Effectiveness of Mobile Learning on Athletic Training Psychomotor

Skill Acquisition

INTRODUCTION

Societal trends have created a demand for increased use of technology in education.^1,2 Today's generation of students, the Millennials, are native to the digital era, not experiencing a time without computers and the World Wide Web.³ They like to multitask, prefer receiving information quickly and having unlimited access to educational content, and function best when networked.² Today's learners use mobile technology daily for entertainment and socialization; therefore, it is logical to incorporate these devices into the educational environment. Mobile learning (m-learning) involves the use of mobile devices such as mobile phones, personal digital assistants (PDAs), and portable media players such as iPods (Apple, Cupertino, CA) for the purposes of acquiring and disseminating knowledge.³ Teaching and learning methods that incorporate the mobile technology skills of today's students may be a successful strategy for engaging this generation in the educational environment.^4,5 Along with engaging the Millennial generation, m-learning may provide an effective solution for institutions facing crowded classrooms, high student to faculty ratios, and an increase in “nontraditional” students.

The US Department of Education (USDE) reports that total enrollment in higher education is expected to increase 17% through 2019.⁶ As more students attend college, classroom space will become limited, and student to faculty ratios will increase. Data from USDE also suggest a demand for increased flexibility in learning opportunities. The percentage of undergraduates who took distance education courses rose from 16% in 2003–2004 to 20% in 2007–2008.⁶ From 2008 to 2019, the projected increase in total postsecondary enrollment is 11% for individuals under the age of 25 and 20% for those aged 25 and older.⁷ These projections indicate a likely increase in the number of students with a job, a family, or both, a population that will require flexible learning opportunities such as distance education. Athletic training education programs can provide flexible education opportunities by incorporating m-learning. M-learning will not only provide flexibility but also will support a variety of learning styles characteristic of today's students.

Identifying the learning styles of students is an important strategy for creating an effective educational environment. Stradley et al⁸ found that no predominant learning-style type characterizes the typical athletic training student; therefore, it is important for educators to address the needs of all students in both the classroom and the clinical setting.⁸ Coker⁹ used the Kolb Learning Style Inventory to examine the preferred learning modes and subsequent learning styles of undergraduate athletic training students to determine their consistency across traditional classroom versus clinical settings. The preferred learning mode in the classroom was reflective observation, whereas active experimentation was more prevalent in the clinical setting.⁹ The learning styles of 58% of respondents changed according to the setting focus.⁹ Gould and Caswell¹⁰ administered the Gregorc Style Delineator and the Preferred Teaching and Testing Method Inventory to 200 undergraduate athletic training students and 100 athletic training education program directors. Athletic training students and program directors had significantly different preferences for teaching and testing methods.¹⁰ Program directors' preferred mind style was “concrete sequential (CS).”¹⁰ Concrete sequential individuals are task oriented, favoring factual and concrete information that is presented in a highly structured environment and incorporates hands-on activities.¹⁰ Undergraduate students' preferred mind style was “abstract random (AR).”¹⁰ Abstract random individuals prefer busy environments, social interaction, and unstructured learning such as group discussions.¹⁰ The different preferences create a potentially mismatched educational environment. M-learning may be a viable option for accommodating both instructors and students. Instructors can use mobile devices to disseminate course material in a factual, concrete, and structured fashion. Several authors^4,11,12 described utilizing mobile devices to disseminate course material. Students can use mobile devices to access background information and complete lectures; thereby, providing instructors more time for in-class, hands-on activities.^3,11–13 The learning management systems utilized by many educators can be accessed effectively via mobile devices.¹⁴ All of these mobile applications may be attractive to CS instructors. Mobile devices provide connectivity for spontaneous communication and collaboration.³ Utilizing this technology in the educational environment may be a successful strategy for engaging AR students. M-learning can support a variety of learning styles (visual, auditory, mixed); and therefore, educators may find mobile technologies beneficial for engaging a diverse group of students. Coker⁹ suggests the use of classroom instructional strategies that provide opportunities for discussions, brainstorming, reflective thinking, and critical thinking, while the clinical setting incorporates simulations, case studies, and hands-on experience to maximize learning potential. According to Davie,³ m-learning can encourage and enhance these types of activities. Several studies have indicated that students have a positive perception of m-learning^11,15,16; however, minimal research^16–21 has investigated the effectiveness of m-learning in health care education. The information gained from e-learning studies will provide insight into how m-learning may impact academic performance.

METHODS

Data Collection

Postinstruction skill examinations were completed the day following skill instruction. The 2 trained examiners, blind to instructional group, administered and scored each examination. Participants completed the examination in random order. Examiners used a 25-point checklist on which they placed a check in the box next to each correctly performed component (Table 1). The required components of each skill were determined from the verbal instructions and physical demonstrations provided by the QC. One examiner read the first set of instructions to the subject and started a timer. The participant had 2 minutes to perform the skill. The first attempt was scored. After the attempt was made or after 2 minutes had expired, the next set of instructions was read. The protocol continued for all 3 skills. To avoid introduction of an additional variable, the order of skill instruction and assessment was not randomized.

Table 1. One-Day Postinstruction Skill Examination Checklist

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RESULTS

Seventy-four participants completed an instructional session (38 in the F2F group and 36 in the QC group) and postinstruction skill examination. A t test indicated the instructional groups were similar in grade point average (t₆₉ = −.708, P = .733). A χ² test of independence revealed a significant difference between groups and their exposure to athletic training in high school (Pearson χ² test (1) = 4.462, P = .035). The QC group had significantly more participants who were exposed compared with the F2F group. The instructional groups did not differ significantly in the responses to the other 3 educational background questions. Table 2 reports the participant demographics.

Table 2. Participant Characteristics

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Prior to instruction, 15 participants indicated on the questionnaire that they could already perform the ankle dorsiflexion goniometric measurement correctly. An independent-sample t test was calculated comparing the goniometric measurement mean score of participants who identified themselves as being capable of correctly performing the skill to the mean score of those participants who did not. No significant difference was found (t₇₂ = .307, P = .760). Given the result of the t test, all of the participants' scores were used in the subsequent data analysis.

Postinstruction skill examination scores varied significantly with instructional method (F_3,70 = .760, P < .001). Follow-up univariate ANOVAs indicated that total scores (F_1,72 = 6.952, P = .010) and knee valgus stress test scores (F_1,72 = 19.356, P < .001) were significantly higher after F2F instruction. Neither middle trapezius manual muscle test or ankle dorsiflexion goniometric measurement exam scores were affected by instructional method. Table 3 reports the comparison of postinstruction examination scores between instructional groups. Inter-rater reliability of each component of the postinstruction exam is reported in Table 4. The reliabilities ranged from poor to good.

Table 3. Comparison of 1-Day Postinstruction Exam Scores Between Instructional Groups

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Table 4. Inter-Rater Reliability of Postinstruction Skill Examination

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DISCUSSION

The goal of this study was to compare the effects of QC instruction versus conventional F2F teaching methods on the acquisition of 3 psychomotor skills. Both instructional groups averaged higher than an 80% on each individual skill exam, indicating that both instructional methods were effective in teaching the valgus stress test of the knee, manual muscle test of the middle trapezius, and goniometric measurement of active ankle dorsiflexion. Our hypothesis was supported in 2 of the 3 skills. The findings support the use of mobile videos as an alternative to a F2F teaching session for 2 of the 3 skills. This finding is similar to those from earlier studies reported in the nursing literature that found inconclusive evidence to support the superiority of one method over another.^24,26

The 3 skills were chosen for the current study because they represented varying levels of difficulty. The valgus stress test was, theoretically, the easiest because the model was completely passive. The manual muscle test was more challenging because the examiner had to provide instructions to the model for him or her to actively participate during the skill. The goniometric measurement was the most difficult because the skill involved providing instructions to the model to perform an action as well as utilizing an instrument.

Despite being the “easiest” skill, the F2F instructional group performed significantly better on the knee valgus stress test as compared with the QC instruction group. Thinking back to the instructional interventions at each data-collection site, the principal investigator theorized this particular outcome was affected by the lack of participant understanding of the term “valgus.” The instruction of this skill did not include an explanation of the word “valgus.” As the valgus stress test was demonstrated by the principal investigator for the F2F group and by the video for the QC group, the statement “apply a valgus force to the knee” was verbalized while the force was applied. No further explanation such as “a valgus force means that pressure is applied to the lateral side of the knee, thereby stressing the medial knee structures” was provided. The QC group may have had a more difficult time than the F2F group deciphering how to apply the correct force because they were viewing the skill demonstration on a small screen rather than in person. The instructional groups performed similarly on the other 2 skills; however, the significant difference in performance on the valgus stress test resulted in an overall significant difference in the total skill examination scores.

Mobile video instruction is an effective teaching strategy. It may be best utilized to supplement traditional F2F instruction. This is the first study to our knowledge that utilized mobile devices to disseminate video instruction. The smaller screen size may have had an impact on the effectiveness of the videos. Other studies have found video instruction to be superior to traditional F2F instruction³³; however, these studies have utilized larger screens typical of a desktop or laptop computer. Lee et al³³ found a 10-minute instructional DVD followed by 10 minutes of skill practice on a mannequin superior to traditional F2F teaching of pediatric intraosseous needle insertion. Cardoso et al³⁴ also studied the use of video instruction on a full-size screen. A pretest/posttest design was used but was not compared with a traditional instruction group. The use of an educational video with a simulation of puncture and heparinization of totally implantable central venous access ports was an effective strategy that increased both cognitive and technical knowledge.³⁴

Durmaz et al⁴¹ compared CBI with traditional instruction on nursing students' knowledge and skill in preoperative and postoperative care management. The study included 82 participants, similar to the current study. No significant difference was found between the practical deep breathing and coughing exercise education skill scores of the students in the 2 groups (screen-based computer simulation laboratory and traditional skill laboratory).⁴¹ An additional study by Jeffries et al⁴² reported no significant differences in 12-lead electrocardiogram skill-examination scores between 2 instructional groups: interactive CD-ROM and traditional lecture/demonstration/skill practice.⁴² Both of these studies support the results of the current study in that mobile learning can be an alternative or adjunct instructional method to traditional classroom or skill laboratory instruction.

Even though the participants were instructed not to, we do not know for sure whether they practiced or sought additional instruction prior to the skill examination. Participants were assigned a human model, not otherwise involved in the study, to avoid peer-assisted learning; however, instructional sessions took place in groups of 3 to 9, which means participants could have watched each other during the practice portion, not unlike what would happen in a normal classroom setting. In order to control the amount of instruction received and to maintain consistency between groups for comparison purposes, the QC group was not given access to the videos outside of the instructional session. Ubiquitous access to the videos is a major benefit of mobile learning, a component not specifically assessed in the current study. Future research should examine the effectiveness of ubiquitous access to mobile videos in comparison to F2F instruction. Given the positive outcomes that many instructors find with student collaboration, it would be beneficial to investigate small-group utilization of mobile learning to determine if students are more likely to engage in skill practice with classmates while having ubiquitous access to educational content.

CONCLUSION

While further research is required to investigate the application of mobile learning to a wider variety of clinical skills, the results of this study provide impetus to look beyond conventional teaching practices to more innovative, flexible methods. Students consistently rate mobile learning highly for providing increased autonomy, a sense of responsibility for learning, and a self-paced learning environment.³⁰ The use of alternative psychomotor skill teaching methods may allow for greater flexibility for both staff and infrastructure resource allocation.³⁵

The results of this study and those from other health care fields demonstrate that m-learning, specifically video instruction, is a viable educational tool that produces similar outcomes to traditional teaching methods. The convenience of mobile technologies for both skill acquisition and revision is unmatched by traditional strategies particularly in the sometimes remote athletic training clinical environments.