Athletic Trainers' Knowledge Regarding Airway Adjuncts

INTRODUCTION

To remain relevant and retain effective patient engagement strategies requires practitioners to assimilate and apply constantly emerging evidence-based information and lifelong learning skills.¹ However, research indicates that knowledge gaps exist among professions and practitioners, which may impact patient outcomes when practitioners fail to recognize changes relevant to their clinical practice. The failure to integrate updated information into professional practice creates a difference between actual and perceived knowledge, which can be dangerous when individuals are unaware they possess a knowledge gap.^2–8 On the other hand, research indicates that patient outcomes improve when practitioners participate in continuing education (CE).^9,10 Therefore, CE sessions may be an effective mechanism to bridge content knowledge gaps and provide more efficacious patient care.

Continuing education in athletic training allows skill development beyond the National Athletic Trainers' Association's (NATA) educational competencies (fifth edition) for entry-level practice.¹ The Professional Education Committee (PEC) is a group of athletic training educators whose job is to review and develop the educational competencies.¹¹ The PEC utilizes the sixth edition (2011) of the Role Delineation Study/Practical Analysis (RDS/PA) to ensure that the educational competencies include all of the necessary knowledge and skills required for entry-level practice.¹² The Board of Certification exam questions are developed to assess athletic training knowledge within the 5 domains defined by the RDS/PA.¹² Finally, undergraduate athletic training programs' abilities to meet these educational competencies and produce competent entry-level practitioners is assessed through the accreditation process.¹²

The educational competencies, RDS/PA, and state practice acts define the scope of practice in athletic training for entry-level professionals. For students enrolled in current Commission on Accreditation of Athletic Training Education-accredited programs, up-to-date content delivery is innate to the educational process; practitioners, on the other hand, must update intentionally through CE.¹³ Changes to established practice guidelines occur when research indicates better patient outcomes using different or modified methods of care.¹⁴ Successful implementation of new information, therefore, requires educating practitioners.¹⁴ As the professional scope of practice expands, new clinical practices are traditionally added to educational program competencies. While this benefits current students, practicing clinicians have no mechanism to determine their knowledge gaps, and if identified, must seek this new information through individual inquiry or CE resources.¹

The use of airway adjuncts was added to athletic training clinical practice with the release of the fifth edition of the NATA educational competencies and proficiencies in 2011.¹ Although this clinical practice is now a component of the NATA educational competencies, knowledge gaps may exist among previously credentialed athletic trainers. Therefore, the purposes of this study were to:

1. Determine the relationship between perceived and actual knowledge (to measure knowledge gap) and

2. Assess differences in pretest and posttest perceived knowledge

METHODS

This study is a knowledge assessment with 2 aims: (1) to measure the relationship between perceived and actual knowledge (correlational) and (2) to measure a change in perceived knowledge and likelihood to pursue CE after an actual knowledge assessment (pretest/posttest).

RESULTS

Since we were unable to accurately determine the number of nondeliverable e-mails from the 2000 sent and exclude them, the response rate was estimated at 7.6% (n = 152). The respondents had an average of 13.84 ± 9.39 years of experience, ranging from 1 to 39 years. Table 1 includes further participant demographic information.

Table 1. Participant Demographics (n = 152)

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Table 2. Perceived Knowledge Questionnaire Statement (Number Reporting)

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Table 3. Actual Knowledge Assessment (n = 152)

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Table 4. Actual Knowledge Assessment Correct Responses by Frequency of Use of Lifesaving Skills (n = 152)

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We identified a poor positive relationship (r = 0.36, P < .001) between pre-PK and AK. We identified no significant change (t₁₅₁ = 1.17, P = .25, 95% confidence interval [CI] = −0.04 to 0.14) in PK from the pretest (pre = 3.43 ± 1.35) to posttest (post = 3.38 ± 1.30), yet the scores indicated that participants perceived only moderate competence with airway adjunct skills (Tables 2 and 3). Furthermore, participants recognized the need for continuing education prior to testing (pre = 4.35 ± 1.30), and as such, no significant increase (t₁₅₀ = −0.91, P = .37, 95% CI = −0.17 to 0.06, effect size [ES] = 0.07, 1 − β = 0.52) in likelihood to pursue continuing education after testing existed (post = 4.40 ± 1.35). When stratifying our sample by gender and employment setting, we identified no significant differences in AK (gender: F_1,135 = 0.213, P = .65, ES = 0.002, 1 − β = 0.074; employment setting: F_1,148 = 0.82, P = .49, ES = 0.016, 1 − β = 0.224). We did, however, recognize significantly higher AK (F_1,145 = 4.63, P = .03, ES = 0.031) among participants employing lifesaving skills more frequently (occasionally = 6.5 ± 0.3) than those that do not (not at all = 5.7 ± 0.3; Table 4). We also identified a poor positive relationship (r = 0.045, P = 0.583) between AK and the likelihood to pursue continuing education. When stratifying the AK scores by years of experience and likelihood to pursue continuing education, we found no significant differences (years of experience: F_2,147 = 2.357, P = .98, ES = 0.031, 1 − β = 0.471; continuing education: F_2,147 = 0.545, P = .581, ES = 0.007, 1 − β = 0.139). Participants who used lifesaving skills more frequently (occasionally = 4.57) were no more likely to pursue continuing education (t₁₄₄ = −1.63, P = .106, 95% CI = −0.77 to 0.075, ES = 0.031, 1 − β = 0.031) than the group that did not use lifesaving skills (not at all = 4.22). Of the 47 respondents (30.9%) who held additional credentials, 14 individuals served as emergency medical technician/paramedics (8.21 ± 1.19) and demonstrated significantly higher scores on the AKA (df = 3, χ² = 24.158, P < .001) than all other groups (performance enhancement = 6.20 ± 1.96; athletic trainers = 5.90 ± 2.39; physical therapists = 5.00 ± 2.28; other = 3.71 ± 0.95).

DISCUSSION

Results indicated a poor positive relationship between perceived and actual knowledge. Our finding is similar to previous research, suggesting weak relationships between perceived and actual knowledge.^2–8 The poor relationship between actual and perceived knowledge, indicating a knowledge gap, can have negative implications for patients. Both clinicians with an inflated sense of and a lack of confidence in perceived knowledge pose risks to patients.^9,10 Overconfidence may lead to the lack of compulsion or desire to gain CE, while a lack of confidence may result in hesitation or selecting a technique the practitioner may be more comfortable with. Our research demonstrates a knowledge gap in airway adjunct use among athletic trainers. The airway adjunct competencies are recent additions to the athletic training scope of practice; thus, practicing clinicians need CE to obtain new knowledge about proper uses. The need for CE may be translated to other emerging skills within the scope of practice. In the medical professions, CE is important for 3 reasons, patient efficacy, maintaining the integrity of the profession, and establishing a legal standard. Practitioners who fail to incorporate new skills/competencies may diminish patient outcomes and mitigate legal standard of care. Thus, CE is essential to bridge the knowledge gap of clinicians.

We also examined the change in perceived knowledge before and after the AKA and identified no significant change in pretest and posttest perceived knowledge. This result suggests that participants were moderately confident in their perceived knowledge at the onset, and the test did not change that perception. Although participants indicated moderate perceived knowledge of airway adjuncts, the participants still perceived they knew more than reality. The results suggest that practitioners failed to accurately recognize their lack of knowledge, which could potentially harm patients. In previous literature,³ a similar phenomenon occurred, where the test and/or feedback did not change PK, but led to a greater desire to seek CE (posttest). Both these findings are counter to theory suggesting both internal (the test) and external (summative score) feedback mechanisms should change PK.³ Regardless, PK did not change after the AKA, suggesting an inflated confidence which will likely lead to an athletic trainer improperly applying the skill.

Based on the literature, emergent care skills should be taught using a scenario-based approach.^17,18 Individuals should review knowledge and skills every 6–12 months to prevent degradation over time.^17–23 Athletic trainers and other health care professionals need to be aware of the decreases of knowledge and skills over time and proactively seek CE. The NATA's position statement on emergency action plans suggests reviewing and rehearsing emergency procedures at least once per year.²⁴ Our results support the ideal that practitioners who use these skills more frequently have a higher AK. Emergency medical technician/paramedics scored significantly higher than any other group of participants, suggesting that individuals who use these skills more frequently retain knowledge and skills more than those who do not. Our results also indicate a knowledge gap among athletic trainers in the use of airway adjuncts. Continuing education is needed to decrease the knowledge gap and to ensure that athletic trainers are meeting the standard of care.

A limitation to this study was the small sample size. Previous research²⁵ found a 20.5% response rate when examining Web-based responses. Walsh et al²⁶ concluded participants self-selected surveys based on topics of which they had knowledge and opinions. These findings suggest that the participants we recruited had little knowledge of airway adjuncts and may have self-selected not to take the survey. Future research should include an educational opportunity after the survey to determine how many athletic trainers actually pursue CE after they selected that it was necessary. Continuing education courses should include a knowledge and skill assessment to determine if the clinician is proficient in the airway adjunct competencies. Since airway adjuncts are an emergent care skill, we suggest CE should focus on skills practice.

CONCLUSIONS

Findings from the current study indicate that a difference in perceived and actual knowledge of airway adjunct use by athletic trainers exists, which suggests that more vigilant use of CE is necessary by athletic trainers. Likewise, athletic trainers recognize a relative lack of knowledge but were not accurate as to the extent of knowledge regardless of testing. Athletic trainers were likely to pursue CE to decrease their knowledge gap. We found a significant difference between actual knowledge and the frequency of use of lifesaving skills, suggesting that individuals that use the skills more regularly are more knowledgeable, implying that more frequent practice may be needed to retain skill competency. Our findings suggest that athletic trainers are aware of the knowledge gap of the proper applications of airway adjuncts and are likely to pursue CE to decrease the gap. Thus, we suggest CE opportunities are necessary to aid practitioners with newer and emerging competencies to ensure that athletic trainers are meeting the standard of care for the profession.