:
An environmental scan informed by seminal medical education efforts was used to describe the thoughts and opinions of MT education stakeholders in Canada. Specifically, stakeholders were interviewed regarding the current state of MT education and their comments were analyzed for common themes.
Results:
Twenty-one stakeholders participated. Four themes were constructed: variation, isolation, stagnation, and accreditation. Variation is described as the impact of differences in content and quality of the education provided in MT colleges. Isolation is described as the feeling of the participant being separated, or disconnected, from the regulator, accreditor, or colleagues due, at least in part, to a lack of communication or networking opportunities. Stagnation is described as a lack of activity, growth, or development within MT education. Participants talked about accreditation, both as a solution for some of the challenges previously mentioned, and as a potential challenge in itself.
Conclusions:
Several challenges to MT education were described by stakeholders that they hoped would be remedied by national MT program accreditation. Despite some limitations, this environmental scan forms a baseline for stakeholder views on massage education in Canada upon which future comparisons can be made. While the environmental scan results are most useful when applied to the MT in Canada context, stakeholders in other countries may also find them interesting and valuable when considering challenges facing their own education programs.
KEYWORDS: Accreditation, pre-service education, learning environment
Health care education is arguably the foundation for the development of health care professionals with changes to the profession impacting education. For example, the CANMeds Framework was developed in 2004 and identifies key abilities physicians must possess to best meet patient health care needs.(1,2) Canadian medical education concurrently evolved to include the CANMeds Framework and implement matching outcomes-based education strategies. It is important to evaluate and monitor the impact of practice and related education changes in health care and other applied fields as recognized in the efforts of Hodge and colleagues(3) in their environmental scan of Canadian medical education in 2011. In their study, Hodges et al. conducted qualitative interviews with key informants to examine how well medical schools were adapting to policy and societal change. Hodge’s environmental scan formed the foundation of a national blueprint for recognized priorities, challenges, innovations, and needs in Canada’s medical education.(3)
Massage therapists have been a part of Canadian’s health care since 1919. Canadian massage therapy (MT) education programs encompass a broad spectrum of program types, lengths, and sizes, depending on the type of institution, province, regulation, and individual program. An estimated 85 education institutions existed in 2013, with many offering multiple MT programs.(4) These programs ranged from six months to three years, and were offered by privately-operated or publicly-funded colleges at a diploma level. At the time of this manuscript’s writing, five provinces regulate massage therapy and require individuals who wish to become a registered massage therapist to graduate from a recognized education program.
Curricular requirements in regulated Canadian provinces are influenced by the respective regulatory colleges through entry-to-practice competencies and exams. Regulated provinces transitioned to the Inter-jurisdictional Practice Competencies and Performance Indicators in 2013 which outline a unified set of entry-to-practice knowledge, skills, and attitudes for massage therapists.(5) This document was developed by a collaboration of the then three Canadian MT regulators, and became the basis for entry-to-practice examination content and has undergone revision.(6) Unregulated provinces rely on voluntary-membership associations to provide guidance regarding educational requirements, with some setting requirements similar to those of regulated provinces or conducting their own entry-to-practice exams.
There has been no form of programmatic accreditation for MT programs in Canada until recently, other than in the province of British Columbia (BC) within which the College of Massage Therapists of British Columbia accredits programs directly. Colleges in other provinces were either not accredited or accredited by American organizations, such as the Commission on Massage Therapy Accreditation (COMTA). After many years of discussion within the profession, a national effort involving the regulatory colleges, provincial association, and other stakeholders resulted in an agreement to accredit MT programs through a third-party organization. Concurrently to these efforts and also in 2013, the Canadian Massage Therapy Council for Accreditation (CMTCA) was created. It released draft accreditation standards and began accrediting Canadian MT colleges in February 2018. It is reasonable to anticipate these various MT education accreditation efforts will have an impact on Canadian MT education generally. Efforts to measure such impacts would benefit from a documented baseline for Canadian massage therapy education prior to widespread implementation of accreditation regulation.
The variety of institutions, regulatory situations, programs lengths and sizes suggest that national standardization will lead to different challenges. Accreditation is thought to benefit the profession of massage therapy by standardizing education quality, increasing practitioner mobility, and increasing access to resources for education institutions.(4) Research by Menard(7) in the US suggests positive outcomes of programmatic accreditation for MT programs, including better value for students and decreased disciplinary actions against graduates. The five Canadian provincial governments to regulate massage therapists are: British Columbia, New Brunswick, Newfoundland & Labrador, Ontario, and Prince Edward Island.(8-12) There are efforts to regulate in many unregulated provinces and territories, and each is at a different stage of the regulatory process. Alberta and Manitoba are in the process of developing a transitional regulatory council,(13,14) while Nova Scotia and Saskatchewan are proposing regulation.(15,16) Other provinces and territories, such as the Northwest Territories, are engaging in general efforts to seek regulation.(17) The diverse regulatory landscape results in differing roles and responsibilities for massage therapists depending on the jurisdiction in which they live and work. This also means that there may be parallel differences in education, although little has been studied or published.
The context described here provides an excellent situation in which an environmental scan could be implemented to examine the priorities and challenges facing MT education stakeholders early in the process of national MT program accreditation. While the environmental scan results will be most useful when applied to the Canadian context, stakeholders in other countries may also find them interesting and valuable when considering challenges facing their own education programs.
The environmental scan described in this work sought to form a baseline upon which future comparisons could be made. By describing the challenges experienced related to MT education during the early accreditation stage, the impact of accreditation on the environment of Canadian MT education can be monitored.
This study used environmental scanning as described by Hodges et al.(3) as a methodological framework for qualitative interviews with MT education stakeholders. All study activity took place between September 21, 2017 and May 11, 2018 and was approved by Humber College’s Research Ethics Board (RP-0257).
Qualitative interviews gathered data from key MT education stakeholders to conduct an environmental scan of Canadian MT education early in the regulatory accreditation process.
Potential participants were educators and administrators from massage therapy programs in Canada. In addition, practitioners, regulators, and advocates were invited to participate. A list of massage-related institutions was compiled from an internet search. Institutions and individuals were contacted by email using publicly available information. Purposive maximum variation sampling(18,19) used a matrix to ensure representation across variables, including publicly-funded and privately-operated institutions, regulated and unregulated jurisdictions, educators and administrators, and different regions of Canada. Individuals were asked to identify other potential participants at the conclusion of the interview. Based upon the work of Hodges et al.,(3) 20 participants were expected to be needed to reach saturation of themes.
Semi-structured interviews were conducted by phone by one member of the research team (JM). An interview guide, based on the Hodges study(3) and input from the research team, was used (Appendix A). The interviews were audio recorded and transcribed using a professional transcription service. Recruitment ended when saturation of themes was reached(20,21)—in other words, when there were no new concepts of analytic interest raised by participants. The transcripts were then reviewed by two members of the research team (BDS, SS) for accuracy.
The transcripts were coded using each participant statement as a unit of analysis. We began by reviewing the overall data and developing a categorization scheme.(22,23) Each transcript was read in its entirety and coded for correspondence to the identified categories, while allowing for the emergence of new categories as data were analyzed in depth. One researcher coded all transcripts and members of the research team also coded one third of the transcripts independently. The results were compared to enhance the credibility and transferability of study findings.
The research team is made up of five individuals with diverse backgrounds. All of the researchers are health care educators. Three of the researchers (BDS, AB, SS) are massage therapy educators and have acted as massage therapy advocates with the provincial massage therapy association. Two researchers who had less connection to the MT profession took the lead on the interviews (JM) and the data analysis (LA).
To enhance credibility, multiple researchers participated in the analysis of the interview transcripts (LA, BS, SS). The initial analysis was done independently. Researchers then compared their results and reviewed any areas of disagreement. The research team engaged in peer debriefing on a monthly basis, which allowed for consensus decision making throughout the process. Transferability of the results is supported by the rich descriptions provided.
Member checking was achieved through an invitation to participate in a webinar session. All participants were invited by email. In this session, the results were presented by two of the researchers (AB, BS). Participants were then asked whether or not they saw themselves in the results as presented. An open discussion followed.
Forty-three individuals from nine provinces and one territory were contacted to participate. Three declined to participate and 19 did not respond to the invitation to be interviewed. Those who did not respond or who chose not to participate came from all areas of the participant matrix. Twenty-one individuals participated. Two were part of a regulatory body, four were employed by or volunteered for their professional association, two were administrators in publicly-funded colleges, four were administrators at privately-operated colleges, three were instructors at publicly-funded colleges, and six were instructors at privately-operated colleges. Six provinces (British Columbia, Alberta, Manitoba, Ontario, Nova Scotia, and Prince Edward Island) were represented in the study. Interviews lasted between 12 and 40 minutes. Three participants joined the webinar provided to review the study findings. They indicated that they saw themselves represented in the results.
Table 1 displays the themes and subthemes which emerged from the coded transcripts about challenges facing MT Education. Specifically, three primary themes each with two to four subthemes emerged in addition to a forth, standalone theme: variation, isolation, and stagnation; the standalone theme was accreditation.
The theme of variation is described as the impact of differences in content and quality of the education provided in MT colleges. At times, this theme seemed inseparable from participants’ experiences of variation within the profession. They described variation in the profession as a challenge for educators, as it made it difficult for them to know what should be included in the curriculum. Participants also described that variation in education creates variation in graduates and, subsequently, practitioners. “I think some of the issue is [lack of] consistency in the curriculum from college to college and from province to province. That [lack of] consistency in the education then reflects in the consistency of the product—which is the student or the future massage therapist.”
This cycle of increasing variation was of great concern. Variation in what constitutes massage therapy was also noted as a contributing factor. “The way that massage therapy is defined across the country is so variable that preparation for entry level practice is also going to be variable, so that’s a challenge”.
Participants were asked to describe their overall perceptions of the current state of MT education. Many used words and phrases such as “in flux”, “scattered”, “at a crossroads”, “all over the map”, and “too chaotic”. Some said that massage therapists in Canada are widely considered some of the best in the world, due, in part, to their education. With that said, there was unanimous agreement that MT education is currently undergoing significant change and lacked standardization. The variation described included differences in privately-operated vs. publicly-funded education programs, and differences between provinces; and variation spanned the length of program, and preparation of instructors.
The wide variation in content and quality in MT programs was felt to stem, at least in part, from differences in privately-operated and publicly-funded education programs. Some shared that MT education originated in privately-operated colleges and is now also offered in publicly-funded colleges. Several participants, from both sectors, suggested that the privately-operated college sector was holding back MT education. Participants felt that too much education was taking place in privately-operated colleges. And while some ‘legacy’ privately-operated colleges have solid reputations, some of the more recently established privately-operated colleges do not. Participants felt that the privately-operated colleges that want to offer a strong program also needed to operate a viable business, and they saw them as financially driven. “I’m not seeing a lot of dedication to anything other than the bottom line.”
The challenge of how to get smaller, private, finance-driven institutions committed to excellence was expressed. Competition for students was identified as an important issue in Ontario, which was described as having too many colleges, all vying for the same students. One participant noted, “[Privately-operated colleges] set the instructors as competitors instead of [collaborators]. [In massage therapy], we see competition and a lack of sharing of resources.” Another stated, “I think they are looking at what will draw people to their school and not necessarily what will make them the best school.” Privately-operated colleges were also seen as not providing education in the humanities or civics, which is part of the public education curriculum and considered by participants to be essential in helping students to think creatively and critically.
Limitations in the publicly-funded college system were also identified. Participants felt that there was a lot of unpaid work being done by part-time instructors. They shared that these instructors are not paid for lesson preparation and other out-of-class work. Participants felt this led to faculty turnover, resulting in quality variation. Furthermore, being part of a publicly-funded college meant that programs were constrained by those institutions’ policies and procedures and were, therefore, less nimble in responding to change.
Some participants felt that “streamlining the number of institutions providing MT in a province might be helpful.” They described that some provinces had a “multitude” of programs and felt that it diluted the quality of MT education. Limiting the number of colleges, they felt, would allow for the remaining programs to hire the best instructors to ensure the curriculum delivered was of the highest quality.
The regulatory status of the province was perceived to result in considerable variation in required program standards across the country. One participant commented, “There are four provinces that have the interjurisdictional competencies that bind us, then, it’s a bit of a wild west out there [in unregulated jurisdictions].” Variation in programs and standards was also reported to pose a problem regarding job mobility. When massage therapists move to a new province, expectations of practice held by the practitioner may differ from those of their clients. “We know what a physiotherapist or a chiropractor does from province to province, but what a massage therapist does, and how they are licensed or regulated or what they practise, or even the definition of massage therapy, is different across the country.” Participants shared that both massage therapists and the public have mixed perceptions. For some, massage therapists were health care professionals; for others, they were service providers. MT was viewed by some as a profession with deep commitment to clients, while for others it was seen as a quick certificate to a job. Participants suggested that this confusion and variation in perception is holding the profession back.
Participants felt that in the past, program quality was measured by program hours. They felt that the move to align curriculum with national competencies was a good one; however, program hours should not be dismissed. Neither competencies nor hours alone were a guarantee of quality education. Some participants reported that privately-operated colleges offered relatively short programs. “I’m very concerned when I see schools that are offering a massage therapy certificate and the ability to pass an entry-to-practice exam with a 6-month or an 18-month course.” Current students also want shorter programs; therefore, some colleges, wishing to be competitive, are under pressure to deliver the curriculum in a compressed amount of time.
Participants differed on whether the educational requirement at entry-to-practice should be a diploma or baccalaureate degree. Some felt that a baccalaureate degree was needed to develop the breadth of knowledge required for professional practice beyond the basic skills needed for treatment, such as “health care is not just a purely a mechanical piece”, and “three years of clinical experience is not enough when teaching certain aspects of our education and training like therapeutic relationships, professional ethics, [and] critical thinking.” Others felt that a MT degree should be offered, but not required, for entry-to-practice, and that it was more important to improve existing programs before taking that step. “We need a degree program in MT, but more urgently [we] need to have a level playing field across the country.” One participant shared that “one of the only ways to get full professional respectability across the country and professionalization of massage therapy is to have it as a degree program or as a college diploma program” linking education credential to perception of the profession. Participants were encouraged that universities were increasingly recognizing MT courses and awarding credit towards a degree. This includes increased articulation agreements between colleges and universities. A pathway to higher education was seen as a desirable next step for graduates.
Another challenge, reported by the majority of participants, was the considerable variation in MT instructor training. Currently, there is no national standardized training or credentialing process for MT instructors. Instructors were described as “practitioner-teacher hybrids”, suggesting that they rely on their clinical experience and not education in teaching and learning. “You need to be an educator and have all of those tools and training and have the professional knowledge and tools. I think in our field, [we] often have a lot of therapists, and they mean well, but sometimes their teaching tools aren’t quite as well versed as their therapeutic knowledge.” Many have a strong background in MT practice with excellent therapeutic knowledge; however, they do not understand adult education principles to support excellence in teaching.
Participants suggested that there was a dearth of experienced, qualified instructors, which was emphasized by the rapid and continuous growth in MT colleges. Variation in instructor qualifications was also attributed to the differences in the privately-operated and publicly-funded education systems; the public system was viewed as setting higher standards for teaching and supporting instructor education. With one revenue stream, “private schools just don’t have the same resources or perhaps just don’t have the same sort of process that a community college would have for credentialing instructors.” Variation in instructors means that the quality of classroom instruction and instructional design may be affected.
The theme of isolation is described as the feeling of the participant being separated, or disconnected, from the regulator, accreditor or colleagues due, at least in part, to a lack of communication or networking opportunities. This theme was thought to impact the ability of MT education to progress and innovate. Participants generally felt that sharing of resources and collaboration would be beneficial for programs, instructors, and ultimately, the student experience.
While appreciating the importance of regulation, and recognizing that regulators are driving the change that is building the profession, several participants who identified as instructors noted that MT regulators did not seem to appreciate the complexity of the education process. They felt that the regulators “operated behind closed doors” and often announced decisions affecting curriculum with little warning. Regulatory participants noted that some instructors and administrators became defensive when asked about a practice or were audited to determine if they were following standards.
Participants also noted the challenge of dealing with multiple regulators. One noted:
“We are regulated by the private training institute branch of the Ministry of Advanced Education in [one province]. They have regulations, and then the [regulatory body] is still the regulator in [the province], so they have requirements, and then the CMTCA is now our accrediting body. Dealing with all these regulatory bodies is quite costly, and sometimes the requirements that one has doesn’t match what another … requires.”
The various ministries associated with MT education were seen as not working in harmony. Lastly, a participant suggested that “there is a deep lack of trust between educators and regulators”, and a sense that communication is only in one direction.
Many smaller colleges have a relatively small pool of instructors. These instructors have little opportunity to share teaching strategies and resources. For example, previous instructors may not pass on what they have created when the course is taught by a new instructor. “[When] I stepped into one of the courses that [I taught] last year, I had nothing”. This lack of sharing of resources also means that each college is occupied with developing the learning resources and evaluation methods. Instructors reported the need to communicate and network with others to share strategies for preparing and succeeding with accreditation. National accreditation was seen as an opportunity for instructors and administrators to share practices and resources. Accreditation is discussed in detail below.
The theme of stagnation is described as a lack of activity, growth, or development within MT education. It was suggested that stagnation related to resources, content, and learning strategies. Participants often related limitations to change or improvement to bureaucratic momentum or red tape, a culture of resistance to change, and resource differences between programs and colleges of different sizes.
An area of stagnation noted by participants was related to learning resources. One participant shared that “… there is a textbook on the [College of Massage Therapists of Ontario’s] list that is older than I am and I am 45!” It was suggested that the reason old texts are used in education programs is because these texts appear on the regulatory body’s list of resources used to inform the content of the entry-to-practice exams. Instructors feel obligated to use these texts, and consequently feel like they are teaching to the exam. In these instances, students are taught the information that may appear on an entry-to-practice exam at the expense of learning current evidence-informed content. “The regulatory body says their role is not to control and education; however, we find our hands get tied by their requirements, impairing educators who want to make change such as incorporating current research or resources.” A separate, but related, issue was that the selection of MT-specific textbooks is limited. Participants reported that instructors and developers used physiotherapy and occupational therapy texts when MT-specific resources were not available or lacked credibility. While physiotherapy and occupational therapy textbooks are useful, they were described as including information that was outside the scope of practice of massage therapists.
A lack of commitment by programs to evidence-informed practice was identified as a challenge for MT education. Many participants noted that massage therapists should be held to similar standards as other health practitioners who are committed to evidence-informed practice. However, they felt that there was a research literacy gap in MT curriculum in general. Some of this was attributed to the lack of research literacy of instructors. “We see a certain amount of unease with research and research translation and current best practices in manual therapy”. Participants were adamant that MT research is critical to support practice and to advance the profession. Further, some routine practices and techniques have recently been questioned as a result of recent research indicating that the curriculum is not evidence-informed in some areas. This gap has left instructors and practitioners feeling that they do not have a solid foundation in some areas.
Participants indicated that, in addition to the research literacy gap in the curriculum, there is a shortage of large scale, rigorous MT research to guide practice. Much of MT research is done by researchers outside the MT profession who view the study through a different lens. “When you start looking at crossover research, like physiotherapy, it is a very different lens that gets looked through”. This gap in research literacy and capacity was seen as a barrier to the development and implementation of evidence-informed curriculum.
Some participants reported that current students preferred to use technology in the classroom, which was seen as a challenge for professors not familiar or comfortable with emerging educational technology. The integration of technology was something to be managed by instructors, who might be unskilled in how to adapt learning strategies due to the lack of education-specific preparation described above. Participants felt that instructors need professional development as to strategies that would effectively engage current learners, such as online learning and simulation. Participants suggested some programs are still using older teaching methods that emphasize rote memorization instead of teaching students to access resources as needed and to apply critical thinking.
Participants talked about accreditation, both as a solution for some of the challenges previously mentioned, and a potential challenge in itself. The accreditation process, while viewed as a major undertaking, was described as “important and necessary”. It was thought to be able to address the main challenge reported by participants—the wide variation in curricula in programs across the country. “I think accreditation is going to help us make that conversation and the language we use more similar across the country.” The majority of participants felt very positive about this initiative. and were optimistic that accreditation would drive the standardization of MT education across the country.
Participants were hopeful that accreditation would help to align content and teaching practices. One noted, “It will enable us to look inwards again from a different way than we ever had before.” Viewing curriculum, teaching, and evaluation methods through a critical lens in preparation for accreditation was expected to improve quality in those domains.
Accreditation was expected to improve strong programs and potentially remove weaker programs. “I think accreditation [will have] a side benefit of maybe weeding out some folks who, once they really have to demonstrate that they are meeting certain requirements and standards, will not bother.” Accreditation, while potentially bringing benefits, could increase program costs and contribute to the challenge alignment with multiple layers of regulatory bodies.
“We are regulated by the private training institute branch of the Ministry of Advanced Education in B.C. They have regulations, and then the CMTBC is still the regulator in BC, so they have requirements, and then the CMTCA is now our accrediting body. Dealing with all these regulatory bodies is quite costly and sometimes the requirements that one has doesn’t match what another regulatory body requires.”
Costs may include the accreditation annual fee, the site visit fee, increases in staffing, and augmentation of student resources. Some participants suggested that some provinces and colleges are balking at regulation and accreditation for cost reasons, as considerable changes will have to be made regarding staffing, class sizes and student and instructor resources.
Massage therapy education in Canada is at a crossroads with regard to accreditation and standardization. The genesis for this study was the impending implementation of national accreditation, which was clearly top of mind for these participants. The challenges facing MT education described by the participants mirrored challenges facing the profession of MT in general, so much so that, at times, it was difficult to separate the two.
The variation in MT education echoed the variation seen in the profession. Massage therapy is regulated in five provinces in Canada. While each of these provinces has a regulatory body to oversee the protection of the public and the standards of practice, each body operates under its provincial legislation which introduces variation at the foundation of the profession.(8-12) With a slightly different scope of practice in these regulated provinces, the resulting education programs naturally include slight differences. The variation that begins with scope of practice extends into standards of practice, which govern how massage therapists operate their practice and engage with patients. Whatever variation in practice that exists within regulated provinces becomes increased in provinces that are not regulated. Without regulation, there is nothing preventing the use of the term massage therapist. Similarly, there is also no educational requirement, resulting in the opportunity for programs to determine the program details.
As variation in MT education reflects variation in the profession, participants shared ideas regarding the many layers of isolation felt in their classrooms, programs, and institutions that mirrored the solitude of professional practice. Massage therapists often perform their work one-on-one with their patients with limited professional supervision or interaction with other therapists. Often, they practise in small clinics as contractors with few opportunities for professional exchange and limited venues for collective sharing. Massage therapists, through self-selection of profession and habitual practice, can develop a comfort with silence, communicating through their hands in their work and independent problem solving, which contributes to their sense of individualism and isolation.(24) When these aspects of MT culture are extrapolated to the educational realm, they may affect massage therapists’ relationships with each other, colleagues, other health care providers, and their professional institutions.
Isolation from colleagues can also result from precarious employment situations and perceived competition among instructors and between institutions. Participants shared that MT instructors are often part-time employees with limited job security. Tenuous security can lead to protectionist behaviours regarding curriculum content, teaching techniques, and course content. When protectionist behaviours are extended to MT institutions, administrators or content curators may think it is advantageous to keep program content private, limiting opportunities for exchange. Participants mentioned a recent educators’ conference in Ontario as an example of a rare opportunity for exchange of ideas and training. Outside of Ontario, the limited number of institutions and their distribution across a country as large as Canada may increase the challenge of holding and attending events that foster these types of broad exchange.
Isolation of educators from regulators may result from differences in perceived role, mirroring the dynamic between regulators and the profession, or for power dynamics related to authority. Regulators’ primary role is that of providing parameters to the profession to protect the public interest and this extends to setting requirements for entry-to-practice education; the regulation of education is a secondary responsibility. This is further reflected in the role of other provincial education ministries in regulating MT institutions. As such, regulatory actions, such as providing clinical or ethical guidance, are primarily aimed at practitioners, leaving MT educators to interpret and apply these to their programs. The requirements of one regulatory layer may not match or be easily related to another. In addition, as the regulator may find itself in an adversarial situation with members of the profession, due to new requirements of practice or disciplinary actions, educators’ views of their actions regarding education requirements may be coloured by their experiences as members of the profession.
Most massage therapists work is individualistic with relatively little direct supervision or oversight by others—perhaps, in part, due to their usual employment status as contractors. Generally, they act independently in their clinical decision-making, treatment planning, and other clinical activities. This level of independence may make the profession uneasy with external review and feedback. When this is extended to the education realm, instructors may be more prone to independent development of curriculum, course content, and content delivery. They may also be less familiar with supervisory rolls, the incorporation of feedback from others, and sharing with colleagues. Systemically, this may have been reflected in participants’ sense of isolation from each other and other colleges. Individual approaches to program development more easily align with practitioner experiences and culture.
When discussing a sense of regulatory isolation, participants also suggested regulatory practice guidance, as found in curriculum and examination documents, did not reflect current research evidence. The incorporation of new learning in the sciences related to MT requires dialogue between researchers, clinicians, and educators. This is often fostered via networking opportunities and social functions facilitated by conferences, seminars, and other profession-focused events that allow for the exchange of ideas between instructors, institutions, and across geographic boundaries. Knowledge translation and integration of new learning into practice and its education is likely limited.
Massage therapy, like many health professions, faces barriers to the continued production of high-quality research applicable to practise including limited funding, few research-focused academic positions, and the profession’s research culture.(25) Research is often fostered within academic institutions and scholarly work at the master’s and doctoral level. As entry-to-practice education in MT is a diploma, there may be limited opportunities for practitioners to transition to higher education. In addition, for those that do continue, there are no MT degrees or graduate programs, leading to degrees in other fields and research generated that may not focus on the profession. The foundation then for knowledge translation into the texts and curricula is inherently limited by the research available. Other studies on the profession suggest that there are limitations in research literacy, awareness of current evidence, and research utilization in practice.(26,27) These limitations likely extend to instructors, particularly those who have not completed graduate or postgraduate education.
Institutional support for research and its integration into instruction is provided through internal research funding, the provision of support staff, access to Research Ethics Boards, applied research centres, and other infrastructure. Smaller institutions are unlikely to be able to provide these, along with the staff hours needed to generate and incorporate research evidence. As MT instruction is often provided by smaller privately-operated colleges, opportunity to generate and incorporate research evidence may also be limited. This supports previous stakeholder interviews conducted in BC that found a lack of progress in conducting and incorporating research in education as primary concerns.(28) Barriers identified included program length and lack of space within current curriculum. Similarly, American massage therapy stakeholders identified supporting research activities and incorporating research evidence in schools as top priorities for the profession’s continued progress, while citing the barriers of limited research capacity in the profession and inconsistent standards for its incorporation in the classroom.(29) Given the limitations, the isolation described regarding protectionist practices and sharing between instructors and colleges could contribute to stagnation. Stakeholders have suggested that increased program length and a transition to baccalaureate degree could address these limitations by allowing time for research content in curricula while creating a better pathway for academic research in massage therapy to be fostered.(28,30)
When compared to medicine, participants here shared many similar concerns about stagnation in curriculum content, design, and educational methods.(3) Echoed here are concerns with the incorporation of evidence and the suggestion of the need for increased basic sciences content. While variations in resources were often ascribed to areas of specialization in medicine, these differences were associated with college size and pressures related to profitability and competition. Also shared between scans was a participant’s sense of generational gap in expectations regarding technology. This suggests that solutions found in medical education regarding content delivery may also serve some of the needs described by participants here.
At its core, accreditation of education programs is introduced to improve quality and standards. Participants described variation, isolation, and stagnation as the main challenges facing MT education. They also described accreditation as a potential solution for these challenges. Quality can be set in an accreditation process as a minimum standard that must be achieved, or as a standard of excellence meant to stretch the educational program.(7) Accreditation agencies have a responsibility to ensure that the educational program offers quality in the student experience, programming according to a given standard, and adequate evaluation of that programming to ensure graduates are career-ready.(31) The frequent return to the theme of accreditation can be viewed through the lens of a desire to address the challenges identified. In this way, the intended outcomes of accreditation could address aspects of variation, isolation, and stagnation through standardization, information sharing, collective national action, and as a force for programmatic change.
Other health professions have attempted to address standardization and modernization of their education programs through better instructor education and improved incorporation of research evidence in curricula.(3,31) While not addressed directly in this study, these approaches could be potential solutions to many aspects of the themes explored here. As many massage therapy instructors’ main qualifications are expertise within the profession as opposed to pedagogy, activities that address their capacity to teach, and the further development of the institutional programs needed to support this, could assist in creating dialogue that reduces aspects of isolation while providing instructors tools to improve their programs. This is potentially limited by the educational opportunities and financial resources currently available to instructors. As for research evidence, improving its dissemination, incorporation, and utilization within massage therapy education could be viewed as a method to reduce variation and address stagnation. This process is reliant on a strong evidence base and the translation of this knowledge into curricula. By extension, any activity that improves capacity or removes barriers to massage therapy research could assist in addressing these concerns. This could also include ensuring that instructors have access to research evidence, and the training needed to understand and share it effectively within the classroom.
As the accreditation of MT programs in Canada has just begun, there is a great opportunity for future research to explore the impact and quality of the accreditation process. This study sought to create a baseline description of the current challenges facing MT education. Once accreditation has been in place for several years, it would be worthwhile to revisit the study to see whether accreditation has had the intended impact, and whether there were unforeseen benefits or additional challenges. Future research should consider multiple perspectives, perhaps adding the voice of the student and their view of challenges affecting their education.
The findings are limited by the use of semi-structured interviews, the proximity of the timing of the study to implementation of accreditation, and lack of participation in the open feedback session. The use of semi-structured interviews was limiting as few questions and prompts were provided to the interviewer. This approach relied on participants to volunteer their thoughts and experiences. However, for this sample, a structured format may have resulted in broader and more comprehensive responses.
As most participants were involved in active discussion of, or preparation for, program accreditation, this topic may have dominated their responses during the interviews. Again, a more structured interview guide with additional questions relating to non-accreditation topics may have resulted in a more varied environmental scan. Finally, lack of participation in the open feedback session limited the trustworthiness of the results as member checking was done by only a few participants. Offering another opportunity to provide comment on the results might have strengthened the results.
An environmental scan was undertaken to describe the thoughts and opinions of MT education stakeholders regarding the priorities and challenges facing MT education early in the process of national MT program accreditation. Participants described three challenges they faced: variation, isolation and stagnation, which they hoped would be remedied by recently implemented program accreditation. Despite some limitations, this environmental scan forms a baseline for stakeholder views on massage education in Canada upon which future comparisons can be made.
We would like to acknowledge that funding for this project was provided by the Massage Therapy Research Fund.
The authors declare there are no conflicts of interest.
1 Frank JR, Danoff D. The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Med Teach. 2007;29(7):642–647.
2 Frank JR, Snell L, Sherbino J. CanMEDS 2015 Physician competency framework. Ottawa, ON: Royal College of Physicians and Surgeons of Canada; 2015.
3 Hodges BD, Albert M, Arweiler D, Akseer S, Bandiera G, Byrne N, et al. The future of medical education: a Canadian environmental scan. Med Educ. 2011;45(1):95–106.
4 National Accreditation Planning Committee. A plan to establish a Canadian accreditation process for massage therapy education programs. Toronto, ON: CMTO; 2013. Available from: http://www.cmto.com/assets/MT-Accreditation-Planning-Committee-Report-Oct2013.pdf
5 College of Massage Therapists of British Columbia, College of Massage Therapists of Newfoundland & Labrador, College of Massage Therapists of Ontario. Inter-jurisdictional practice competencies and performance indicators for massage therapists at entry-to-practice. Toronto, ON: CMTO; 2012. Available from: http://www.cmto.com/assets/Inter-Jurisdictional-Competency-Standards-June-2012.pdf
6 College of Massage Therapists of British Columbia, College of Massage Therapists of New Brunswick, College of Massage Therapists of Newfoundland & Labrador, College of Massage Therapists of Ontario. Inter-jurisdictional practice competencies and performance indicators for massage therapists at entry-to-practice. Vancouver, BC; FOMTRAC; 2016. Available from: http://www.fomtrac.ca/wp-content/uploads/2016/10/FOMTRAC-PCs-PIs-September-2016.pdf
7 Menard MB. Choose wisely: the quality of massage education in the United States. Int J Ther Massage Bodywork. 2014;7(3):7–24.
8 Government of New Brunswick. Massage Therapy Act, 2013. St. John, NB: Queen’s Printer; 2013.
9 Government of Newfoundland and Labrador. Massage Therapy Act, 2005. St. John’s, NL: Queen’s Printer; 2005.
10 Government of Ontario. Massage Therapy Act, 1991. Ottawa, ON: Queen’s Press; 1991.
11 Government of Prince Edward Island. Massage Therapists Regulations 2019. Charlottetown, PE: 2019. Available from: https://www.princeedwardisland.ca/sites/default/files/legislation/r10-1-5-regulated_health_professions_act_massage_therapists_regulations.pdf
12 Government of British Columbia. Massage Therapists Regulation. Victoria, BC: Queen’s Printer; 2008.
13 Massage Therapy Association of Manitoba. Our road to regulation. Winnipeg, MB: MTAM; 2018. Available from: https://mtam.mb.ca/75/road-to-regulation
14 Transitional College for the College of Massage Therapists of Alberta. Winter 2018 update. Edmonton, AB: MTA; 2018. Available from: https://www.mtaalberta.com/doc/Regulation/TC-CMTA-Winter_Update_2018.pdf
15 Massage Therapist Association of Saskatchewan. Legislation in Saskatchewan. Saskatoon, SK: MTAS; 2018. Available from: https://www.saskmassagetherapy.com/?page=1111https://www.saskmassagetherapy.com/index.php?page=1107&id
16 Nova Scotia Legislature. Massage Therapy Act. Halifax, NS: Queen’s Printer; 2003.
17 Northwest Territories Massage Therapists Association. Frequently asked questions. Yellowknife, NT; 2018. Available from: https://www.nwtmta.org/faqs.html
18 Gentles SJ, Charles C, Ploeg J, McKibbon KA. Sampling in qualitative research: Insights from an overview of the methods literature. The Qualitat Rep. 2015;20(11):1772–1789.
19 Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful sampling for qualitative data collection and analysis in mixed method implementation research. Adm Policy Ment Health. 2015;42(5):533–544.
20 Morse JM. The significance of saturation [editorial]. Qual Health Res. 1995;5(2):147–149.
21 Thompson C. If you could just provide me with a sample: examining sampling in qualitative and quantitative research papers. Evid Based Nurs. 1999;2(3):68–70.
22 Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Serv Res. 2007;42(4):1758–1772.
23 Corbin J, Strauss A. Basics of Qualitative Research: Techniques and Procedures for Developing Grounded Theory, 4th ed. Boston, MA: SAGE Publications; 2015.
24 Fortune LD, Gillespie E. The influence of practice standards on massage therapists’ work experience: a phenomenological pilot study. Int J Therapeut Massage Bodywk. 2010;3(3):5–11.
25 Kania-Richmond A, Menard MB, Barberree B, Mohring M. “Dancing on the edge of research”— What is needed to build and sustain research capacity within the massage therapy profession? A formative evaluation. J Bodyw Mov Ther. 2017;21(2):274–283.
26 Gowan-Moody DM, Leis AM, Abonyi S, Epstein M, Premkumar K. Research utilization and evidence-based practice among Saskatchewan massage therapists. J Complement Integr Med. 2013;10(1):189–198.
27 Baskwill A, Dore K. Exploring the awareness of research among registered massage therapists in Ontario. J Complement Integr Med. 2015;13(1):41–49.
28 Shroff FM, Sahota IS. The perspectives of educators, regulators and funders of massage therapy on the state of the profession in British Columbia, Canada. Chiropract Man Ther. 2013;21(1):1–9.
29 Munk N, Dyson-Drake J, Mastnardo D. What should we do different, more, start and stop? Systematic collection and dissemination of massage education stakeholder views from the 2017 Alliance for Massage Therapy Educational Congress. Int J Therapeut Massage Bodywk. 2019;12(1):29.
30 Shroff FM, Sahota IS. How can massage therapy move forward? Registered massage therapists touch on key points shaping their profession in British Columbia, Canada. Home Health Care Manage Pract. 2012;24(4):182–192.
31 Peer KS, Rakich JS. Accreditation and continuous quality improvement in athletic training education. J Athlet Train. 2000;35(2):188–193.
Thank you for agreeing to discuss your experience of Massage Therapy as a Profession in a semi-structured interview format. We expect the interview may take about 30 minutes of your time.
We hope to learn more from you and other stakeholders (knowledgeable educators, administrators, and researchers) about the context and factors that influence quality education in Massage Therapy.
Before we start, do you have any questions about the project? I’d also like to remind you that we are recording this interview for note-taking purposes. However, any information that you share will be kept confidential.
What is your background/experience with Massage Therapy education? (role, years of experience, institution, province).
How would you describe the current state of MT education in Canada?
I’d like to get your perspective on the most important challenges facing MT education. Can you tell me about challenges (issues or priorities) facing MT education?
Are you aware of any innovations or best practices that are emerging to address those issues or challenges? Can you describe those?
What are some of the barriers that are hindering change and innovation in MT education? How do educators get over those?
What factors are facilitating change and innovation in MT education? What can be done to support those?
Do you have any recommendations for policy makers and educators? Other comments?
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INTERNATIONAL JOURNAL OF OF THERAPEUTIC MASSAGE AND BODYWORK, VOLUME 13, NUMBER 4, December 2020