Developing a Virtual Learning Environment for Clinical Education Amidst a Pandemic

KEY POINTS

• Faculty, students, and preceptors need clear, written learning objectives to provide a consistent delivery of a comprehensive and valuable virtual learning environment.

• Preceptors benefit from collaboration with one another and the athletic training program faculty by sharing various learning platforms to instruct and assess learning objectives and outcomes.

• The objectives and implementation strategies of the virtual learning environment can be integrated to create an improved comprehensive approach to clinical education.

• Athletic training students are exposed to more diverse learning opportunities when an athletic training program uses elements of a virtual learning environment in conjunction with the traditional clinical learning environment such as increased interprofessional education and improved application of evidence-based practice.

INTRODUCTION

The traditional educational system came to an abrupt halt in March 2020 amidst a global pandemic because of coronavirus disease 2019 (COVID-19),¹ a respiratory illness that can spread from person to person through respiratory droplets produced when an infected person coughs or sneezes or by touching a surface or object that has the virus on it and then touching one's own mouth, nose, or eyes.¹ Although the halt in the educational system posed an unprecedented challenge at all educational levels and for every academic discipline, health care programs were impacted because of the necessary clinical component of such programs. Athletic training was among those health care programs whose on-site clinical education experiences for its students were immediately suspended. Many institutions of higher education moved to mandatory remote learning, and access to clinical education sites was restricted for nonessential personnel, such as athletic training students (ATSs).² Athletic training programs (ATPs) were faced with the task of delivering clinical education for all students through a virtual learning environment (VLE) model. Further complicating the situation was that no blueprint for a VLE existed for athletic training clinical education. A VLE is defined as a platform of integrated teaching and learning tools designed to enhance a student's learning experience.³ The platform typically integrates synchronous and asynchronous class sessions, videos, PowerPoint slides (Microsoft Corp), HTML files, and other public domain data into structured multimedia learning material and optimizes learning by presenting learning materials through various means.³ Additionally, a VLE provides the student a flexible learning environment and improves collaboration among all participants.³

Leading the way for all ATPs was the accrediting body for ATPs, the Commission on Accreditation of Athletic Training Education (CAATE). The CAATE released its first public update¹ regarding clinical education on March 11, 2020, encouraging ATPs to be innovative in their response to support student learning with regards to the potential impact of COVID-19 on clinical education. Each ATP was allowed to modify its own clinical education policies as long as they were consistent with its institution's COVID-19 response plan. Through a public update on April 1, 2020, the CAATE stated its approval of the use of telehealth/telemedicine in the teaching and assessment of psychomotor skills.⁴ However_, not all in-person/face-to-face clinical learning and psychomotor skills assessment can be supplemented via virtual learning/technology solitions.⁴ The CAATE was mindful to protect the autonomy of each institution in its delivery of a VLE. The purpose of this paper is to describe the development and implementation process undertaken by ATP administrators, faculty, and preceptors for a VLE.

San Diego State University's (SDSU's) ATP celebrated its 51st anniversary in 2019, making it one of the longest and oldest ATPs in the United States.⁵ At the time of transition to remote learning, the SDSU ATP demographics consisted of 68 undergraduate ATP students, 51 preceptors, and 11 clinical sites including public and private National Collegiate Athletic Associated–affiliated institutions Like all ATPs across the nation, SDSU was pressed to develop and implement a virtual learning program to ensure the continuation of a quality clinical education for all students. The university mandated a pause of spring semester classes for 1 week with the sole intent to allow program administrators and faculty to convert to online learning. This 1-week pause allowed the ATP administrators to develop a strategic plan and collaborate with the ATP's preceptors to develop a VLE for the remainder of the semester. Three areas of focus areas drove the development of the plan. The first focus was to ensure the continuation of high-quality clinical education for all students. The second was to honor each clinical site's autonomy in its delivery of clinical education, respective to its unique setting and resources. Just as the CAATE was respectful of each institution's autonomy to modify its respective ATPs, the SDSU ATP was considerate of each site's unique clinical education delivery potential. The third focus was to safeguard continued compliance with the CAATE Standards.

DEVELOPING A VLE PROGRAM

Development of this bridge program for clinical education was driven by the faculty and preceptors' commitment to securing a valuable learning opportunity for the ATSs despite the extenuating circumstances of the COVID-19 pandemic. Because of the high number of students and preceptors, the diversity of clinical sites, and the various resources available at each site, a VLE that was short-sighted and lacked flexibility would not provide an equitable educational experience for all students. The ATP developed clear, definitive objectives for the VLE, but afforded each site the autonomy to determine how it could best implement the objectives of the VLE based upon its individual strengths and limitations.

Initial VLE Development

The initial plan was purposely tentative in design. The clinical coordinator collaborated with her coinstructor for the ATP's practicum courses to design and outline an initial VLE that aligned with the current ATP objectives. The goal was to establish a primitive plan to drive the conversation when they presented the draft to the preceptors. The following initial objectives were established. The objectives and examples of activities are provided in Table 1.

Table 1 San Diego State University Athletic Training Program Virtual Learning Environment Program Objectives

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The first objective involved transitioning away from the minimum/maximum semester clinical hour requirement and weekly hour requirements towards individual contacts or “check-ins” for the remainder of the semester. A minimum of 3 and a maximum of 5 contacts between Monday and Friday each week were required. The ATS was required to complete a minimum of 2 contacts with his or her assigned preceptor each week and to complete 1 contact per week with a peer at a different academic level (eg, a student in the class above or below). The goals of the weekly contacts were to promote peer teaching, learning, and mentoring similar to what an ATS experiences in the clinical setting and to facilitate a collaborative team effort, which is a critical element within the sports medicine umbrella.

A contact consisted of any of the following: a project, a journal review, staff meetings via the various remote videoconferencing streaming devices, and telehealth/telemedicine sessions in which the ATS participated. Each clinical site selected its own preferred telehealth/telemedicine format and both the preceptors and ATSs were trained accordingly before implementation. Contacts were recorded through ATrack (ATrack and Eternal Interactive, Inc) using the same process ATSs used to record their clinical hours. However, in the “All Activity Types” category, the ATS selected either Virtual Clinical Education with Preceptor (preceptors approved these contacts) or Virtual Clinical Education Peer Mentoring (practicum course instructor approved these contacts). The ATS also selected the athletic training domain from the “All Events” category (Tables 2–5) that best reflected the learning opportunity (eg, health care administration and professional responsibility).

Table 2 SDSU Athletic Training Program (ATP) Clinical Site: San Diego State University Virtual Learning Opportunities

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Table 3 San Diego State University Athletic Training Program (ATP) Clinical Site: University of San Diego Virtual Learning Opportunities

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Table 4 San Diego State University Athletic Training Program (ATP) Clinical Site: University of California, San Diego Virtual Learning Opportunities

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Table 5 San Diego State University Athletic Training Program (ATP) Clinical Sites: Community Colleges and High Schools Virtual Learning Opportunities

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To provide structure for the ATS, a rubric was developed to better enable ATSs to understand the total number of contacts required to facilitate positive progress in their clinical education. With only 5 weeks remaining in the spring semester, the accumulation of 17 to 19 contacts by the end of the spring semester was considered exceptional, acquiring 15 to 16 contacts met the standard, and acquiring fewer than 14 contacts did not meet the standard. Contacts were determined based on the average amount of days, not hours, an ATS would participate in a face-to-face clinical learning experience during the final 5 weeks remaining in the spring semester. The number of contacts required to meet the standard exemplified in the rubric was agreed upon by the ATP faculty and preceptors, taking into consideration the clinical educational needs of the ATSs and the professional demands of the preceptors.

The second objective of the VLE required every ATS to reevaluate and update his or her semester goals in conjunction with his or her assigned preceptor. Given the abrupt change in the delivery of clinical education, it was important for students to align their goals to their new VLE with consideration of different opportunities and limitations.

The third objective was to continue ATSs' growth in their psychomotor and psychosocial skills via various remote videoconferencing streaming devices. Each ATS completed the assessment and evaluation injury scenarios with the assigned preceptor via videoconferencing. The preceptor would introduce and/or review a skill set with the ATS. The ATS would practice the skill set under the guidance of the preceptor and would also be assessed via videoconferencing.

The fourth objective entailed allowing ATSs to complete their remaining clinical competencies via various remote videoconferencing streaming devices, where applicable. Alternative methods were provided for competencies requiring special equipment. A common approach involved the ATS watching an educational/instructional video and/or reading a research article. Once the assignment was completed, the assigned preceptor conducted a debriefing with the ATS discussing the material while he or she demonstrated competency via oral discussion and/or demonstrating a clinical skill on another individual. Based on the discussion and/or live demonstration, the preceptor would then determine if the ATS was competent in that specific skill. For the equipment-based competencies, final assessment with the appropriate equipment will be conducted once the institution returns to face-to-face instruction.

The fifth objective focused on the preceptors creating positive virtual learning opportunities that replicated the physical clinical setting. These included, but were not limited to, engaging the ATS in telehealth/telemedicine appointments with his or her assigned preceptor and a patient, the ATS assisting his or her assigned preceptor with health care administration projects such as updating emergency action plans or policy and procedure manuals and developing treatment and/or rehabilitation simulations, and the preceptor using video and alternative resources (eg, evidence-based practice [EBP], National Athletic Trainers' Association Position Statements) to teach and assess clinical skills.

Preceptor Engagement

After the initial draft of the VLE was developed, 49 of the 51 preceptors met virtually with the ATP's program director, clinical coordinator, and practicum course instructor on March 24, 2020. The meeting was a healthy and robust discussion that, most notably, resulted in the addition of a cumulating universal project that became the sixth objective of the VLE (Table 1). All ATSs were required to complete the universal project in collaboration with their preceptor. The universal project was developed based upon the singular question: “What will it look like when we return to the athletic training setting post–COVID-19?” (Table 6).

Table 6 San Diego State University Athletic Training Program Virtual Learning Environment Program Universal Project

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It was the result of the collaboration between the program faculty and the preceptors that ultimately finalized the 6 objectives of the VLE and its formal adoption by the ATP. All clinical sites committed to the same learning objectives and outcomes of the VLE. An all-program virtual meeting was held on March 27 to introduce and explain the new virtual clinical education plan to the students and address any questions or concerns. The following week was SDSU's spring break, which again provided a pause for the clinical sites to develop their site-specific learning opportunities in compliance with the ATP's VLE objectives. When classes resumed on April 6, 2020, the clinical sites developed unique and individualized learning opportunities that aligned with the objectives of the VLE (Tables 2–5). Just as students received different clinical experiences from site to site because of the unique demands, size, and patient population when they were physically present at the site, students received that same diversity of experience within the VLE.

STUDENT REFLECTION

At the end of the semester, students were required to complete a reflection paper about their experience with the VLE as a final practicum course assignment. Reflection has been identified as an important component of the learning process in clinical education.^6,7 Reflection after a clinical experience encourages the synthesis and integration of new knowledge and skills with previous experiences.^6,7 Additionally, this reflection assignment provided valuable qualitative feedback regarding the VLE to faculty and preceptors. The ATSs were made aware that their qualitative statements would be share in an anonymous manner with the ATP administration and preceptors for the purpose of clinical education development and growth. The authors used an inductive conventional content analysis to analyze the data, with 2 authors reading all reflection assignments. The 2 authors were full-time members of the ATP faculty. Once all assignments were read, these 2 authors coded responses, which involved identifying key passages that highlighted key themes related to the students' experience with the VLE. Next, the 2 authors created labels for emergent themes and met to identify and compare themes and specific student comments. The 2 authors then shared their preliminary results with the other authors for peer review before finalizing themes and student comments. According to the institution where the SDSU ATP completed the educational technique, this project did not need research ethics approval in accordance with the 2019 requirements of the Common Rule and the federal definition of research.⁸

Themes and specific comments provided by students in the reflection assignments are provided in Table 7. Overall, feedback regarding the VLE was overwhelmingly positive. Students reported increased self-motivation as a result of the program, as well as improved communication skills (written and verbal) and self-confidence due to the frequent remote videoconferencing, telehealth/telemedicine appointments, and the increased need to communicate with preceptors and faculty via e-mail. Other major themes among students were an improved ability to adapt to new situations, increased independence, personal and professional growth, and the ability to stay positive and focused in the face of unexpected challenges. As a direct result of the site-specific strategies listed above, students reported increased appreciation and application of EBP and a more in-depth understanding and confidence related to organization and administration topics.

Table 7 Student Reflection Themes and Specific Comments

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The most common challenge reported by the students during the transition to the VLE was disappointment that their face-to-face clinical education was interrupted and sadness from missing the day-to-day interactions with preceptors and patients. Another challenge reported by some students was difficulty staying motivated to complete the various aspects of the program. Students reported difficulty studying without normal peer groups and with the rapidly changing situation in their personal and professional lives. As a result of these challenges, students reported the need to develop intrinsic motivation and reported personal growth and an improved ability to adapt to new situations.

CLINICAL RELEVANCE

The immediate future and the potential new reality of the delivery of clinical education remain unpredictable as a result of COVID-19. Based upon the students' experience expressed in their final reflections and the response of the clinical sites, the following takeaways of the VLE were observed: (1) students learned and appreciated the administrative aspect of athletic training in a far greater capacity, (2) students appreciated the increased exposure and application of EBP in developing rehabilitation plans as well as new policies and procedures, (3) students were exposed to interprofessional education on a more consistent basis, (4) students improved significantly in both their professional written and verbal communication skills, (5) students demonstrated improved critical thinking skills, (6) students developed better time management skills and intrinsic motivation, (7) students learned to embrace change and demonstrate the ability to adapt to an ever-changing environment beyond their control, and (8) students developed enhanced psychosocial skills such as empathy because of the ability to identify and cope with the various stages of grief in themselves, their peers, preceptors, and patients.

With increased time to plan and collaborative efforts with fellow ATPs, VLEs can become a more robust and valuable learning experience for ATSs. Additionally, when ATPs are able to return to face-to-face clinical education, the objectives and implementation strategies of the VLE can be integrated to create an improved comprehensive approach to clinical education. The various multimedia learning platforms of the VLE provide preceptors a larger toolbox from which to instruct and assess learning objectives and outcomes. For example, the VLE can provide more opportunities to consistently incorporate EBP and administrative components into an ATS's clinical education. The use of the various remote videoconferencing streaming devices allows preceptors to be able to assess an ATS's psychomotor skills in real time and through repetitive views. This enhanced toolbox also affords ATSs a more diverse learning experience, which innately lends to greater retention and success.

FALL 2020 UPDATE TO VLE: LESSONS LEARNED FROM THE INITIAL OUTBREAK

With the continuation of the global pandemic, SDSU announced on May 12, 2020, that it would be moving forward with virtual instruction through SDSU Flex. Through SDSU Flex, the intention was to offer a flexible and connected community experience in fall 2020. Unique to SDSU and its regional context, and respecting county, state, and federal orders, the SDSU Flex model provided a collaborative learning, research, and community service environment with a blend of in-person, hybrid, and virtual offerings.

Although the ATP was not permitted to offer didactic and laboratory courses via face-to-face or hybrid delivery, it was permitted to allow ATSs to engage in face-to-face clinical experiences based upon availability at each clinical site and with his or her assigned preceptor. The ATP was prepared for another VLE experience for fall 2020, albeit with some modifications based upon lessons learned in the spring of 2020. Table 8 outlines the updated SDSU ATP VLE clinical experience plan objectives for the fall of 2020. Most notable among the modifications for the fall of 2020 are the following:

1. A return to the traditional model of clinical hours with a minimum/maximum semester hour policy and not weekly contacts as were used in the spring 2020 VLE.

2. The transition of clinical scenarios to clinical simulations to better align with the clinical integration proficiencies and ensure that a psychomotor as well as a psychosocial component is encapsulated within each clinical simulation.

3. Where appropriate, preceptors will provide face-to-face clinical education opportunities for ATSs. Many ATSs experienced a hybrid clinical experience.

4. The universal discussion competency (Table 9) was overwhelmingly valued by both ATSs and preceptors; thus, it was retained as an objective of the VLE. For the fall 2020 semester, ATSs and preceptors alike were required to complete a COVID-19 contact tracing course designated by the ATP. Completion of the course was required before each ATS's start date with his or her assigned preceptor.

5. The addition of “Coffee Talk,” a psychosocial development objective for the ATS, was a new learning objective for fall 2020. On a weekly basis, the ATS and his or her assigned preceptor would engage in conversations about professional and personal experiences related to athletic training. The conversations were intended to replicate the conversations that take place in the clinical setting.

Table 8 San Diego State University Athletic Training Program (ATP) Virtual Learning Environment Clinical Experience Plan Objectives Fall 2020

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Table 9 San Diego State University Athletic Training Program Virtual Learning Environment Clinical Experience Universal Competency Fall 2020

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The learning objectives of the VLE were developed with the very intentional purpose that they could be achieved regardless of the delivery method—face-to-face, hybrid, or virtual. Thus, the learning objectives are ones that can be continued when we return to the “new normal” clinical education experience.