Modular Approach to Evaluting the Clinical Proficiencies

EVALUATION OF THE ATHLETIC TRAINING CLINICAL PROFICIENCIES:
A MODULAR APPROACH

NOTE:
This document is a MODEL that can be used for athletic training clinical education. Other models may be used. The purpose of this document is to present the key elements involved with clinical education and present a non-multiple checklist method for evaluating the Clinical Proficiencies.

The Athletic Training Educational Competencies (Competencies) and the Clinical Proficiencies (Proficiencies) are both descriptive and prescriptive. The individual cognitive, psychomotor, and affective competencies are prescriptive in that they describe the content that must be taught in a CAAHEP-accredited entry-level athletic training program. The professional application of the competencies, Proficiencies are intended to be both prescriptive and descriptive. Viewing the Proficiencies only as prescriptive can increase the workload and diminish the intent of this portion of the student's education.

There are roughly 1,230 individual proficiencies. Since the Proficiencies are itemized, it may be tempting to make a clinical, learning over time "checklist" using each of these items. While this is a model that would meet the JRC-AT's evaluation criteria, this checklist would be overly cumbersome and time consuming and it is not the most effective approach to clinical education.

Rather than viewing the Proficiencies in a prescriptive manner (i.e., as a "checklist"), another approach is to view it as a descriptive document. A review of the individual proficiencies will reveal a significant amount of overlap within and between Subject Areas. This redundancy was not an oversight, but rather, intended to characterize integrated functions within our professional practice.

The overlap between subject areas also serves as a model clinical evaluation system for the proficiencies, one that forms several large evaluation modules rather than a thousand individual "check offs". Creating integral modules encapsulates this content, making the instruction and evaluation more efficient and systematic.

We should see an increase in clinical competence and confidence as a student progresses through the educational process. A senior student should be on the verge of performing at the level of an entry-level professional. A sophomore student should be on the verge of demonstrating skills of a junior student. During the earlier levels, clinical assessment should be focused at the psychomotor level. That is, can the student perform the individual skills needed to fulfill the larger task at hand? From a didactic standpoint, addressing each of the various forms of cryotherapy is important. In the clinical setting, the student's ability to integrate cryotherapy into the patient's injury management (including the decision-making of which modalities to use and not to use) should be the focus.

As the student progresses through the major, he or she should be the ability to synthesize the individual skills into the larger clinical outcome. Keep in mind that many of these progressions will be staggered. As a student is developing mastery of one content area, he or she may be just learning a new area.

Most accredited programs already have the basic structure in place to meet the revised clinical education standards. By addressing all of the educational competencies, programs are addressing the background requirement for the Proficiencies and therefore have built the basis for the "Learning Over Time" concept.
 

WHAT IS A CLINICAL PROFICIENCY?

By definition, the Clinical Proficiencies are grouped sets of the cognitive, psychomotor, and affective competencies that result in desired professional outcomes. The cognitive competencies provide the student with an understanding of the science, theory, and techniques related to the proficiency. Psychomotor skills are the student's ability to physically manipulate a device or perform a skill. Affective competencies relate to professional and ethical considerations in professional practice. The Proficiencies are contained within the competencies and describe the expected clinical skills.

Most Clinical Proficiencies are based on several clinical behaviors. Evaluation of an injured shoulder (a Clinical Proficiency) incorporates the clinical behaviors of history taking, inspection, palpation, range of motion testing, ligamentous testing, special tests, and so on.

While learning about shoulder evaluations in the classroom and laboratory, the student may learn dozens of ligamentous and special tests and the theory behind them. Finite evaluations may be made on the student's ability to perform the Apley's Scratch Test, The Apprehension Test, and all other psychomotor skills delineated in the clinical proficiency. However, this and of itself does not define the final outcome measure: the student's ability to evaluate the shoulder.

When demonstrating a descriptive clinical proficiency, the student must analyze the problem, consider the facts at hand, and make decisions about which tests are - and which tests are not - applicable, and why. A student who performs each and every test during an actual shoulder evaluation is not displaying the ability to discriminate between appropriate or inappropriate tests.

This means that each student may not be faced with a situation where each and every one of the subtasks identified in the proficiencies is actually evaluated in the clinical setting. However, at the classroom and laboratory level, the program must assure that the specific behaviors are evaluated.

EVALUATING THE PROFICIENCIES

Accreditation standards require that multiple evaluations of these skills are performed, but that DOES NOT mean that three "check offs" need to be performed for each proficiency. Using the Teach It, Practice It, Do It model, the first evaluation would be performed in the classroom via written examinations. This approach would evaluate the cognitive and affective components of the proficiency. Psychomotor skills would then be evaluated in the laboratory component by an ACI. Lastly, the student's ability to apply these skills clinically would be evaluated in the clinical setting, either using actual patients or through simulations, again under the auspices of an ACI (possibly in conjunction with other health care providers). The focus of the clinical evaluation is on the integration, skill, and accuracy of the primary teaching objective, not the individual proficiencies.

Where

How

Learning Areas Assessed

Possible Documentation

Classroom

Written examinations
Case studies

Cognitive
AffectiveTheory behind psychomotor skills

Course syllabus
Sample examinations
Written case study reports

Laboratory

Practical examinations
Role Playing

Psychomotor skills
Clinical proficiencies
Affective traits

Course syllabus
Psychomotor evaluation tools

Clinical

Actual patient care
Scenarios

Clinical proficiencies primary teaching objectives
Educational competencies

SyllabusACI/CI/CS evaluation forms
Videos
ATC evaluation forms (Professional assimilation)

During the accreditation process the program must indicate how each of the proficiencies are being addressed in the program. Specifically:
 

  1. The class (or lab) that the proficiency is specifically taught (cognitive and affective competencies). Because the proficiencies are based on the cognitive, psychomotor, and affective competencies, the classroom instruction is documented through the Competency Matrix (cognitive and affective competencies). Written examinations also are included in the "multiple evaluations" and "learning over time" concepts. The Proficiency Matrix that demonstrates where the formal instruction of the Proficiencies occurs reinforces this.
  2. Where it is evaluated (psychomotor competencies). This is usually in the course(s) and the associated laboratory sessions identified above. The psychomotor competencies can be evaluated (using subset skills where applicable) in the laboratory setting prior to the student being evaluated on real patients in the clinical setting. At this point an ACI or appropriately qualified individual (e.g., exercise physiologist, physician, health counselor) conducts the evaluation. This information can be derived via the Competency Matrix using the psychomotor competencies and the Proficiencies Matrix under formal evaluation.
  3. When it is evaluated during clinical education (clinical proficiencies). This is where the student assimilates the various skills and sub-set skills that form the proficiencies and applies them in a clinical problem solving manner. Approved Clinical Instructors perform evaluation of the proficiencies. Here the student is taking the individual elements of the proficiency and synthesizing the skills into a larger clinical outcome. The Athletic trainers and other health care or professionals can provide feedback regarding the students' affective and other subjective traits. This is verified with the clinical course syllabi and written ACI/CI evaluation of the student.

Using the Therapeutic Modalities Clinical Proficiencies as a model, consider teaching objective number 2:
- Cryotherapy (The student will demonstrate the ability to select the appropriate parameters for, and then apply, the following:

     a. cold whirlpool treatment
     b. controlled cold therapy unit
     c. ice pack
     d. vapo-coolant spray
     e. ice immersion
     f. ice massage
     g. cryokinetics

The Therapeutic Modalities cognitive Competencies numbers 1, 4, 8, 9, 12, 14, 19, and 21 would relate to cryotherapy (in part or whole). Written examinations would measure the student's understanding of these concepts. In the laboratory, the student would demonstrate proficiency for each of the seven types of cryotherapy listed above. Then, in the clinical setting, the student would demonstrate the integration of cryotherapy as a whole into the patient's injury management, discerning what modalities to use (and those that are not appropriate) and why. At this point not all of the seven modalities would need to be evaluated in the clinical setting. The program would be responsible for determining the appropriate clinical level for evaluation of this skill following formal instruction as a part of their instructional plan.

RELYING ON OTHER EXPERTS

Most athletic training education programs rely on the expertise of other professions. Exercise physiologists, biomechanists, physicians, health counselors, and so on may be responsible for instructing the Competencies. Programs can use these content experts as defacto ACIs for the laboratory evaluation of the Proficiencies. However, the program director is ultimately responsible for assuring that all applicable proficiencies were evaluated and that each student has successfully competed each. This does not require the physical presence of the AT program director (or ATC-ACI) within in the learning environment. Documentation similar to that used to communicate the instructional needs of the Competencies to allied instructors could suffice for this.

An ACI would then evaluate the student's ability to integrate these knowledge and skills into professional practice in the clinical setting. For example, if an exercise physiologist teaches and instructs the competencies and proficiencies that relate to the taking of blood pressure, an ACI would then determine the student's ability to integrate this into a preparticipation physical examination and/or the management of head injuries.

SEQUENCING OF THE CLINICAL EXPERIENCES

Although this topic receives relatively little space in this document, the importance of an appropriate curricular sequence on a successful clinical education plan cannot be understated. Even the best clinical education plan will fail if the student's course sequence does not match the clinical expectations.

The sequence in which the proficiencies are taught and evaluated must be commensurate with the expectation of the student's clinical education opportunities. Keep in mind that a student must first be taught a skill prior to performing that skill in the clinical setting. Therefore the curricular sequence must be commensurate on the learning objectives described during clinical education and field experience. Close coordination between didactic and laboratory learning and clinical expectations enhances the practice-oriented approach to clinical education. No learning can occur in a vacuum. It is important that students are able to transfer their classroom and laboratory learning to the practice setting.

All too often the emphasis of clinical education is to provide service, to be a labor force. As such, the educational emphasis is on learning how to do the "assigned job" first and to develop "overall" skills if the opportunity arises. In this model, the clinical education plan is an internship supplemented by course work. A good clinical education plan focuses on both professional skills and professional integration.

PROFESSIONAL INTEGRATION

The time spent during practice-based clinical education (e.g., the athletic training room, practice/game coverage, clinics) should not be entirely focused on the proficiencies. Practice-oriented education also incorporates the psychosocial assimilation into the work environment. The value of the experience itself should not be overlooked during the clinical education process.

Clinical education is a process where students begin to develop their professional identity, an identity that embraces more than just the physical ability to perform job-related tasks. The student is socialized (the process of becoming competent in meeting the traditional professional expectations) into the profession by way of professional assimilation and acculturation. Professional identity is and affective trait based on the concepts of security, affiliation, and self-esteem.

 
Security is the student's need for a reasonably predictable future; this occurs through studying and practice. Test taking, skill demonstration, role playing, and receiving feedback on professional abilities enhances the sense of security.
Affiliation allows the student to gain a sense of value within their professional group. Initially, this is the program and the student's peers; later, it will be the athletic training profession.
Self-esteem development is the process of the student's feeling of self-worth and occurs in both the professional and personal spheres. A traditional component of self-esteem is reinforced through performance on tests, clinical skill assessments and other measures of competence. An often-overlooked component of self-esteem is the student's sense of his/her reasoning capabilities (i.e., the process by which conclusions or decisions are made). Asking a student to demonstrate a clinical proficiency is not nearly as important to self-esteem as asking why the proficiency was performed in the manner it was or how the proficiency would be performed differently in a different situation. Self-esteem is also reinforced through interactions with patients, instructors, physicians, parents, health care providers, and even coaches.

Learning to be an athletic trainer is more than obtaining the rote skills and knowledge required for professional practice. It also includes learning how athletic trainers establish and maintain relationships with others in their lives (i.e., patients, athletes, peers, spouses, and children). As the "healer", students must see how they and their work contribute to the lives of their patients and society. The measure of this is the student's understanding how the patient perceives the athletic trainer and the care provided. A student's failure to meet the patient's expectations means the student will have difficulty addressing his or her own psychosocial needs or have a misguided perception of those needs (i.e, an over-stated or under-stated perception). As the "professional", the student assumes "membership" in a peer group that demonstrates ethical, competent practice and helps the profession present itself to society.

While "clinical education" is structured to teach, reinforce, and evaluate classroom learning, "field experience" is designed for the student's professional assimilation. Neither of these aspects should occur in isolation from the other.

CREATING A SAMPLE MODULE

The Assessment and Evaluation content area will be used for the basis of this example. Certainly other modules and/or interrelationships could be made. As we go through this, please have a copy of the Athletic Training Educational Competencies (ed 3) (or a downloaded copy of the Proficiencies) available for reference. The Proficiencies will be referenced by Content Area (e.g., Acute Care), Teaching Objective (TO-#) and, when applicable, subtask (TO-2-1-a).

Keep in mind that this is only presented as an example. There are several ways to meet the same end.

When this system was developed, it started with the end (outcomes) and progressed back to the beginning (sort of like The Usual Suspects, but not as attention grabbing). The first question asked was "What are the major outcomes described by the proficiencies?" For the purposes of this paper the primary content areas were used to identify the outcomes; certainly other groupings could be developed.

Begin the process by examining the objectives of your current classroom, laboratory, and clinical courses and identify what evaluation methods are already in place. A quick dissection of your current psychomotor and clinical evaluation forms should identify which proficiencies are being taught and evaluated.

ASSESSMENT AND EVALUATION

Let's use the Assessment and Evaluation pool, as it's the most straightforward of these groupings. At face value, this content area contains a minimum of 327 individual skills (excluding multiple special tests, etc.). However, after a closer look at the content of these proficiencies, several methods to condense these requirements into clinically relevant (and practical) models emerge.

The Assessment and Evaluation proficiencies are described by six teaching objectives. Teaching Objective 6 (evaluation of major body areas) is the crux of this content area. It is safe to assume that all programs have had some form of injury evaluation skill assessment as a programmatic requirement. Likewise, most programs teach the evaluation segment over a minimum of two academic terms.

By successfully completing the nine evaluations presented in TO-6, the student will have also demonstrated mastery of the proficiencies in TO-1, 3, 4, and 5 thus eliminating 90 "check offs" from this area.

  Other Proficiencies Evaluated (Assessment and Evaluation Area) *
TO-6 Body Area TO-1
(postural eval)
TO-3
(palpation)
TO-4
(neurological)
T0-5
(ROM)
Head and Face   TO-3-1-a, b, d TO-4-1-a, e TO-5-1-a
Cervical Spine TO-1-2-a TO-3-1-a, b, d TO-4-1-b, c, d, e TO-5-1-b
Shoulder TO-1-2-b TO-3-1-a, b, d TO-4-1-b, c TO-5-1-c
Elbow   TO-3-1-a, b, d TO-4-1-b, c, d, e TO-5-1-d
Forearm, Wrist, Hand   TO-3-1-a, b, d TO-4-1-b, c, d, e TO-5-1-e, f
Thoracic/Lumbar Spine TO-1-1-a, b, c
TO-1-2-c
TO-1-3-a, b, c
TO-3-1-a, b, c, d TO-4-1-c, d, e TO-5-1-h, I
Hip/Pelvis TO-1-1-d, f
TO-1-2-d
TO-3-1-a, b, d TO-4-1-c, d, e TO-5-1-g
Knee TO-1-1-e, g
TO-1-2-e
TO-3-1-a, b, d TO-4-1-b, c, d, e TO-5-1-j
Leg, Ankle, Foot TO-1-1-h, i, j, k
TO-1-2-f
TO-3-1-a, b, d TO-4-1-b, c, d, e TO-5-1-k, l
* In addition to the proficiencies described in TO-6

At first glance the above Table may be a bit overwhelming (and confusing), especially if you try to focus on the codes. Look at the Table again, but this time notice how each row (body part evaluation) fulfills several other proficiencies.

Focusing on the Body Area Proficiencies (TO-6) for the knee, let's take a look at how this could fit into an academic and clinical plan:

Prerequisite Courses   Classroom Laboratory   Clinical Education    
Prior Experiences     Field Experiences          

Prerequisite Courses (Cognitive and Psychomotor Theory)

 
- Anatomy/Physiology I
- Anatomy/Physiology II
- Kinesiology
 
Here the student receives the background knowledge required to evaluate. (In this example we'll say that the kinesiology course teaches and evaluates the use of a goniometer.)

Prior Experiences (Affective and Cognitive)

 
- Injuries seen while the student was on a field experience or observation.
- Personal injuries suffered.
- Injuries observed while in non-professional roles (e.g., on television)
 
Although the some of the above situations may not ordinarily be considered a formal part of the educational process, each contributes to the student's overall understanding of our role in health care, the process of injury evaluation, and, in the case of personal injury, empathy for the injured individual. And as knowledge and skill are acquired and a sense of professional identity is gained, the student will be able to critique these situations when they occur in the future.

Evaluation Course (Cognitive, Affective, and Psychomotor)

 
The actual evaluation course (recognizing that this topic is often distributed between two or three courses) presents the cognitive, psychomotor, and affective competencies needed to perform the Proficiencies described in the regional evaluations. This opportunity should also be used to integrate relationships with prerequisite courses and enhance the student's synthesis of knowledge and skills (competencies) from other courses and reinforces how it relates to the current topic.

Evaluation Laboratory (Psychomotor Skills and Clinical Proficiencies)

 
The lab may focus on the teaching, practice, and evaluation of the psychomotor skills and incorporate the use of subset skills. As the student develops acumen, these individual components will come together to form the evaluation Proficiencies. For the purpose of example, we'll assume that these psychomotor skills are taught in this laboratory.
 
A sample evaluation tool for these skills is presented in Appendix A. Although the student's overall lab grade will be based on the aggregate performance for all lab assignments, the Program Director (through ACI evaluation) must ensure that each student has successfully completed each of the proficiencies and the relevant psychomotor skills.
 
However, rather than the psychomotor skills being taught in isolation, the lab sessions should also begin to instill in the student the integration of these skills into an overall systematic evaluation and relate these findings to areas beyond the scope of evaluation and into such topics as management, rehabilitation, and record keeping.

Clinical Education in the Professional Practice Setting (Evaluation of the Clinical Proficiencies)

 
Clinical education is instructed and evaluated by an ACI. Here the emphasis is on the primary teaching objectives and the student's ability to integrate the competencies into the larger outcome. Clinical thinking and decision-making are hallmarks of this portion of the evaluation process.
 
For the purposes of example in this section, let's say that the student is asked to evaluate a patient who has suffered a knee injury (either an actual patient or a simulated patient). Through the history-taking, inspection, and palpation, the student focus in on the integrity of the medial collateral ligament, ACL, and medial meniscus (all which we are assuming would be correct).
 
In this evaluation model, the ACI would not focus in on "checking off" each segment of the history taking process, marking that each structure was palpated, and use subset skills for the other psychomotor skills. The student has already demonstrated finite proficiency in these areas. We are now evaluating the skill, efficiency, and accuracy of applying them as a part of a formal evaluation (Appendix B) using a visual analog scale (VAS) (Appendix C).
 
Note that not all of the psychomotor skills taught in lab would (or should) be included in our scenario. The student's ability to discriminate between those tasks that are not appropriate in this situation and those that are is equally as important as actually performing the skills. Indeed, this differentiates between rote memorization and clinical decision-making.
 
Recall that we used our kinesiologist to teach and evaluate the use of a goniometer. In this hypothetical case, our kinesiologist is not a certified athletic trainer and therefore is not an ACI. However, this instructor was relied on to perform one of the evaluation steps of this proficiency. In this evaluation the ACI rechecked the goniometric proficiencies (as well as other skills), thus meeting the "learning and evaluation over time" principle.

Field Experience (Practicing the Clinical Proficiencies/Professional Assimilation)

 
Here the emphasis is on translating classroom and laboratory learning to the work-place environment. Students practice, master, integrate, and apply their skills during the field experience. This portion of the clinical affiliation does not have to be supervised by an ACI, but the mentor should continue to provide constructive feedback regarding the student's ability.
 
The field experience is also the ideal venue to begin instilling the security, affiliation, and self-esteem required for the student to gain a sense of professional identity.

A potential problem does exist in this methodology. As Dr. Knight has noted, relying on actual patients to practice on is a "hit or miss" proposition. Some students will be able to be evaluated while working with actual patients. In other cases scenario or role-playing situations will need to be devised. A review of injury records, prior clinical evaluations, and so on can be used to help identify those Proficiencies that are likely to be encountered using an actual patient base and those that will be fulfilled through role playing and/or simulation exercises.

CREATING LARGER UNITS

The prior section we emphasized building upon a set of smaller tasks to build a larger skill: Modules. From this we can also use modules to build larger Units that contain more than one Content Area. Recall that clinical assignments (formally "sport assignments") are now based on Lower Extremity, Upper Extremity, Equipment Intensive, and General Medical experiences. From this we can integrate like modules into proficiency units, assuming that the course sequence permits this.

CLINICAL ROTATION POSSIBLE/EXAMPLE UNITS
Lower Extremity Foot, ankle, lower leg, knee, and hip
Upper Extremity Hand, wrist, forearm, elbow, and shoulder
Equipment Intensive Head, cervical spine, and lumbar/thoracic spine
General Medical Abdomen and thorax

While each experience will have overlap, a student completing an upper extremity clinical assignment such as with volleyball may not be exposed to injuries to each of the areas listed above. The ACI and/or Clinical Coordinator would be responsible to provide simulation activities or role playing to evaluate student mastery of the proficiency. The ACI would track the completion of the skills via the student evaluation form(s) associated with the clinical course associated with the experience. In essence, each student will have a minimum of four separate evaluation forms, one for each of the four required experiences. Each evaluation will demonstrate that the student has mastered the proficiencies associated with the clinical assignment.

SUMMARY

In some instances, the final structure of your clinical education plan may not end up being significantly different than it currently stands. In other cases changes in approach and application will be needed.

The process of evaluating and revising your clinical education plan should include the following steps:

  • Complete your Competency Matrix to identify where each of the cognitive, psychomotor, and affective competencies are being taught and evaluated.
  • Complete the Proficiency Matrix to identify where each of the Proficiencies are being taught and evaluated.
  • Review your current laboratory and clinical evaluation forms to identify that the appropriate proficiencies are being taught and evaluated.
  • - Review and analyze your current clinical assignment structure and identify where you feel the appropriate units best fit.
  • - Create a syllabus for each clinical assignment that includes:

 
o The objectives of the assignment (i.e., demonstration of the Proficiencies)
o The method of assessment
o The method of measuring the appropriate level of competence.
  • - Periodically validate your methods via student and clinical instructor evaluations, outcome evaluations (NATABOC examination scores, employer evaluations), and other means deemed appropriate by the program and/or institution.
 
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