Program Directors' and Clinical Instructors' Perceptions of Important Clinical-Instructor Behavior Categories in the Delivery of Athletic Training Clinical Instruction

Abstract

Objective:

To investigate the perceived importance of clinical instructors' behaviors and behavior categories in the roles of program director (PD) and clinical instructor (CI) and to ascertain the relative importance of these items within each role.

Design and Setting:

From the literature, we developed a questionnaire, validated by a panel of experts, to collect data regarding the perceived importance of 30 specific CI behavior statements within 5 categories (instructional, interpersonal, evaluative, professional, and personal). The instrument used in the study had a Cronbach alpha of .92.

Subjects:

Independent groups of 75 PDs and 242 CIs from Commission on Accreditation of Allied Health Education Programs–accredited entry-level undergraduate athletic training programs returned usable surveys.

Measurements:

We computed mean and variation measures for each behavior and category and analyzed these items for between-role and within-role category differences.

Results:

Program directors and CIs differed significantly in the perceived importance of the evaluative category of CI behaviors as well as in 3 specific evaluative behaviors. Program directors and CIs did not differ in the other 4 categories. For within-role groupings, we noted significant differences of perceived importance among the behavioral categories.

Conclusions:

Program directors and CIs perceived all 5 categories to be very important, and they should work to demonstrate these behaviors in clinical-education settings. Collaboration between the groups enhances the understanding of role responsibility in the delivery of athletic training clinical instruction.

Clinical education is a critical component of professional allied health education.¹ Clinical education provides students with experiences in real-life situations involving actual patients, and it offers students the opportunity to apply theory to practice while fostering problem solving, decision making, and critical thinking.^2–4 In clinical-education settings, students practice and develop psychomotor skills and incorporate the attitudes, values, and beliefs of professional practice.^5,6 A key component of student development in the clinical setting is the quality of clinical instruction. Athletic trainers recognize that they hold the role of clinical instructor (CI) and report that clinical instruction represents a large portion of their daily responsibilities.⁷ Contributing factors in the successful implementation of the clinical-education component of athletic training education are the development, training, and evaluation of quality CIs.^8,9

The relationship between the CI and the student is a unique teacher-student phenomenon, allowing for an individualized clinical experience designed to meet the needs of the student as well as the objectives of the athletic training education program. Quality clinical instruction is important to facilitate student learning of cognitive, psychomotor, and affective domains fundamental to clinical practice. Many certified athletic trainers involved in athletic training education programs (ATEPs) serve as CIs. Clinical instructors may teach, evaluate, and supervise athletic training students in clinical-education field experiences.¹⁰ These individuals are expected to provide quality learning experiences for athletic training students and to demonstrate sound CI behaviors.

Researchers have identified important CI behaviors in nursing,^11–17 medicine,^18,19 nurse anesthesia,^20–22 and physical therapy.³ In previous athletic training CI research, Curtis et al²³ identified helpful and hindering CI characteristics as perceived by athletic training students, and Laurent and Weidner²⁴ identified perceived behaviors among students and CIs that facilitate learning. Moreover, authors of literature reviews^25,26 in athletic training have discussed CI effectiveness. Although tools are available that identify CI effectiveness as perceived by students,²⁷ the athletic training profession has not formally identified important CI behaviors from the perspective of CIs, as well as program directors (PDs), who may evaluate the effectiveness of CIs in their education programs. Therefore, our purpose was to investigate the perceived importance of CI behaviors and categories between the roles of PD and CI and to ascertain the relative importance of these items within each role.

METHODS

Subjects

Program directors and full-time, on-campus CIs from all Commission on Accreditation of Allied Health Education Programs (CAAHEP)–accredited, entry-level undergraduate athletic training education programs (N = 130 programs) as of March 2001 were invited to participate in the study. A total of 79 programs returned surveys. Full-time, on-campus CIs are those individuals who are full-time employees of the institution sponsoring the ATEP. These individuals include full-time faculty members and full-time athletic staff members who serve as CIs in the ATEP. In an attempt to survey those CIs with the greatest experience in athletic training and athletic training education, part-time employees and graduate assistants were excluded from the study.

Instrumentation

The Clinical Instructor Behavior Instrument (CIBI), designed by the lead researcher, was used to collect demographic data (role, age, sex, professional status, years of experience serving as a CI or PD) as well as data regarding the perceived importance of 30 specific CI behaviors within 5 categories of CI behaviors (instructional, interpersonal, evaluative, professional, and personal). The process used to design the CIBI involved (1) reviewing the available literature in the allied health professions regarding individual behaviors and categories of CI behaviors, (2) reviewing previously published surveys, and (3) consulting a panel of experts regarding the readability of the CIBI. Categories of important CI behaviors and individual items representing CI behaviors were identified through a review of literature in nursing,^12–17 medicine,^18,19,28 nurse anesthesia,²⁰ physical therapy,³ and athletic training.²³ Through factor analysis^13,19,28 and content analysis of critical incidences,^{14–16,20,23} we identified several categories of CI behaviors. Synthesis of the available research indicated 5 common categories of CI behaviors: instructional, interpersonal, evaluative, professional, and personal.

Several survey instruments from the allied health literature were also reviewed for relative descriptors of CI behaviors.^{12,13,15,17,29} At the time of the survey development, we found only one survey in the athletic training literature³⁰; this survey did not include the personal category of CI behaviors, which had been previously identified in the literature as a category of CI behaviors.^{12,14–16,28} Additionally, the survey instruments identified in the available literature used professional identifiers in the tool as well as in the title; thus, it was necessary to develop the CIBI in the context of athletic training.

Before the survey was finalized, a panel of 15 reviewers consisting of higher-education and public-school faculty and administrators reviewed the CIBI for item readability and to establish face validity. Corrections and suggestions were collected from the panel regarding the readability of the CIBI. As a result, survey directions were changed, and the readability of some of the items was improved. No CI behavior statements were deleted from the survey, and no behavior categories were changed. Because we wanted to survey the entire population of ATEPs, pilot data were not collected. The survey instrument in this study has a high level of internal consistency, with a Cronbach alpha measure of .92.

Each statement in the CIBI represented a CI behavior descriptive of a specific category of CI behavior (instructional, interpersonal, evaluative, professional, or personal). Six behavior statements represented one category of CI behaviors. The respondents did not know which behavior statements pertained to which specific category of CI behaviors. The respondents were asked to rate each behavior statement according to its perceived importance using a 5-point, Likert-type scale (5 = most important, 4 = very important, 3 = important, 2 = somewhat important, 1 = least important) (Table 1). In addition, respondents were asked to identify on the survey form their primary role in the ATEP as either PD or CI. Respondents were instructed to choose only one role; thus, forced-choice independent groupings were created.

Table 1.

Clinical-Instructor Categories and Associated Behaviors

Procedures

The lead researcher contacted all 130 PDs by either e-mail or phone to determine the number of surveys to send to each ATEP. A total of 625 surveys (130 PDs, 495 CIs) representing all 130 ATEPs served as the sample frame, from which 79 programs returned surveys. A packet of material containing a cover letter, the CIBI, and a self-addressed stamped envelope was mailed to each PD. The PD was asked to distribute the CIBI to full-time on-campus CIs serving in the ATEP and to collect the surveys from the respondents. If a respondent indicated part-time or graduate assistant status on the returned survey, we excluded the survey from the study. The Human Subjects Review Board of the College of Human Resources and Education at West Virginia University approved the study.

Statistical Analysis

We computed PD and CI mean summative scores and mean Likert-scale scores for the 5 categories of CI behaviors. Using the Shapiro-Wilk test, we found that the data were not normally distributed (P < .05); therefore, we used the nonparametric Mann-Whitney test to determine the difference between scores assigned by PDs and CIs regarding the perceived importance of the 5 CI categories.

The Friedman analysis of variance by ranks was used to determine differences among category scores within PDs and CIs. When differences were found, we used the Wilcoxon signed rank test with a Bonferroni correction to control for alpha inflation in determining significant pairwise comparisons (10 comparisons). Data were analyzed using the Statistical Package for the Social Sciences (version 11.0; SPSS Inc, Chicago, IL). An alpha level of .05 was established to determine differences between scores assigned by PDs and CIs, and an alpha level of .005, due to the Bonferroni correction, was established to determine pairwise differences (.05/10 = .005).

RESULTS

We sent 625 surveys to the PDs of the 130 CAAHEP-accredited, entry-level undergraduate athletic training education programs. A total of 336 (54%) usable surveys were returned from 79 (61%) ATEPs; 19 were excluded from data analyses. Thus, we used 317 (51%) surveys for data analysis. Of the respondents, 75 were identified as PDs, and 242 were identified as full-time, on-campus CIs. Ages ranged from 22 to 70 years, with a mean age of 36 years. Male respondents totaled 186 and females 131. Regarding professional status of the respondents, 11 were identified as professor, 29 as associate professor, 77 as assistant professor, 122 as instructor, and 78 respondents indicated “other” or did not indicate professional status. Years of experience as a CI ranged from 0 to 31, with a mean of 9 years. Years of experience as a PD ranged from 0.5 to 27 years, with a mean of 9 years.

We noted a significant difference between scores assigned by PDs and CIs regarding the perceived importance of the evaluative category of CI behaviors (P = .011) (Table 2). Program directors assigned significantly greater scores to the evaluative category than did CIs. We found no significant differences (P < .05) between scores assigned by PDs and scores assigned by CIs regarding the perceived importance of the instructional, interpersonal, professional, or personal categories of CI behaviors (Figure 1).

Table 2.

Perceived Importance of Clinical-Instructor Behaviors by Program Directors and Clinical Instructors

Figure 1.

Perceived importance of clinical-instructor behaviors by program directors and clinical instructors. *Program directors assigned significantly higher scores to the evaluative category than did clinical instructors (P < .05).

Program directors and CIs differed in the perceived importance of 3 specific evaluative CI behaviors: (1) provides useful and constructive feedback, (2) demonstrates objectivity and fairness in the evaluation of the student, and (3) defines clearly the expectations of students (P < .05). Mean scores assigned by PDs were greater than those assigned by CIs.

The Friedman analysis of variance by ranks revealed significant differences regarding the perceived importance of the 5 categories within PDs and CIs (P < .005). Program directors assigned significantly greater scores to the evaluative category than to the instructional, interpersonal, or personal categories (P < .005). In addition, PDs assigned significantly higher scores to the instructional, interpersonal, evaluative, and professional categories (P < .005) than to the personal category. No significant differences were seen in scores between the instructional and interpersonal categories, instructional and professional categories, interpersonal and professional categories, or evaluative and professional categories (P > .005) (Figure 2).

Figure 2.

Program directors' ratings of importance of behavior categories. Text box within each category bar represents the categories that are rated significantly lower (P < .005).

Within CIs, significantly greater scores were assigned to the professional category than to the instructional, interpersonal, evaluative, or personal categories (P < .005). In addition, the instructional, interpersonal, professional, and evaluative category scores were significantly greater than the personal category score (P < .005). Clinical instructors also assigned significantly higher scores to the instructional category than to the interpersonal category (P < .005) and to the evaluative category than to the interpersonal category (P < .005). No significant differences were noted in scores between the evaluative and instructional categories (Figure 3).

Figure 3.

Clinical instructors' ratings of importance of behavior categories. Text box within each category bar represents the categories that are rated significantly lower (P < .005).

DISCUSSION

Identifying important CI behaviors is essential in order to begin the process of assessing and developing sound clinical instruction. We found that PDs and CIs held similar views regarding the perceived importance of CI behavior categories but differed significantly regarding the perceived importance of the evaluative category of CI behaviors. Although both groups considered these behaviors to be very important, differences in the degree of importance each group assigned to this category were noted. Program directors found the evaluative category significantly more important than did CIs. Our results support findings by Hartland and Londoner,²² who surveyed PDs and CIs in nurse anesthesia programs regarding the perceived importance of 22 CI behaviors. Program directors assigned significantly higher mean scores than CIs to 2 behaviors representing evaluative behaviors (evaluation/counseling and timely feedback). In our study, PDs also perceived 3 specific evaluative behaviors to be significantly more important than did CIs. In addition, within-group analysis indicated that PDs perceived the evaluative category as significantly more important than the instructional, interpersonal, or personal categories.

Hartland and Londoner²² speculated that PDs found evaluative behaviors more important because they are directly related to program accreditation. Given the current climate in athletic training education regarding careful evaluation of student clinical skills and demonstration of learning over time, it is not surprising that PDs identified evaluative behaviors as more important than instructional, interpersonal, or personal behaviors, as well as more important than CIs did. Evaluative CI behaviors involve identifying student expectations and include the amount and type of feedback given to the student. As we noted, it is important for CIs to provide useful and constructive feedback to students and specific suggestions for improvement. In addition, CIs must correct students tactfully and demonstrate objectivity and fairness in student evaluations. It is possible that PDs' emphasis on the importance of evaluative behaviors reflects the need to evaluate and document student performance in the clinical setting, which ultimately may affect program accreditation. Clinical instructors should note that PDs perceived these behaviors as important. Thus, CIs should demonstrate sound evaluative behaviors when working with students. In addition, CIs should be mindful of the relative importance of evaluation in overall educational-program quality.

Research in nursing¹¹ and nurse anesthesia²¹ indicates that PDs rate interpersonal CI behaviors as most important. Although interpersonal behaviors did not receive the highest rating of importance in our study, they were still considered very important. However, PDs and CIs rated interpersonal behaviors as significantly more important than personal behaviors. The interpersonal relationship aspect is critical in the clinical setting when ratios of students to CIs are small.⁴ Effective relationships involve CIs allowing students to express opinions, encouraging students to ask for help, and demonstrating interest and confidence in, and respect for, the student. As our data indicate, CIs should be available and accessible to students and should provide support and encouragement. Teaching involves interaction and often depends upon the relationships developed between the CI and the students. Demonstrating interpersonal behaviors in the clinical setting enhances the student-teacher relationship⁴ and provides a possible explanation for why both groups rated interpersonal behaviors as important.

Within-group analysis of CIs supports related literature indicating that CIs rate professional behaviors as significantly more important than instructional, interpersonal, evaluative, or personal behaviors.^12,21,31,32 Other literature available in the allied health professions^32–34 indicates that CIs identify evaluative CI behaviors as the most important; however, this finding is not supported by our results. Many CIs serve as practitioners as well as teachers. Therefore, they must demonstrate professional responsibility by staying up to date regarding clinical practice in order to meet the needs of athletic training students, athletes, and other patients.

In our study, CIs and PDs identified professional behaviors as very important CI behaviors. Clinical instructors hold several roles in the clinical setting, including practitioner, supervisor, instructor, and professional role model.^35,36 The professional role of a CI is very important,^37,38 and acting as a professional role model has been identified by CIs in nursing as an important behavior of CIs.^12,31,32 In athletic training, Laurent and Weidner²⁴ reported that CIs and students identified modeling behaviors as the most important category of CI behaviors. It is possible that CIs in CAAHEP-accredited ATEPs perceive their primary role in the clinical setting as that of a professional role model who demonstrates essential skills and behaviors. Clinical instructors who act as professional role models while demonstrating clinical knowledge and competence are exhibiting important professional behaviors. Our results indicate that CIs perceive the role as a professional as the most important.

Both PDs and CIs identified behaviors in the instructional category as very important. Program directors identified instructional behaviors as significantly more important than personal behaviors, whereas CIs identified instructional behaviors as significantly more important than both interpersonal and personal behaviors. In the clinical setting, instructors engage in the teaching process, which includes identifying objectives for learning, assessing learning needs of students, planning learning activities, guiding students' learning, evaluating learners, and facilitating clinical conferences and discussions.^2,4,39–41 Our data indicate that it is important for CIs to explain procedures clearly and to explain the basis for actions and decisions. While students are learning clinical skills, CIs should demonstrate clinical skills for students and provide adequate practice opportunities for students to refine their skills. In addition, CIs should guide students toward decision making by stimulating and encouraging problem solving and critical thinking regarding various clinical situations or problems.

Although PDs and CIs identified personal behaviors as very important, this group of behaviors was perceived as significantly less important within both groups than the other 4 categories. In the nursing literature,^12,33,34,42 CIs identified the personal category of CI behaviors as the least important. The personal behaviors identified in this study represent an individual's personality, which is an integration of traits, motives, beliefs, and abilities. In addition, personality also includes character, morals, and emotional responses to various situations. Clinical-instructor behaviors representing teaching methods and practices (instructional and evaluative behaviors) as well as professional and interpersonal behaviors were rated as significantly more important by both groups than individual personality traits. The current findings indicate that the most important CI behaviors may not represent personality traits but are better reflected in instructional, interpersonal, evaluative, and professional behaviors.

Athletic Training Education Implications

Program directors and CIs can use these results to develop and implement an evaluation tool for CIs that would identify the demonstration of these important behaviors and also assess problem areas in clinical instruction. Program directors and CIs can develop a tool for identifying the frequency of demonstrating these behaviors or the presence or absence of the use of these behaviors when teaching and evaluating students. An evaluation tool would allow PDs to provide feedback to individual CIs concerning their demonstration of these behaviors. Clinical instructors may find this instrument useful for reflective self-evaluation and development. When reflecting on their clinical teaching performance, CIs can simply question whether or not they demonstrate these behaviors when serving as instructors and role models in the clinical setting. Clinical instructors will be able to gain an understanding of their teaching behavior, which will allow them to further improve on their strengths and to address their weaknesses. Through reflective self-evaluation, CIs will be better able to improve their instruction.

To facilitate ongoing CI development, ATEP administrators and CIs can use the current information to plan programs pertaining to the evaluation and assessment of student learning and the use of instructional methods, as well as to develop strategies to demonstrate important CI behaviors. Program directors can use the information to select and train CIs at on-campus sites. Because CIs have typically been selected based on their willingness to serve as CIs, this information can become an objective measure when selecting CIs who demonstrate the most important CI behaviors. In addition, development programs designed for those athletic trainers willing to serve as CIs should address the use of these important CI behaviors to better enhance instruction in the clinical setting.

CONCLUSIONS

Although perceptions differed between the groups, PDs and CIs identified all 5 categories of CI behaviors as very important. Clinical instructors should note the importance of behaviors in the 5 categories as identified by colleagues as well as PDs, and they should be encouraged to demonstrate behaviors in all categories to improve clinical instruction. In addition, both PDs and CIs should recognize their differences in perceptions of the importance of different CI behaviors, and they should work together to understand each group's role responsibilities and those behaviors that are important to each group. In addition, PDs and CIs should recognize that they are members of a collaborative team who must work together to ensure quality instruction in the clinical setting.

Further Research

Further research should include an on-site investigation to determine the frequency with which CIs demonstrate CI behaviors in the 5 categories. In addition, research would determine if differences exist between perceptions and actual practice concerning these behaviors. Also, statistically validating an evaluation tool for CI behaviors is important. To increase the generalizability of results to include off-campus, affiliate-site CIs, further studies should address the perceptions of these individuals regarding important CI behaviors. Currently, CIs who teach and evaluate the application and integration of the Clinical Proficiencies must complete training as an Approved Clinical Instructor (ACI) from a Clinical Instructor Educator (CIE).¹⁰ Because ACIs must undergo a retraining session from a CIE once every 3 years, future researchers should identify the long-term influence of ACI training on the perceived importance of CI behaviors. In addition, because we did not survey students, it would be beneficial to continue to study student perceptions of important behaviors and to compare the views of students with those of practicing professionals in order to facilitate and enhance learning in the clinical setting.