Feedback in Clinical Education, Part I: Characteristics of Feedback Provided by Approved Clinical Instructors

Context Providing students with feedback is an important component of athletic training clinical education; however, little information is known about the feedback that Approved Clinical Instructors (ACIs; now known as preceptors) currently provide to athletic training students (ATSs). Objective To characterize the feedback provided by ACIs to ATSs during clinical education experiences. Design Qualitative study. Setting One National Collegiate Athletic Association Division I athletic training facility and 1 outpatient rehabilitation clinic that were clinical sites for 1 entry-level master's degree program accredited by the Commission on Accreditation of Athletic Training Education. Patients or Other Participants A total of 4 ACIs with various experience levels and 4 second-year ATSs. Data Collection and Analysis Extensive field observations were audio recorded, transcribed, and integrated with field notes for analysis. The constant comparative approach of open, axial, and selective coding was used to inductively analyze data and develop codes and categories. Member checking, triangulation, and peer debriefing were used to promote trustworthiness of the study. Results The ACIs gave 88 feedback statements in 45 hours and 10 minutes of observation. Characteristics of feedback categories included purpose, timing, specificity, content, form, and privacy. Conclusions Feedback that ACIs provided included several components that made each feedback exchange unique. The ACIs in our study provided feedback that is supported by the literature, suggesting that ACIs are using current recommendations for providing feedback. Feedback needs to be investigated across multiple athletic training education programs to gain more understanding of certain areas of feedback, including frequency, privacy, and form.

Feedback in Clinical Education, Part II: Approved Clinical Instructor and Student Perceptions of and Influences on Feedback

Context: Approved Clinical Instructors (ACIs; now known as preceptors) are expected to provide feedback to athletic training students (ATSs) during clinical education experiences. Researchers in other fields have found that clinical instructors and students often have different perceptions of actual and ideal feedback and that several factors may influence the feedback exchanges between instructors and students. However, understanding of these issues in athletic training education is minimal. Objective: To investigate the current characteristics and perceptions of and the influences on feedback exchanges between ATSs and ACIs. Design: Qualitative study. Setting: One entry-level master's degree program accredited by the Commission on Accreditation of Athletic Training Education. Patients or Other Participants: Four ACIs and 4 second-year ATSs. Data Collection and Analysis: Individual, semistructured interviews were conducted with participants and integrated with field notes and observations for analysis. We used the constant comparative approach to inductively analyze data and develop codes and categories. Member checking, triangulation, and peer debriefing were used to promote trustworthiness of the study. Results: Participants described that feedback plays an important role in clinical education and has several purposes related to improving performance. The ACIs and ATSs also discussed several preferred characteristics of feedback. Participants identified 4 main influences on their feedback exchanges, including the ACI, the ATS, personalities, and the learning environment. Conclusions: The ACIs and ATSs had similar perceptions of ideal feedback in addition to the actual feedback that was provided during their clinical education experiences. Most of the preferences for feedback were aligned with recommendations in the literature, suggesting that existing research findings are applicable to athletic training clinical education. Several factors influenced the feedback exchanges between ACIs and ATSs, which clinical education coordinators should consider when selecting clinical sites and training ACIs.

Perceptions of Approved Clinical Instructors: Barriers in the Implementation of Evidence-Based Practice

Context: As evidence-based practice (EBP) becomes prevalent in athletic training education, the barriers that Approved Clinical Instructors (ACIs) experience in implementing it with students need to be understood. Objective: To investigate barriers ACIs face when implementing EBP concepts in clinical practice and in teaching EBP to professional athletic training students and to investigate the educational emphases to improve the barriers. Design: Qualitative study. Setting: Telephone interviews. Patients or Other Participants: Sixteen ACIs (11 men, 5 women; experience as an athletic trainer = 10 ± 4.7 years, experience as an ACI = 6.81 ± 3.9 years) were interviewed. Data Collection and Analysis: We interviewed each participant by telephone. Interview data were analyzed and coded for common themes and subthemes regarding barriers and educational emphases. Themes were triangulated through multiple-analyst triangulation and interpretive verification. Results: Barriers to EBP incorporation and educational emphasis placed on EBP were the main themes reported. Resources, personnel, and student characteristics were subthemes identified as barriers. Resource barriers included time, equipment, access to current literature, and knowledge. Coworkers, clinicians, and coaches who were unwilling to accept evidence regarding advancements in treatment were identified as personnel barriers. Programmatic improvement and communication improvement were subthemes of the educational emphasis placed on EBP theme. The ACIs reported the need for better integration between the clinical setting and the classroom and expressed the need for EBP to be integrated throughout the athletic training education program. Conclusions: Integration of the classroom and clinical experience is important in advancing ACIs' use of EBP with their students. Collaborative efforts within the clinical and academic program could help address the barriers ACIs face when implementing EBP. This collaboration could positively affect the ability of ACIs to implement EBP within their clinical practices.

Relationship Between Approved Clinical Instructors' Assessment of Athletic Training Student Clinical Performance and Their Clinical Grade

Context: Approved Clinical Instructors (ACIs) are integral to athletic training students' professional development. ACIs evaluate student clinical performance using assessment tools provided by educational programs. How ACI ratings of a student's clinical performance relate to their clinical grade remains unclear. Objective: To examine relationships between ACI evaluations of student clinical performance using an athletic training-specific inventory (Athletic Training Clinical Performance Inventory; ATCPI) and the student's clinical grade (CG) over a clinical experience. Design: Correlational. Setting: Large metropolitan university. Participants: 48 ACIs (M=20; F=28; Certified for 7.5+3.2yrs; ACIs for 3.2+1.5yrs) evaluating 62 undergraduate students (M=20; F=42). Interventions: ACIs completed the ATCPI twice (mid-semester, and end-of semester) during their student's clinical experience. The ATCPI is a 21-item instrument: Items 1–20 assess the student's clinical performance based on specific constructs (Specific) and item 21 is a rating of the student's overall clinical performance (Overall). ACIs also assigned students a clinical grade (CG). Pearson product-moment correlations examined relationships between Specific, Overall, and CG, with separate paired t-tests examining differences (p<.05). Main Outcome Measures: The ATCPI used a 4-point Likert-type scale anchored by 1 (Rarely) and 4 (Consistently), and CG (A=4, B=3, C=2 D =1, 0=F). Results: Two-hundred and sixty-six ATCPI instruments were completed over 4 academic years. The ATCPI demonstrated acceptable reliability (Cronbach's alpha=.88). All three measures were positively correlated (Specific and Overall, r(264)=.65, P <.001; Specific and CG r(264)=.63, P <.001; Overall and CG r(264)=.55, P<.001). No differences existed between Specific (3.5±0.4) and CG (3.5±0.7; t=.60, P =.55). However, Overall (3.6±0.7) was significantly higher than both Specific (t=−3.45, P<.000) and CG (t=2.05, P =.04). Conclusions: ACIs reliably assessed students' specific clinical performance and provided a relatively accurate grade. However, since the overall scores were higher than specific item scores, ACIs overestimated students' overall clinical performance. Additional research is necessary to examine the ATCPI as an assessment tool across multiple institutions and to determine how other variables affect ACI assessments of student performance.

Approved Clinical Instructors' Perspectives on Implementation Strategies in Evidence-Based Practice for Athletic Training Students

Context: Understanding implementation strategies of Approved Clinical Instructors (ACIs) who use evidence-based practice (EBP) in clinical instruction will help promote the use of EBP in clinical practice. Objective: To examine the perspectives and experiences of ACIs using EBP concepts in undergraduate athletic training education programs to determine the importance of using these concepts in clinical practice, clinical EBP implementation strategies for students, and challenges of implementing EBP into clinical practice while mentoring and teaching their students. Design: Qualitative study. Setting: Telephone interviews. Patients or Other Participants: Sixteen ACIs (11 men, 5 women; experience as a certified athletic trainer = 10 ± 4.7 years, experience as an ACI = 6.8 ± 3.9 years) were interviewed. Data Collection and Analysis: We interviewed each participant by telephone. Interview transcripts were analyzed and coded for common themes and subthemes regarding implementation strategies. Established themes were triangulated through peer review and member checking to verify the data. Results: The ACIs identified EBP implementation as important for validation of the profession, changing paradigm shift, improving patient care, and improving student educational experiences. They promoted 3 methods of implementing EBP concepts with their students: self-discovery, promoting critical thinking, and sharing information. They assisted students with the steps of EBP and often faced challenges in implementation of the first 3 steps of EBP: defining a clinical question, literature searching, and literature appraisal. Finally, ACIs indicated that modeling the behavior of making clinical decisions based on evidence was the best way to encourage students to continue using EBP. Conclusions: Athletic training education program directors should encourage and recommend specific techniques for EBP implementation in the clinical setting. The ACIs believed that role modeling is a strategy that can be used to promote the use of EBP with students. Training of ACIs should include methods by which to address the steps of the EBP process while still promoting critical thinking.

Perceived Preparedness of Graduate Assistant Approved Clinical Instructors for Supervision of Athletic Training Students in Professional Programs

Context: Approved clinical instructors (ACIs) are crucial for the development of athletic training students. Graduate students often serve as ACIs and usually do not have extensive clinical experience, and therefore may not feel adequately prepared to supervise students. Objectives: 1) To determine the perceived preparedness of graduate assistant ACIs in the supervision of athletic training students in professional programs; 2) To determine perceptions of ACI training. Design: Prospective, exploratory. Setting: Programs that have been accredited by the Commission on Accreditation of Athletic Training Education (CAATE) for five years or more. Participants: Thirty-three out of 140 graduate assistant ACIs (23.5% response rate) at 27 athletic training programs. Instrumentation: A 47-item Graduate Assistant ACI Perceived Preparedness online questionnaire. Data Analysis: Frequencies and percentages were used to describe the responses for questionnaire items; an ANOVA was used to examine self-assessment ratings among participant groups. Results: Participants felt prepared in learning styles (79%), ACI responsibilities (100%), evaluation and feedback of student performance (79%). They felt most prepared to evaluate and provide feedback in students' clinical skills and least prepared in evaluating and providing feedback for professional behaviors. The greatest challenges faced by participants included time constraints (69.7%), controlling the learning environment (57.6%), and understanding institutional policies and procedures related to clinical education (39.4%). When asked to self-assess their first-year performance supervising students on a scale of 0 (worst performance) to 10 (best performance), the mean [SD] score reported was 6.97 [1.2]. There were no differences in first-year self-assessment performance ratings between participants who thought ACI training was adequate and/or beneficial and those who did not (P=0.05). Conclusion: Most of the participants felt prepared to be an ACI as a graduate assistant and believed the ACI training to be adequate and beneficial. There were no differences in self-reported first-year performance ratings between participants who believed their training to be adequate and beneficial and those who did not.

Athletic Training Approved Clinical Instructors' Reports of Real-Time Opportunities for Evaluating Clinical Proficiencies

Context: Appropriate methods for evaluating clinical proficiencies are essential to ensuring entry-level competence in athletic training. Objective: To identify the methods Approved Clinical Instructors (ACIs) use to evaluate student performance of clinical proficiencies. Design: Cross-sectional design. Setting: Public and private institutions in National Athletic Trainers' Association (NATA) District 4. Patients or Other Participants: Approved Clinical Instructors from accredited athletic training education programs in the Great Lakes Athletic Trainers' Association, which is NATA District 4 (N = 135). Data Collection and Analysis: Participants completed a previously validated survey instrument, Methods of Clinical Proficiency Evaluation in Athletic Training, that consisted of 15 items, including demographic characteristics of the respondents and Likert-scale items (1 = strongly disagree to 5 = strongly agree) regarding methods of clinical proficiency evaluation, barriers, educational content areas, and clinical experience settings. We used analyses of variance and 2-tailed, independent-samples t tests to assess differences among ACI demographic characteristics and the methods, barriers, educational content areas, settings, and opportunities for feedback regarding clinical proficiency evaluation. Qualitative analysis of respondents' comments was completed. Results: The ACIs (n = 106 of 133 respondents, 79.7%) most often used simulations to evaluate clinical proficiencies. Only 59 (55.1%) of the 107 ACIs responding to a follow-up question reported that they feel students engage in a sufficient number of real-time evaluations to prepare them for entry-level practice. An independent-samples t test revealed that no particular clinical experience setting provided more opportunities than another for real-time evaluations (t119 range, −0.909 to 1.796, P ≥ .05). The occurrence of injuries not coinciding with the clinical proficiency evaluation timetable (4.00 ± 0.832) was a barrier to real-time evaluations. Respondents' comments indicated much interest in opportunities and barriers regarding real-time clinical proficiency evaluations. Conclusions: Most clinical proficiencies are evaluated via simulations. The ACIs should maximize real-time situations to evaluate students' clinical proficiencies whenever feasible. Athletic training education program administrators should develop alternative methods of clinical proficiency evaluations.

Situational Supervision for Athletic Training Clinical Education

Introduction: The medical education model provides the basis for athletic training students to learn theoretical and practical skills. Clinical rotations are completed where they apply what they have learned under the direct supervision of a clinical instructor (CI) or approved clinical instructor (ACI). Approved clinical instructors are taught how to evaluate athletic training students' clinical skills and proficiencies, yet are left to decide for themselves how students should be supervised. No formal supervision training is required for potential CIs/ACIs. Situational Supervision is one potential model that can be used by athletic training educators to provide guidance to CIs/ACIs regarding student supervision. This model provides a method for students to be supervised according to their knowledge base, experience and self-confidence. Objective: To present the Situational Supervision Model that can be used to develop athletic training students' clinical skills. Background: Based on Blanchard and Hersey's Situational Leadership, Situational Supervision provides CIs/ACIs with one supervision model that can be used in athletic training clinical education. Description: As students become more comfortable with clinical skills and mature in motivation and competence, CIs/ACIs need to adapt supervision styles to match the students' progressing development. Clinical Advantages: Using situational supervision, clinical instruction becomes a cooperative interaction between CIs/ACIs and athletic training students that is dependent on the students' needs and abilities, which may result in higher satisfaction and production for both the students and the CIs/ACIs.

Questioning Skills Demonstrated by Approved Clinical Instructors During Clinical Field Experiences

Context: The current trend in athletic training clinical education places greater emphasis on the quality of interactions occurring between Approved Clinical Instructors (ACIs) and athletic training students (ATSs). Among other attributes, the ability of ACIs to facilitate and direct quality clinical learning experiences may be influenced by the skill with which the ACI is able to use selected teaching strategies. Objective: To gain insight into ACIs' use of questioning as a specific teaching strategy during the clinical education experiences of undergraduate ATSs. Design: Qualitative case study design involving initial and stimulated-recall interviews, prolonged field observations, and audio recording of ACI-ATS interactions. Setting: The primary athletic training facility at one athletic training education program accredited by the Commission on Accreditation of Athletic Training Education. Patients or Other Participants: The 8 ACI participants included 3 full-time athletic training education program faculty members and 5 graduate-level assistants. The 24 ATS participants included 1 senior, 17 juniors, and 6 sophomores. Data Collection and Analysis: Transcribed data collected from 8 initial interviews, 23 field observations, 23 audio-recorded ACI-ATS interactions and 54 stimulated-recall interviews were analyzed through microscopic, open, and axial coding, as well as coding for process. The cognition level of questions posed by ACIs was analyzed according to Sellappah and colleagues' Question Classification Framework. Results: The ACI participants posed 712 questions during the 23 observation periods. Of the total questions, 70.37% were classified as low-level cognitive questions and 17.00% as high-level cognitive questions. The remaining 12.64% were classified as other. Conclusions: Although all ACIs used questioning during clinical instruction, 2 distinct questioning patterns were identified: strategic questioning and nonstrategic questioning. The way ACIs sequenced questions (their questioning pattern) appeared to be more important than the number of specific cognitive-level questions posed. Nonstrategic questioning appears to support knowledge and comprehension, whereas strategic questioning appears to support critical thinking.