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Objective: To identify and compare clinical-instruction behaviors based on the experience level of the instructor.
Design and Setting: Systematic observation, employing the Clinical Instruction Analysis Tool—Athletic Training II was used to identify clinical instructors', athletic training students', and athletes' behaviors.
Subjects: Thirty clinical instructors (19 men, 11 women, mean age = 31.7 ± 10.4 years) with novice, intermediate, and advanced experience volunteered to participate.
Measurements: We summarized data into contribution and target categories. Frequency data of the categories were analyzed across experiential level of the clinical instructor.
Results: Differences among clinical instructors' experience levels existed in the frequency of athletic training student behaviors (χ22 = 9.6, P = .008). Post hoc comparisons identified differences in the frequency of athletic training student-initiated behaviors when novice clinical instructors were compared with intermediate (F2,27 = 5.52, P = .023) and advanced (F2,27 = 5.52, P = .026) instructors. No significant differences were seen between the clinical instructors' experience levels and total clinical instructors' contribution, total athletes' contribution, silent observation, clinical instructors' use of questions, clinical instructors' use of skill feedback, clinical instructors' use of screening and evaluation techniques, and athletic training students' use of screening and evaluative techniques.
Conclusions: Certified athletic trainers in their initial year of instructor experience appear to lack the requisite clinical-instruction knowledge, skills, and abilities to facilitate athletic training student behavior in a clinical setting. Program directors and clinical coordinators should assign instructors' responsibilities to certified athletic trainers who have more experience or demonstrate the ability to foster student interaction.
The triad of athletic training clinical instruction consists of the athletic training student, the clinical instructor, and the athlete. Teachers, students, and patients contribute interactional behaviors in allied health education. In the field of athletic training, those patients are athletes.
The experience of clinical instructors is referred to in the Standards and Guidelines for an Accredited Educational Program for the Athletic Trainer.1 A guideline suggests that clinical instructors should have one year of experience in their respective fields.1 In the 2002–2003 academic year, Commission on Accreditation of Allied Health Education Programs (CAAHEP)-accredited athletic training education programs are required to provide Approved Clinical Instructors (ACIs) to their students for the purpose of teaching and evaluating clinical skills.1 Some CAAHEP-accredited athletic training education programs depend on certified athletic trainers who have less than one year of experience to provide supervision during clinical instruction.
Research in education provides evidence that experience is a predictor of teaching effectiveness.2–6 Novice teachers express a significant amount of indecision2 and lack pedagogic content and demonstration ability.3 Experienced teachers provide more skill feedback to students3; demonstrate higher self-efficacy4–5; are more efficient problem solvers; have more structured lesson content; and spend less time planning.6
In both clinical instructor and traditional teaching roles, experience is an important consideration when defining the appropriate responsibilities of individuals.1,6–8 Little research has been conducted to observe and analyze the behavior patterns that emerge within athletic training clinical education. Systematic observation allows researchers to identify and compare behaviors of athletic training clinical instructors based on the experience level of the instructor. Our purpose was to compare the frequency of selected clinical-instruction behaviors with the experiential level of athletic training clinical instructors.
Thirty subjects volunteered to participate in this study. Subjects selected were certified athletic trainers listed on the university's Joint Review Committee for Accreditation of Athletic Training Education Programs Annual Report. All subjects were directly supervising athletic training students enrolled at 5 CAAHEP-accredited athletic training education programs. Of the 5 accredited programs, 1 was located in District 5, 1 in District 6, and 3 in District 9 of the National Athletic Trainers' Association.
Experience was based on years of experience as a clinical instructor, not simply number of years since certification as an athletic trainer. Table Table11 contains clinical-instructor demographic information. Novice clinical instructors were defined as having less than 1 year of clinical-instructor experience. Intermediate clinical instructors were defined as having 1 to 4 years of clinical-instructor experience. Advanced clinical instructors were defined as having 5 or more years of clinical-instructor experience. No subjects had any formal instruction in clinical-instructor effectiveness immediately prior to the investigation.
Equal, stratified samples were used for novice, intermediate, and advanced clinical instructors. The desired sample size from each university was 2 clinical instructors per experience group. Random-selection techniques were used when more than 2 clinical instructors from each group were available to participate. Informed consent was obtained from each individual included in the videotape record. The University of Southern Mississippi Human Subject Protection Review Committee granted approval of this study.
Ten subjects from each of the novice-, intermediate-, and advanced-experience groups of clinical instructors were videotaped for one 30-minute session during clinical-instruction episodes. The athletic training students were observed during the required practicum content of their educational program. Subjects, athletic training students, and athletes were included in the videotape records.
A behavior-focused, direct-observation interval recording system9,10 was used with the Clinical Instruction Analysis Tool—Athletic Training II (CIAT-AT II) (Table (Table22).11 We developed this instrument during 30 hours of real-time observation over 2 months in a variety of settings. Six instructors were videotaped for a total of 4 hours of clinical instruction in 4 different settings.
The observation interval for this study was set at 3 seconds. This ensured that a continuously occurring behavior was captured once per interval. If multiple behaviors occurred in a 3-second interval, they were all recorded. Instrument reliability was established using interobserver agreement11; the standard of agreement for a system with more than 11 categories is 85%.9 Our percentage of agreement using 2 trained observers was 95.4%.11 Three experts in athletic training education confirmed the face validity of the instrument.
The CIAT-AT II behaviors, definitions, and examples are shown in Table Table3.3. Each coded behavior was associated with a letter, A through Q, (eg, A = behavioral feedback, B = skill feedback: corrective). The coding scheme included a number that indicated who initiated the behavior (eg, 1 indicated the clinical instructor; 2, the athletic training student; and 3, the student-athlete). The 4 categories of screening and evaluative techniques (ie, questioning, clarifying and explaining, documentation, and manipulation) were used only when initiated by a clinical instructor or an athletic training student. Individuals do not initiate silent observation and noninterpretive behaviors, so they were coded without numbers.
After permission was granted by each educational institution, volunteers completed the informed-consent process. The camera was arranged in each athletic medicine facility where clinical instruction occurred. Situations were not contrived and were captured as part of a normal day during normal times of clinical instruction. Clinical instructors wore a telemeterized microphone to increase sound capture. The camera was placed as inconspicuously as possible to reduce the Hawthorne effect12 of direct observation. A wide-angle lens and picture zoom allowed sufficient videotape capture at an increased distance from the clinical instruction. The videotape records were analyzed using a VHS videocassette recorder with stop-shuttle switch capabilities. We assured accurate interval recording on behavioral observations with a 3-second cue tape. Using the CIAT-AT II, data from each 30-minute clinical-instructors' session were coded and categorized into the following contribution and target behaviors:
Frequency counts from the 8 contribution and target-behavior categories were calculated for each experience level.
Using the Statistical Package for the Social Sciences (version 7.5, SPSS Inc, Chicago, IL), descriptive statistics were calculated for each independent variable (contribution and target behaviors). Separate chi-square analyses for total clinical instructors' contribution, total athletic training students' contribution, total athletes' contribution, silent observation, athletic training students' use of screening and evaluative techniques, clinical instructors' use of screening and evaluative techniques, clinical instructors' use of skill feedback, and clinical instructors' use of questions on the dependent variables (novice, intermediate, and advanced clinical instructors) were conducted to reveal frequency differences. To maintain an equal distribution among the 3 experience groups, expected frequencies were set at 33.3% of the total for each of the contribution and target categories (Table (Table4).4). An alpha level of P < .05 was set a priori for all analyses.
Table Table44 summarizes the observed and expected frequencies used to calculate the chi-square statistic. Table Table55 summarizes the frequencies, means, and standard deviations of total clinical instructors' contribution, total athletic training students' contribution, silent observation, athletic training students' use of screening and evaluative techniques, clinical instructors' use of screening and evaluative techniques, clinical instructors' use of skill feedback, and clinical instructors' use of questions by experience level.
Using chi-square analysis, we determined that differences occurred between clinical instructors' experience levels in the total athletic training students' contribution category (χ22 = 9.6, P = .008). Post hoc multiple comparisons of total athletic training students' contribution indicates differences between the novice and intermediate (F2,27 = 5.52, P = .023) and novice and advanced (F2,27 = 5.52, P = .026) groups.
No differences existed among clinical instructors' experience levels in total clinical instructors' contribution (χ22 = 0.80, P = .67), total athletes' contribution (χ22 = 3.20, P = .20), silent observation (χ22 = 1.07, P = .59), clinical instructors' use of questions (χ22 = 0.80, P = .67), clinical instructors' use of skill feedback (χ22 = 0.80, P = .67), clinical instructors' use of screening and evaluation techniques (χ22 = 0.80, P = .67), or athletic training students' use of screening and evaluation techniques (χ22 = .27, P = .88).
Clinical instruction is a unique component of allied health education in which students learn in a structured and supervised environment. Marrying didactic learning with a pragmatic setting allows students to practice being professionals with the safety net of supervision. The finding that athletic training student-initiated interactions are less likely to occur with novice clinical instructors is evidence that clinical instructors' experience affects student behavior. This finding is consistent with the literature, which supports increased teaching efficacy with increased teaching experience.2–6
With respect to an athletic trainer's entire career, an individual has few experiences to provide medical care to athletes during the first year of professional practice. With experience, one can develop an acutely accurate and discriminating perspective with respect to the nature and severity of illness and injury and appropriate intervention. A novice athletic trainer who is responsible for clinical instruction is less likely to differentiate a teaching patient case from a nonteaching patient case. This situation is likely to hinder an athletic training student from participating in activities that a more experienced clinical instructor would encourage.
Silent-observation frequencies did not differ among experience levels of the clinical instructors. Silent observation can occur passively when individuals are not engaging one another, or it can happen deliberatively when clinical instructors allow students to reflect on experiences. We did not capture the nature of silent observation. Future investigation on the appropriateness of silent observation and reflective time is warranted.
Use of screening and evaluation techniques by students and clinical instructors did not differ among clinical instructors of various experience levels. The clinical-instruction sessions were not contrived, and the types of sessions (ie, rehabilitation, evaluation, taping, or bracing) were not controlled for specific educational content. We may not have had enough sessions relating to the behaviors of screening and evaluative techniques (ie, health-history questioning, documentation, performing a manual muscle test) to find differences. This issue could easily be controlled in a subsequent study by focusing on clinical-instruction sessions that are rehabilitation, immediate care, and evaluation intensive.
Clinical instructors' use of skill feedback was much lower than other observed behavior categories in all experience levels. Feedback is a critical aspect of skill proficiency.13,15–17 Athletic training students identified clinical instructors' feedback as a helpful behavior.13 Surgical-skill proficiency has been measured in a computer-assisted learning group and a lecture and feedback seminar group.16 Skill performance in the lecture and feedback seminar group was better.16 Furthermore, corrective feedback is a critical variable in skill acquisition.17 Skill feedback helps students to identify successful and problematic performances. This understanding is important to the refinement of skill. Development of skill-feedback models for athletic training clinical instructors warrants further investigation.
In 1971, one of the routes to become a certified athletic trainer consisted of earning a minor in education.18 As our profession developed its own body of knowledge, dependence on teacher preparation waned. Certification requirements no longer included a pedagogy requirement.18 Workshops preparing Approved Clinical Instructors at CAAHEP-accredited athletic training programs are important to support the development of clinical-instruction techniques.1
It is important to note that subjects were not offered a clinical-instruction preparatory lesson before our investigation, nor did we control the content of clinical instruction. Similarly, subjects were not familiar with the CIAT-AT II instrument. This tool and evaluation process, if used in conjunction with training, can introduce a tangible, behavior-driven framework for clinical instructors.
A significant part of clinical instructors' training, especially for inexperienced individuals, should include techniques to encourage the athletic training student to participate in learning opportunities. As program directors and clinical coordinators systematically evaluate clinical-instruction effectiveness, special attention should be given to inexperienced teachers.
We thank Gregg R. Bennett, PhD; Mitchell L. Cordova, PhD, ATC, FACSM; Jan Drummond, PhD; Greg A. Gardner, PhD, ATC, LAT; Christopher D. Ingersoll, PhD, ATC, FACSM; B. Andrew Krause, PhD, ATC; Karen S. Lundy, PhD, RN, FAAP; and Benito J. Velasquez, DA, ATC, LAT, for their assistance in this project.