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J Athl Train. 2002 Oct-Dec; 37(4 suppl): S-236–S-240.
PMCID: PMC164431

A Model for Learning Over Time: The Big Picture


Objective: To present a method of describing the concept of “learning over time” with respect to its implementation into an athletic training education program curriculum.

Background: The formal process of learning over time has recently been introduced as a required way for athletic training educational competencies and clinical proficiencies to be delivered and mastered. Learning over time incorporates the documented cognitive, psychomotor, and affective skills associated with the acquisition, progression, and reflection of information. This method of academic preparation represents a move away from a quantitative-based learning module toward a proficiency-based mastery of learning. Little research or documentation can be found demonstrating either the specificity of this concept or suggestions for its application.

Description: We present a model for learning over time that encompasses multiple indicators for assessment in a successive format. Based on a continuum approach, cognitive, psychomotor, and affective characteristics are assessed at different levels in classroom and clinical environments. Clinical proficiencies are a common set of entry-level skills that need to be integrated into the athletic training educational domains. Objective documentation is presented, including the skill breakdown of a task and a matrix to identify a timeline of competency and proficiency delivery.

Clinical Advantages: The advantages of learning over time pertain to the integration of cognitive knowledge into clinical skill acquisition. Given the fact that learning over time has been implemented as a required concept for athletic training education programs, this model may serve to assist those program faculty who have not yet developed, or are in the process of developing, a method of administering this approach to learning.

Keywords: Approved Clinical Instructor (ACI), clinical proficiency, mastery, portfolio, psychomotor skills

The formal process of learning over time has recently been introduced to the athletic training profession. In the academic and clinical settings, learning over time is primarily associated with psychomotor skills and clinical proficiencies. However, the cognitive and affective domains must be considered when developing the overall curriculum plan. Athletic training, similar to many other professions, has always required the learning of clinical proficiencies. Students practice these skills many times before final testing. At no time were the skills and proficiencies taught, tested once, and then forgotten. What has changed pertaining to learning over time is that the required proficiencies are presented early in the academic program and formally assessed in a logical progression.1 Prior planning and the need for documentation of testing has now become a key component for student learning in the overall educational process. Our purpose is to define the concept of learning over time and how it can be applied to the athletic training educational setting and to present one model.

Students need to work and learn at their optimal level. This optimal level is believed to be an accumulation of structured learning experiences that have greater positive benefits than merely the number of required clinical hours. Number of hours accumulated in a clinical setting has little influence on examination performance.2 Less emphasis should be placed on the number of hours needed and more on acquiring the knowledge, skills, and abilities delineated in the Athletic Training Educational Competencies.2,3 Shifting the emphasis away from required clinical hours to learning over time prepares students leaving Commission on Accreditation of Allied Health Education Programs (CAAHEP)-accredited programs to be competent to practice in the field of athletic training, as validated by the National Athletic Trainers' Association Board of Certification (NATABOC) certification examination and state regulatory boards.

By definition, learning over time is the documented, continuous process of skill acquisition, progression, and student reflection.4,5 This concept reinforces the demonstration of a systematic progression through the cognitive, psychomotor, and affective domains within different educational settings.5 Learning opportunities may vary from structured classrooms and laboratory settings to clinical rotations consisting of practicums, internships, and field experiences.

The concept of learning over time is not new. Many educators say that it is part of their curriculum design; however, little research or documentation can be found relating to how long or how much practice is needed before learning or mastery of a psychomotor skill occurs. The physical education profession uses mastery learning to develop individual gross motor skills to some extent. Lettus et al6 referred to the concept of learning over time as part of portfolio assessment. In nursing, clinical portfolio assessments are described as a means to evaluate a student's ability to apply nursing skills and to look at the decision-making process in the clinical setting. However, the authors focused on the use of portfolios, not learning over time.6

Learning over time has indirectly been a part of the athletic training curriculum design for many years. Without using the actual phrase, “learning over time,” the athletic training profession has been using the concept. The former Oral/Practical (now the Practical portion) of the NATABOC certification examination requires athletic training students to review and be tested on material that was taught and practiced several months or years earlier. The implementation of a comprehensive examination such as this could be considered a cumulative assessment for learning over time.

Assessment of learning over time is designed around multiple indicators and sources of evidence.5 These assessment methods for athletic training students vary from watching their interactions with patients or athletes, discussing their cases with them, and requiring them to demonstrate skills in test-like environments to evaluating them by using scenarios that assess decision-making skills. Assessment includes not only what they demonstrate but also what they choose not to do or say.5 When learning over time, it is important that students have many opportunities to acquire specific knowledge, skills, values, and proficiencies. The key to assessing learning over time is the ability to demonstrate and document a student's progressive development of skills taught in a closed environment and transferred to the practical application in the clinical setting.1

Learning over time is not limited to individual skills and should not be restricted only to tiers of psychomotor-oriented tasks.1 For example, the “big picture” pertaining to the evaluation of an inversion ankle sprain or the rehabilitation for a medial collateral ligament injury of the knee is what is expected for mastery of entry-level clinical proficiencies. Clinical proficiencies are not a collection of unrelated elements or skills. Rather, they are a common set of entry-level skills that need to be integrated into the athletic training educational domains.4,5

Houglum and Weidner1 used the example of learning over time as a continuum (Table (Table1).1). On the far left side of the continuum, the instructor teaches the individual skills and monitors the athletic training students' progress very closely. On the right side of the continuum, the student progresses from taking the individual skills learned to using them in a meaningful way, as expected of an entry-level athletic trainer. At this end of the spectrum, the Approved Clinical Instructor (ACI) or the Clinical Instructor (CI) only intervenes as needed.1 A psychomotor-oriented checklist may be used in the beginning stages of mastery of clinical proficiencies; it is located on the far left of the continuum. These activities on the left side are helpful in learning and mastering individual skills. However, students preparing to enter the athletic training profession need their actions to approach the right side of the continuum for an accurate reflection of optimal proficiency. Optimal proficiency is determined by the ACI's perception of when entry-level standards of the profession are mastered.

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Table 1. Learning-Over-Time Continuum1

Progression: Psychomotor Skills → Clinical Proficiencies

Many times, it is difficult for athletic training students to successfully transfer knowledge gained in the classroom into the clinical setting. We cannot assume that mastery of psychomotor skills and clinical proficiencies will occur simply because a student is presented with the material in the classroom.7 Learning over time needs to be presented in a logical progression. The process begins with learning, then performing, and finally retaining. The learning of didactic material and exposing students to clinical-education experiences starts the process. Once the knowledge and clinical skills are acquired, the student then progresses through the continuum to the development of critical-thinking and decision-making skills.5

Before the progression from classroom knowledge to field application can begin, the clinical proficiencies must be identified. The proficiencies that are expected for entry into the athletic training profession can be found in the 1999 edition of Athletic Training Educational Competencies.3 Each clinical proficiency comprises an array of psychomotor, cognitive, and affective components to be broken down into subtasks that will ultimately form the foundation for a comprehensive proficiency. A plan to accomplish this could include the following:

  • Break down into subtasks the psychomotor skills and basic knowledge needed to perform each of the clinical proficiencies.
  • Introduce the psychomotor skills and didactic information early enough in the educational process to ensure sufficient time for retention to occur.
  • Develop a progressive prerequisite structure for all psychomotor skills and didactic information to ensure students' readiness for each clinical proficiency.
  • Develop objective criteria to demonstrate that each clinical proficiency has been mastered.
  • Design a matrix or blueprint of all clinical proficiencies to ensure that instruction and testing occur.5,7,8

Program Matrix or Institutional Planning

After the key subtasks of the clinical proficiencies are addressed, a program matrix or institutional plan can then be developed and put into practice. Developing a matrix of clinical proficiencies and their subsets aids educators by providing a road map or blueprint to mastery.7 An example of this blueprint consists of 5 distinct levels (Table (Table22).

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Table 2. Clinical-Education Matrix

First Level. The first level of the matrix is the introduction and demonstration of the basic skills and concepts by the instructor in a controlled environment (eg, classroom or laboratory setting) (Table (Table3).3). At this stage in the learning process, it is very important that these concepts and psychomotor skills are learned and practiced correctly. Instruction may be aided by the use of textbooks, videos, and interactive software. A variety of teaching and learning methods should be considered at this point. As noted by Brower et al,9 athletic training students learn in a variety of ways and at different paces.3 They also need ample practice time and monitoring by a trained eye. The collaboration of students in small groups or with a partner may be helpful in stimulating early discussions pertaining to the greater understanding of the overall concepts. The use of a peer-review system may also be helpful in forcing students to practice psychomotor skills before formal objective testing by the ACI. An instructor must create multiple opportunities for practice (eg, class time, open laboratory time, and clinical-rotation down time). Opportunities to practice recently presented skills are essential for learning.7

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Table 3. Sample Psychomotor-Skills and Clinical-Proficiencies Matrix Worksheet4,8

Second Level. The second level of the matrix reinforces learning that has occurred earlier in a controlled environment. In most cases, athletic training concepts and psychomotor skills are not introduced during this level: prior learning is reinforced. Reinforcement may occur in a structured practicum within the clinical setting or in an isolated practicum class. As an example, this level may have very specific psychomotor skills associated with it in order to build on future clinical proficiencies.

In addition to the ACI's testing of individual psychomotor skills as part of a practicum requirement, follow-up with specific corrections and constructive interaction with the student is important during the second level.5 Retesting and increasing the challenges of the tasks by using scenarios and case studies and expecting progression to a higher level of learning is key. A disadvantage of this level is that the practice and evaluation are still in a closed environment with healthy subjects. In other words, true abnormalities and instabilities and actual pain perceptions may be difficult to accurately assess.

Third Level. The third level in the development of the matrix revolves around the teachable moment. At this level, it is difficult to document the point when specific, desired outcomes have occurred or even whether the opportunity arises. However, with respect to learning over time, this level is very important in bringing individual skills and concepts from the classroom that have been formally evaluated by the ACI to the clinical environment. As students are given more clinical responsibilities with regard to evaluation, rehabilitation, and treatment of athletic injuries, the ACI and CI must allow student learning to move from the left side to the right side of the learning-over-time continuum (Table (Table1).1). For the mastery of psychomotor skills and clinical proficiencies, the third level deals more with confidence building and the application of knowledge than with providing the student with opportunities to practice or having specific clinical skills assessed.7 This level of learning over time is perhaps the most important in terms of affective and cognitive learning for the athletic training student. Many times, this stage is a student's first exposure to a positive sign or a patient's reaction to a truly painful stimulus. It is important to note that when specific tasks are performed incorrectly, immediate intervention and feedback should be given.7 The ability of the student to not only perform a psychomotor skill, such as the empty-can test, but also to interpret findings related to pain, weakness, and functional limitations truly indicates the student's progress toward the right side of the continuum.

Fourth Level. To maintain appropriate documentation of all clinical proficiencies, the setting for part of the fourth level of the matrix takes place in a structured environment. Psychomotor skills and clinical proficiencies learned and practiced in the earlier levels of the athletic training educational program are used. This level of learning over time involves the scenario-based testing of individual skills and proficiencies. Testing is designed to increase the clinical challenges encountered by the students. Individual psychomotor skill sets, case studies, and structured progressions are developed so that students must apply prior learning, modifying previously learned concepts and skills to fit a given situation. Ideally, some of the assessment and documentation occurs as part of the clinical experience when actual injury and abnormal conditions present themselves on a daily basis. However, due to the lack of uniformity in injury incidence and the different abnormalities students see in their clinical-education experiences, portions of the assessment of proficiencies not occurring naturally during clinical rotations need to be performed in a controlled and structured environment.

Fifth Level. The final level is based on assessment and student feedback. Feedback is gathered by student and program assessment, exit interviews, and a self-reporting survey. The self-reporting survey (Table (Table4)4) may be included as part of the senior's exit interview. This component of the fifth level is a discussion of the student's strengths and concerns. These concerns should lead to an action plan. The fifth level is the culmination of a senior-level practicum, final assessment examinations (written and practical), and evaluations from each student's final clinical rotation.

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Table 4. Sample Self-Reporting Survey

Evaluation and Documentation

Before formal documentation of clinical proficiencies can occur, planning is needed to ensure that individual skills and all clinical proficiencies are given the proper emphasis and time needed to demonstrate learning over time. Table Table55 is an example of a basic matrix that allows for mapping of clinical proficiencies and the individual psychomotor skills needed to master the proficiency. This visual reference serves as a written document to help ensure that all skills and proficiencies are addressed and the proper sequencing has occurred.

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Table 5. Clinical Proficiencies and Psychomotor Skills Matrix4,8

At the end of a student's educational experience, a portfolio is a common method of documenting that learning over time has occurred in respect to clinical proficiencies. This portfolio is built upon throughout the athletic training student's entire educational experience. Sample contents of a student portfolio may consist of the following items5,7:

  1. Psychomotor Skills Assessments
    1. Individual skills check sheets
    2. Clinical-education–practicum packets: inservices attended and clinical requirements met
  2. Evaluation of Clinical Proficiencies
    1. Rehabilitation laboratory tests
    2. Evaluation laboratory tests
    3. Therapeutic modalities laboratory tests
    4. Self-reporting survey
    5. Exit interview
  3. Reviews of Affective Clinical Traits
    1. Journals
    2. Clinical instructors' evaluations (midterm and final)
  4. Written Examination Results
  5. Assessment Examination Results
    1. Mock examinations (written)
    2. Mock examinations (practical)
  6. Case Studies
  7. Projects Completed
    1. Rehabilitation design and budget
    2. Athletic training facility design and budget
    3. Poster presentation
  8. Research Papers: Critical analysis of special tests and published manuscript
  9. Videos
  10. Computer Simulations
  11. Capstone Project: Senior Presentation


Learning over time, in relationship to clinical proficiencies, should focus on the “big picture.” Individual psychomotor skills are important for all athletic trainers; however, what is needed by students to become entry-level athletic trainers should not be forgotten. Students must be able to evaluate a head injury, treat an acute injury, and design a rehabilitation program for the shoulder. The big picture is not based upon skills alone. It incorporates many specific psychomotor, cognitive, and affective competencies into meaningful clinical outcomes. Mastery of clinical proficiencies enables the student to select, administer, and interpret results. Houglum and Weidner1 stated that learning over time involves the entire patient, not just the injury itself. This process is a systems model, not a block of isolated, unrelated sets of activities.1 The entire picture needs to be seen, as opposed to an isolated injury away from the person and the situation. We present a model of how learning over time can be incorporated into the athletic training education program. Other models must include a similar comprehensive approach with a logical progression to ensure mastery of educational objectives and clinical proficiencies over time.


  • Houglum P, Weidner T. Terminology: a rose is a rose, but according to whom? NATA News. Dec, 2001. pp. 40–41.
  • Turocy P S, Comfort R E, Perrin D H, Gieck J H. Clinical experiences are not predictive of outcomes on the NATABOC examination. J Athl Train. 2000;35:70–75. [PMC free article] [PubMed]
  • National Athletic Trainers' Association . Athletic Training Educational Competencies. 3rd ed National Athletic Trainers' Association; Dallas, TX: 1999.
  • National Athletic Trainers' Association Education Council Clinical education definition. Available at: Accessed December 14, 2001.
  • National Athletic Trainers' Association. Learning over time models . In: Clinical Instructor Educator Seminar Workbook. Vol. 8. National Athletic Trainers' Association; Dallas, TX: 2001. pp. 8–9.
  • Lettus M K, Moessner P H, Dooley L. The clinical portfolio as an assessment tool. Nurs Admin Q. 2001;25:74–79. [PubMed]
  • Amato H K, editor. Fort Worth, TX: Clinical competencies: mastery over time. Presented at: National Athletic Trainers' Association Athletic Training Educators' Conference. January 19–21 2001.
  • Amato H K, Gebauer C A, Brader H. Fort Worth, TX: Clinical competencies: mastery over time. Presented at: National Athletic Trainers' Association Educators' Conference. January 19–21 2001.
  • Brower K A, Stemmans C L, Ingersoll C D, Langley D. An investigation of undergraduate athletic training students' learning styles and program admission success [abstract] J Athl Train. 2000;35(suppl):S-55. [PMC free article] [PubMed]

Articles from Journal of Athletic Training are provided here courtesy of National Athletic Trainers Association