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Objective: The education of an athletic training student involves a balance between theory and application, which can be stated as a balance between classroom and clinical education. The instructors in these settings should work together to promote the overall educational process. Our primary purpose was to measure the observations and perceptions of physical presence, cooperation, and communication between clinical and classroom instructors and secondarily to determine if these have a perceived effect on the education of the student.
Subjects: Clinical instructors, classroom instructors, and athletic training students in Commission on Accreditation of Allied Health Education Programs-accredited and National Athletic Trainers' Association-approved athletic training education programs.
Measurements: Data were analyzed using various correlation techniques, a general linear model, and a one-way analysis of variance.
Design and Setting: We designed a questionnaire to measure the observations and perceptions of physical presence, cooperation, and communication between the clinical and classroom instructors.
Results: Of the 30 athletic training educational programs solicited for involvement in this study, 19 responded (63%). A total of 737 questionnaires were distributed, and 547 were returned (74%). Classroom instructors rated observations of cooperation between clinical and classroom instructors at a significantly higher frequency than did clinical instructors. Students rated observations of communication at a significantly lower frequency than did the clinical and classroom instructors. All 3 groups agreed that the physical presence, cooperation, and communication between the clinical and classroom instructors has a large effect upon the education of the student.
Conclusions: Clinical instructors must be educators as well as care providers. At the same time, classroom instructors must make efforts to include clinical instructors in all aspects of the educational process. Also, athletic training students should be exposed to the inner workings of their educational programs, so they may have a better understanding and appreciation of how theory and application tie together.
Athletic training students are exposed to a wide variety of educational experiences in several settings. The classroom and various clinical settings are some of the locations in which athletic training students are provided the knowledge and experiences necessary for the National Athletic Trainers' Association (NATA) Board of Certification (NATABOC) examination. By learning skills in more than one setting, the students are exposed to a potential theory-practice or theory-application gap. Waterman et al1 asserted that theory is not practice, so there must be distinctions between one and the other: hence, the presence of a theory-application gap. They maintain that the term “theory-application gap” suggests a straightforward problem that must be addressed. However, Lindsay2 suggested that the theory-application gap is not a problem and is necessary to push the boundaries of current practice; in order to improve what is currently practiced, it is necessary to apply new theories to move forward. Many athletic training education programs have clinical and classroom instructors employed by 2 different departments, athletics and academics. As a result, the departments share the role of educating the athletic training student.
Howard and Leppert3 illustrated that collaboration of instructors can help to create a balance between education and service. Programs with a wide separation between the 2 departments may have a division between theory and practice. The National Commission on Allied Health Education4 stated that the primary role of an allied health education program is to prepare students with entry-level job competencies in their field of study by providing a curriculum that combines didactic and clinical education. The effectiveness of a Commission on Accreditation of Allied Health Education Programs (CAAHEP)-accredited athletic training education program may depend on several factors, including the working relationship of the clinical and classroom instructors. Anecdotal discussion of this issue was overwhelmingly supportive of the idea that an educational program in which the clinical and classroom instructors do not work together must have a negative effect on the education of the student.
For this study, this working relationship will be defined as the physical presence, cooperation, and communication between the clinical and classroom instructors. In order to determine if clinical and classroom instructors are physically present, cooperating, and communicating in an effective manner, observations and perceptions of clinical instructors, classroom instructors, and athletic training students were assessed. Physical presence was defined as physically being together in the same educational setting. Cooperation was defined as a combination of resources and efforts to reach common educational goals. Communication was defined as an open exchange of thoughts, ideas, and opinions about the educational process. Our primary purpose was to measure the observations and perceptions of physical presence, cooperation, and communication between the clinical and classroom instructors and secondarily to determine if this working relationship has a perceived effect on the education of the student.
We used a questionnaire (Appendix) to measure the observations and perceptions of physical presence, cooperation, and communication between clinical and classroom instructors.
Subjects consisted of clinical instructors, classroom instructors, and athletic training students involved in CAAHEP-accredited and NATA-approved athletic training education programs. At the time of this study, there were approximately 75 CAAHEP-accredited and NATA-approved athletic training programs. Thirty randomly selected programs were solicited for involvement in this study. Twenty-one programs gave formal consent, and 19 of these programs returned questionnaires.
We designed a demographic and observation and perception survey instrument. The instrument was used to collect demographic data to allow the researchers to categorize the certified athletic trainers (ATCs) according to work responsibilities and the athletic training students according to educational level after formal admission to an athletic training education program. Certified athletic trainers were categorized as clinical or classroom instructors based upon where the majority (more than 50%) of their work responsibilities lay; those who reported a 50/50 split of responsibilities were excluded from the analysis. Subjects were asked to estimate their observations of physical presence, cooperation, and communication between the clinical and classroom instructors. Subjects were also asked to rate their perceptions of the quantity or frequency of physical presence and the quality of cooperation and communication between clinical and classroom instructors on a 5-point Likert-type scale anchored by poor (1) and excellent (5). Additional space was provided for open-ended responses for each survey item.
The following procedures were used to establish face validity and internal consistency of the instrument. A focus-group meeting was conducted with 3 athletic training students representing a cross-section of matriculation levels. They were asked to read the instrument and provide feedback on items that needed clarification. The instrument was then distributed to 3 athletic training program directors who were asked to review the instrument with regard to the readability and ease of completion of the items. Changes were made based on responses from the students and program directors. The instrument was then distributed to 6 ATCs and 12 athletic training students to establish internal consistency. The ATCs represented 3 clinical and 3 classroom instructors. The athletic training students represented a cross-section of matriculating students. The Cronbach alpha calculated for the 3 independent variables were .86 for physical presence, .84 for cooperation, and .85 for communication.
The study was approved by the institutional review board. We obtained written permission from program directors of each of the participating athletic training programs before data collection. No subjects were identified by name or by institution.
At the time of the study, a current list of all CAAHEP-accredited and NATA-approved athletic training education programs was obtained from the Joint Review Committee on Athletic Training. Thirty programs were randomly selected and a solicitation letter describing the procedures was sent to each program director. Program directors were then contacted by telephone to solicit involvement. When the program director was solicited for involvement in the study, an account of the total number of clinical instructors, classroom instructors, and athletic training students within each program was obtained. Participating program directors were then mailed a packet of questionnaires and return envelopes. Separate envelopes were provided for each clinical and classroom instructor to ensure open and honest responses. An additional envelope was used to collect all student questionnaires. The program director was asked to solicit the involvement of one of the students to collect the student questionnaires. All completed questionnaires placed in sealed envelopes were collected by the program director and returned in a self-addressed, postage-paid envelope. Each program was assigned a specific alphanumeric code to allow the researchers to monitor which programs responded. The same code was placed on the survey forms and return envelopes of the clinical or classroom instructor and athletic training student. Twenty-one days from the initial mailing, a follow-up telephone call was made to the programs that had not responded.
Descriptive statistics were employed for the entire population. Data were analyzed using SPSS (version 8.0, SPSS Inc, Chicago, IL) to calculate a variety of tests, including a general linear model, Pearson correlational techniques with a Fisher Z test, and a one-way analysis of variance. The .05 level of significance was used.
Due to the qualitative nature of this issue, several limitations and assumptions were expressed before the study began. Clinical instructors and classroom instructors may have had varying levels of practical experience, which could have affected their observations and perceptions of physical presence, cooperation, and communication. Athletic training students may have developed a preference for a particular instructor, which may have biased responses. The number of returned questionnaires was limited due to self-selection. Some participants may not have participated due to personal bias. We assumed that all subjects responded honestly to the questionnaire.
Of the 30 programs solicited, 19 (63%) participated in the study. A total of 737 questionnaires were distributed, 155 to ATCs and 582 to athletic training students; 547 were returned, for a response rate of 74%. Certified athletic trainers returned 111 questionnaires (71%), with 1 incomplete form. Nine of the ATCs who responded classified themselves as splitting their time evenly between athletics and academics. These subjects' data were not included in the analysis. Athletic training students returned 436 questionnaires (75%), with 12 incomplete forms that were not used in the analysis.
Certified athletic trainers were predominately male (65.5% for classroom instructors, 58.3% for clinical instructors), while the athletic training students were predominately female (59.7% women, 40.3% men) (Table (Table11).
Classroom instructors were, in general, older than clinical instructors (36.13 years versus 31.65 years), had more years of certified experience (12.34 years versus 8.54 years), and had spent more time working at that institution (8.55 years versus 5.45 years) (Table (Table2).2). Sixty-seven ATCs (66.3%) held a master's degree.
For the athletic training students (n = 424), the average age was approximately 21 years (mean = 20.89 years). Just over half of the students (n = 218, or 51.5%) reported being in the first or second semester of enrollment.
Each program had approximately 10 students (mean = 9.76) taking the NATABOC examination in the previous year, with approximately 6 students (mean = 5.76) passing all 3 sections of the examination on their first attempt. The overall first-time passing percentage for all programs combined was 54%, well above the national average of 31.7%, as reported by the NATABOC for that time period.5
The main hypothesis of this study, stated in the null, was that there would be no significant difference between clinical instructors', classroom instructors', and athletic training students' observations and perceptions of physical presence, cooperation, and communication between clinical and classroom instructors.
A general linear model was used to test this hypothesis. The Pillai trace multivariate test indicated a statistically significant difference between the groups (F12,868 = 4.45, P < .001). The test of between-subject effects demonstrated that the significant difference was in the observed frequency of cooperation (F1,98 = 3.12, P < .05) and communication (F1,98 = 8.46, P;th< .001) (Table (Table3).3). Therefore, based upon these data, the null hypothesis was rejected at the .05 level of significance.
The Tukey Honestly Significant Difference multiple-comparison test showed that the clinical and classroom instructors observed the cooperation differently, with the classroom instructors rating observations of cooperation at a higher frequency than the clinical instructors (Table (Table4).4). The students also observed the communication differently than did the clinical and classroom instructors, rating observations of communication at a lower rate than the clinical and classroom instructors.
On a scale of 1 to 5, subjects shared the opinion that the working relationship between the clinical and classroom instructors affects the education of the student (4.1353 ± 1.0158).
Based on the findings and limitations of this study, we made several interpretations. Classroom instructors reported a higher frequency of observed cooperation between the clinical and classroom instructors. Students observed the communication at a lower frequency than the clinical and classroom instructors. Subjects agreed that the working relationship has a large effect on education.
Classroom instructors reported a higher frequency of observed cooperation between the clinical and classroom instructors. This finding could be interpreted several ways. Perhaps classroom instructors are more concerned about, or more focused on, cooperating and working with the clinical instructors. Conversely, classroom instructors may be observing cooperation that the clinical instructors do not observe. The education of athletic training students requires the involvement of both the clinical and classroom instructors. The fact that classroom instructors observed more cooperation than did the clinical instructors might suggest that the classroom instructors feel that collaboration is necessary to improve the education of the students. However, this collaboration should be a 2-way endeavor. Paraphrasing from some of the open-ended responses on the questionnaire, classroom instructors should make an effort to involve clinical instructors in policy decisions rather than imposing the policy, and clinical instructors should make a conscious effort to involve classroom instructors in what is taking place in the clinical environment.
McDaniel and Colarulli6 identified 4 dimensions of successful collaboration: integration, interaction, active learning, and faculty autonomy. Curricular integration allows students to make connections between divergent subject matter. This can lead to a better understanding of the information. Clinical and classroom instructors must collaborate to enhance the educational environment. True collaboration can create conflict when the faculty members are accustomed to a high level of autonomy. Out of conflict comes compromise, sharing, and understanding of new ideas.
Robinson and Schaible7 developed guidelines for successful collaborative teaching. The team should be restricted to 2 members, and they should agree upon a trial period. Selection of the team should be done by the members themselves rather than administrators. The team members should have an open discussion of teaching philosophies, methods, and grading criteria. Most importantly, the members should anticipate teaching and interpretation differences. The authors assert that by following these guidelines, effective collaborative relationships can be created. Athletic training educators may benefit from applying these guidelines to their own programs.
Lachat et al8 presented a model for bridging the education-practice gap at Georgetown University Hospital. This “bridging” is achieved with the appointment of clinical educators. These clinical educators have dual appointments within 2 distinct departments, the Department of Nursing and the School of Nursing. The Department of Nursing is housed within the hospital, while the School of Nursing is housed within the university. From their experience, the dual appointment encourages a more efficient use of nursing resources. Athletic training education programs that have a similar 2-department model need individuals who can bridge the gap.
Fine9 discussed a symbiotic relationship between nursing educators and nursing directors, outlining several ways in which the educator and director can work together in order to improve the education of the student and the quality of care given to the patient. This is achieved by improving the teaching of basic technical skills and the establishment of nurse-patient contracts.
We found that students observed the communication at a lower frequency than the clinical and classroom instructors. It is possible that students are not privy to all of the communication among staff members. Several open-ended responses from students indicated that they were aware of communication but were not there to see it. Athletic training students should be allowed to gain some exposure to or insight into the inner workings of their educational program so they may better understand and appreciate how it functions.
Clinical instructors, classroom instructors, and students agreed that the working relationship between clinical and classroom instructors has a large effect on the education of the athletic training student. This was an important result. Up to that point, the assertion that the interaction between the clinical and classroom instructors affected the education of the student was purely anecdotal. We did not show a direct cause-and-effect link between the interaction of clinical and classroom instructors and the education of the student. However, the agreement of the subjects is encouraging in that it does support the idea that the interaction of clinical and classroom instructors is an important indicator for student success.
The moderate to high intercorrelation of the physical presence, cooperation, and communication variables suggests that they all measure as one combined attribute. This implies that they are all components of the broader idea of a working relationship between clinical and classroom instructors.
The education of athletic training students requires the involvement of both the clinical and classroom instructors. The fact that classroom instructors observed more cooperation than did the clinical instructors might suggest that the classroom instructors feel that collaboration is necessary to improve the education of the students. Conversely, it could be said that classroom instructors are observing cooperation that the clinical instructors do not observe. This collaboration should be a 2-way endeavor. Recently, the profession of athletic training has placed a new emphasis on clinical instruction. The profession is shifting away from counting hours of clinical experience and moving toward a competency-based experience. Collegiate athletic trainers working within an accredited athletic training education program must be both educators and care providers for their athletes, a situation similar to attending physicians working within teaching hospitals. At the same time, classroom instructors must make efforts to include the clinical instructors in all aspects of the educational process. We hope all clinical and classroom instructors will strive to reach a balance within their educational programs.
Future areas of research include a closer examination of the working relationship on a case-by-case or institution-by-institution basis. This might allow for greater objectivity instead of allowing each individual to characterize his or her program. Another area of interest would be to study why clinical and classroom instructors observe cooperation differently.
We thank the many program directors, staff members, and students who participated in this study. We also thank Jim Gallaspy, MEd, ATC, for his guidance, patience, and counseling and the late Mary B. Johnson, PhD, ATC, for her encouragement.