Self-Perceived Educational Preparedness of Entry-Level Athletic Trainers Regarding Preventing Sudden Death in Sport

Participants

A total of 13 participants (7 males, 6 females) took part in our study. The participants were either students enrolled in their final semester of undergraduate education (n = 6) or recent graduates currently practicing as a clinical AT, either through a graduate assistantship, internship, or full-time employment (n = 7). This mixed sample was purposeful, as we aimed to gain a holistic view. All students were taught under the 4th edition of the NATA Educational Competencies. We completed data collection during the spring semester in 2011.

We initially sent emails explaining our study and steps for data collection to 150 randomly selected program directors (PDs) in Commission on Accreditation of Athletic Training Education (CAATE)–accredited programs to help facilitate enrollment into our study. This helped recruit the participants, as currently there is no database for student members enrolled in CAATE programs.^12,13 The PD was asked to first review the email, which also contained the consent form and background questionnaire survey, and was then asked to forward it to all current students and recent graduates. Any interested participant directly contacted the investigators. In addition, the researchers capitalized on preexisting professional relationships to help identify potential participants meeting the criteria.¹⁴ After the initial emails were sent, recruitment continued by snowball sampling,^12,14 as recruited participants were used to recruit additional participants.

Data Collection

Based upon our purpose, the researchers developed a 2-phase research agenda. Phase I included a background questionnaire (Appendix), which was structured and used close-ended questions. Phase II included a series of interview questions using a semistructured, open-ended format. This format was selected because of the flexibility it afforded to further explore the topic, particularly because of the autonomy afforded each ATP,¹² as well as based on the triangulation it allowed with a more structured questionnaire. Phase I focused on each of the top 10 causes of sudden death in sport,^5,7 particularly the participant's knowledge of the topic, awareness of literature on the topic, and time spent learning about the topic. Phase II focused on the educational experiences of the participant as an ATS while learning about sudden death. Specifically, the participants were asked to describe their learning experiences, methods of instruction used by their faculty/instructor, and comfort level with educational material regarding the causes of sudden death in sport. Information gained in Phase I helped moderate and guide data collection in Phase II. The design of the interview guide was purposeful, as we were concerned with educational training received before eligibility for the BOC examination as well as any on-the-job training or continuing educational training.

A 5-member research team developed both the background questionnaire and the interview guide. Members included 2 athletic training educators, 2 graduate assistant ATs, and 1 qualitative researcher. Each member of the panel was selected as a result of his expertise in content, methodology, and/or clinical practice. Before data collection, the background questionnaire and interview guide were reviewed by 2 AT experts not involved with data collection procedures. Both experts have extensive background in AT education and the topic of preventing sudden death in sport. After the initial review by the 2 experts, we conducted a pilot study with a small cohort of ATSs (n = 2). Updates and changes were made to the interview items to improve the clarity of the questions posed.

All participants filled out a background questionnaire in order to gain demographic information and base of knowledge regarding the prevention of sudden death (Phase I). After all documents were completed, a phone interview time was established. Semistructured phone interviews were conducted with all participants after completion of the background questionnaire. Interviews were scheduled at the convenience of the participant, conducted during the last 2 weeks of April, and lasted approximately 30 minutes. All interviews were audio recorded, transcribed verbatim, and destroyed once transcription was complete. All transcriptions were electronic and stored on the computers of the principal investigator and the student researchers. Only the researchers involved in our study had access to the transcripts, which were destroyed upon completion of data analysis. Pseudonyms were assigned to all participants.

Data Analysis and Trustworthiness

We analyzed interview transcripts using a modified grounded theory approach, as summarized by Strauss and Corbin¹⁵ and Glaser and Strauss^,16 as well as by other researchers.^14,17 The transcriptions were read completely to gain a holistic understanding of the data. On subsequent readings specific incidents and commonalities were given labels to represent their meaning within the transcripts. The research agenda and questions guided our analysis of the data. Once initial coding procedures were completed, the researchers discussed the concepts and commonalities and were found to be in agreement with regard to the overarching themes of the interviews. Background questionnaires were analyzed using means, standard deviations, and frequencies. These data were combined to support the findings from the interview data.

The credibility of the research procedures and trustworthiness of the data analysis and interpretation were established using 3 strategies: (1) methodological triangulation, (2) transcript verification, and (3) multiple analyst triangulation.¹² Using both in-depth phone interviews and a survey questionnaire helps triangulate the results from the interviews by verifying and supporting the data generated from the survey questionnaire.^11,12 Participant verification was secured by allowing the interview participants the ability to review their transcripts from the recorded interviews. Participants were allowed to make any changes or updates to ensure accuracy. Multiple analyst triangulation was met by having the researchers code independently and then meet to discuss themes and commonalities. The researchers were in agreement with regard to the results.

Compartmentalization

Compartmentalization can be summarized by 3 key categories: cognitive knowledge, skill implementation, and clinical integration, as depicted in the Figure. Participants acknowledged gaining the appropriate knowledge related to sudden death, but they realized that only certain concepts received hands-on training or afforded a chance to critically apply the knowledge gained in the classroom setting.

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Cognitive Knowledge

Information regarding sudden death or emergency care procedures was distributed, according to the participants, throughout their undergraduate academic experiences, rather than in a single class solely devoted to emergency procedures. Several participants indicated that time spent on sudden death was very limited, with a majority of the coursework devoted to evaluation of orthopaedic injuries and management of those pathologies. James illustrates this finding when he shared the following: “I'd say from sophomore year throughout [the program], [sudden death] is not a major time commitment, just because there is so much other material we have to know.” After assuming a full-time position, another participant realized she felt inadequately prepared regarding sudden death. Denise disclosed the following:

These disorders were taught straight from the book instead of saying these are the things that might happen that can differentiate what you're going to do. When I came [to my first job] I felt like there were athletic trainers who were more prepared than me, who knew more about sudden death prevention and management.

Classic didactic practices were the most commonly utilized method of instruction in terms of managing a condition that may lead to sudden death. Allen said, “I'd say mostly lecture was the primary means of education.” Hannah had a similar reflection regarding the use of instructional methods, explaining

It was more lecture based and [class] discussion. We'd have a PowerPoint, a scenario presented, and interactive discussion led by the teacher. I don't remember anything other than practicing spine boarding and CPR [cardiopulmonary resuscitation].

Laurie, too, reflected, “For CPR and first aid there was a lab component, but as far as heat illness and other pathologies, that was only taught through lecture.” Delivery of information related to sudden death in sport, as supported by the previous quotes as well as the following, was mainly achieved through traditional lecture, and in some cases class-led discussions, but rarely were these reinforced with skill development. Mandy said, “[We learned] about the different conditions, not necessarily hands-on practice of evaluating and managing these conditions.”

Information was also gathered regarding the ATSs' knowledge of the NATA position statements that were specifically related to sudden death in sport. Many, but not all, of the participants were aware of the position statements. However, full comprehension of the information contained in each position statement was limited. Several indicated that the position statements were not used as a part of their educational preparation. In Table 1 we present the 12 NATA position statements associated with preventing sudden death and how many of our participants remembered using each during their educational training. Three ATSs reported never learning about sickle cell trait; therefore, they were not familiar with the condition or that the NATA issued a position statement.

Table 1.  National Athletic Trainers' Association (NATA) Position Statement Use in Class and Students' Comfort Level

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Skill Implementation

Throughout our interviews, participants consistently acknowledged that they had received minimal hands-on practice of a majority of the psychomotor skills associated with preventing sudden death, such as taking blood sodium or glucose levels, administering an epinephrine auto injector, or rectal temperature assessment. Practice or laboratory time was primarily focused on the more traditional skill sets related to emergency care, such as first aid, CPR, and spine boarding. Table 2 presents the average time (in hours) spent on each of the leading causes of sudden death, as estimated by the participants. For each condition, the participants were asked “How many hours of classroom time were spent on the education of [that specific condition].” They gave a wide range of answers, as indicated by the large standard deviations. Head injuries, cardiac conditions, and exertional heatstroke were reported to be the conditions that were given the most emphasis in our participants' ATPs. While discussing his educational experiences with sudden death, Joe said “I don't remember anything other than practicing spine boarding and CPR.” When asked specifically about other skill sets, such as cold-water immersion or oxygen, Joe said “No, we did not practice those skills.” James echoed Joe's evaluation of time spent in a clinical skills lab:

Table 2.  Number of Perceived Hours of Class Time Spent per Condition

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We'd go over something [in class], then have a lab session for the topic. We did not do a lot of lab work with the emergency protocols or conditions. The majority of the lab stuff [related to sudden death] did deal with spine boarding.

Several participants noted being lectured on a particular topic or concept related to sudden death, but not having the opportunity to practice the skills being discussed. Andrea alluded to a lack of skill development, sharing this reflection: “I think if our emergency class went more in depth into conditions that cause death and if we had time to practice the different procedures associated with these conditions I'd be a little more comfortable.” Another participant recognized that more time was spent on the day-to-day type of injuries an AT was likely to see rather than conditions related to sudden death. He shared,

It really wasn't stressed as much in our education. We focused more on getting evaluation experience and the day-in, day-out operation of athletic training. There [were] some times where we would go over it, but it wasn't as much as I think it should be.

This group recognized the importance of practicing clinical skills before they actually use them in clinical setting. When asked about ways to improve competence and confidence with management of a potential case of sudden death all participants discussed more hands-on training, beyond spine boarding or CPR. Denise said, “Absolutely [need more time practicing].” Another shared, “The kind of hands-on experience [we had in the classroom], such as more time practicing cold-water immersion or oxygen administration, actual automatic external defibrillator (AED) administration could be improved on as well.” Similarly, another stated the following:

I think more hands-on practice in the classroom that gives you opportunities to practice different skills. And also more time focused on each specific condition and how to manage those situations in class in general, instead of just touching on different topics in many classes.

Opportunities for development of skills related to the diagnosis and treatment of certain conditions related to sudden death in sport were not afforded to the ATSs, as highlighted by the participants' reflections. CPR and spine boarding skills were consistently discussed, but other skills, such as oxygen administration or cold-water immersion, among others, were rarely mentioned.

Cognitive Knowledge

Comparable to the literature regarding instructional methods utilized to educate the ATS on EHS practices,^2,10 our findings indicated the prevalence of a traditional lecture-based style to deliver the foundational concepts related to sudden death in sport. The use of lecture is most important when delivering the foundational concepts related to a topic, particularly when discussing the signs and symptoms of a condition or ways to evaluate or manage the condition. When initially introducing the conditions related to sudden death in sport, AT educators are encouraged to utilize this method of instruction, as it allows for the development of a strong underpinning. Lecture, however, offers little opportunity for the development of analytical thinking for the learner, and therefore other methods are necessary to foster the development of clinical competence.³⁰ Mazerolle et al³¹ found that the ATS who is not afforded the opportunity to gain hands-on training with rectal temperature assessment and cold-water immersion for the recognition and treatment of EHS feels less comfortable with the use of the devices, a crucial factor that impedes incorporation of those methods into actual clinical practice by the AT.¹⁰ This same concept can be applied to other emergency procedure skills, including equipment removal, AED usage, and supplemental oxygen administration.

Several more traditional instructional methods that still capture the more traditional components of a lecture-based style but facilitate learning in a more real-time environment are available to the AT educator. Dialogical discourse, experiential learning, and background connection activities can afford the AT educator the chance to provide realism with regard to the information being delivered in the classroom setting.^2,30 Athletic training educators appear to capitalize on the use of case studies and case-contrived, problem-based scenarios to replicate authentic learning experiences, something previously indicated as important for learning and development of confidence clinically.⁴ The use of contrived scenarios with instructor-driven or peer-driven discourse is helpful for learning and is also used by AT educators when covering EHS.² Although an important means to promote realism and critical application of knowledge, the scenarios discussed by our participants did not require implementation of skills related to the recognition and care of many of the causes of sudden death in sport.

Similar to the findings of Mazerolle et al,^2,10,31 information being delivered by the traditional means of instruction was derived from the NATA position statements. Our findings also support the findings of another study³ examining the educators' views on preparing the ATS to manage an emergency situation, which indicates that more instruction time is spent on such topics as general emergency planning, heat illnesses, cardiac issues, and concussions. Interestingly, however, our participants were more versed regarding the NATA position statements on emergency planning and concussions but were less comfortable with those related to sudden cardiac death, the leading cause of death in sport and often a topic considered of importance for AT educators.³

Skill Implementation

A predominant theme echoed by many of our participants was the lack of laboratory time to practice hands-on skills associated with preventing sudden death, which echoes the results of previous research.^8,31,32 As discussed by this group of AT students and professionals, the majority of laboratory time was spent on first aid, CPR and AED, and spine boarding, and little or no time was allotted for skills such as rectal temperature assessment, Epi pen training, or glucose testing. This can be partially explained by an AT educator's previous clinical experience, which has been found to mediate selection of topics covered and time allotted for learning.³ The finding can also be rationalized by an AT educator's previous educational training and comfort level with providing instruction and feedback to the ATS.²

The NATA's 5th Edition of the Athletic Training Education Competencies¹ makes significant changes regarding concepts related to sudden death in sport. Specifically, those changes include the following: “the addition of skill in assessing rectal temperature, oxygen saturation, blood glucose levels, and use of a nebulizer and oropharyngeal and nasopharyngeal airways.”^1(p5) The update to the competencies reflects the recommendations of NATA position statements and the most current evidence regarding these concepts. Athletic training educators must be prepared to provide the ATS not only with this information via lecture but also with the chance to develop competence in using those skills through directed instruction during laboratory sessions. The AT professional must be aware of all NATA position statements and must also be prepared to utilize the recommendations made within those statements in order to provide optimal care to their patients. The seriousness of sudden death in sport requires the AT educator to facilitate learning opportunities that provide the ATSs with the chance to apply their knowledge and skills in an authentic experience to develop clinical competence.

Clinical Integration

The lack of integration in the clinical setting emerged partly as a result of the previous theme, laboratory time, but also because of the reliance on lecture-based techniques to deliver the information regarding sudden death in sport. Our participants indicated that their AT educators try to bring realism to the topics through various methods, including case studies, personal stories, and class discussion. However, they also noted that they were rarely forced, during these classroom experiences, to implement or apply their knowledge. Again, the ATS seeks authentic learning experiences to gain understanding and competence, but in the case of sudden death, as a result of its rarity, the chance to practice those skills in a controlled environment is imperative to gain competence.

The use of clinical practicum experiences is often an instructional method used by ATPs to facilitate real-time learning; however, as mentioned previously, cases of sudden death do not occur regularly, as do other musculoskeletal injuries; therefore, the chance to apply the necessary skills is limited. When an emergency situation occurs, such as a suspected spinal injury, a supervising clinical instructor is more likely to use the student as a means to alert emergency medical services, limiting her opportunity to actual apply her knowledge and skills in the management of the situation. Recognizing this, AT educators need to provide more experiences that foster realism to allow for competence to develop (such as spine boarding on the ice, or in the mud, or helping an asthmatic athlete). In addition to incorporating more realistic classroom experiences, AT educators should consciously implement critical thinking methods in order to replicate real-life situations.

The importance of replicating real-life situations in the classroom is paramount because a study conducted by Mensch and Ennis⁴ revealed that many ATSs and AT educators reported that treating real patients in clinical rotations was more meaningful than laboratory or classroom experiences. Solely teaching the material and performing laboratory sessions is simply not enough, because there is nothing that brings both the cognitive knowledge and psychomotor skills together in a practical manner. Many of our participants recalled minimal integration of clinical scenarios in the classroom; therefore, bringing more real-life scenarios into the classroom can begin to bridge the gap between classroom and clinical practice.

Additionally, real-time experience has been shown in other literature^33–36 to increase student's self-efficacy, which can be essential in the development of confidence as a clinician and is a construct used in adult learning literature. Hoban and Hoban^34(p9) stated, “Based on Bandura, self-efficacy is defined as one's confidence that he or she has the ability to complete a specific task successfully and this confidence relates to performance and perseverance in a variety of endeavors.” An important aspect of the definition to note is that self-efficacy is task specific. Cervone and colleagues'³⁶ description of self-efficacy states that the biggest influence in self-efficacy is a mastery experience. Bandura's Social Learning Theory of self-efficacy³³ further explains that if someone cannot experience the specific skill personally, watching a peer perform the task will increase his perceived self-efficacy. This means that the best way to increase a student's self-efficacy with a task is to allow him to experience and perform it himself. If this is not plausible, watching a peer perform the same task can also increase self-efficacy in a task. Athletic training educators should be cognizant of this theory and aim to afford students mastery experiences in order to increase their self-efficacy with emergency procedures.

Recommendations

Our study illustrated that entry-level ATs are not being provided with the opportunity to develop clinical competence to deal with emergency situations and prevent sudden death in sport. In order to better prepare ATs, the AT educator should incorporate more realistic case scenarios into the classroom, provide more hands-on training with all skills related to sudden death in sport, and, finally, create opportunities for critical application of both knowledge and skills associated with preventing sudden death. This will increase students' self-efficacy and therefore clinical usage of best practices within our profession.

In regard to emergency procedures, traditional instructional methods should not be completely dismissed; however, they should not be the sole method of education. Hands-on training for all skills must be afforded each ATS. During the laboratory sessions the following must be provided to the ATS: (1) the instructor must model the skills before the ATS practices; (2) feedback for learning and improvement must be given; and (3) an authentic environment for implementation must be created to provide realism.² Furthermore, effort should be made to create an environment in which ATSs are encouraged to critically think and apply what they have learned, including both their knowledge and skills. Most often the ATS is only asked to recall the information during class discussions or case study presentations, rather than implement the necessary skills she has recalled as important to implement. Case studies, scenarios, and problem-based learning can still serve as the foundation, but the AT educator must require the ATSs to go beyond memory recall and apply their knowledge and skills to demonstrate higher-level thinking.

Limitations

We recognize that our study has some limitations. The first was a small sample size, which was a split sample of last-year AT students and recent ATP graduates. Although our results support those of previous literature,^2,10,31 the findings can really only be generalized to those AT professionals who have recently completed their degree programs. The rationale behind including both recent graduate ATs and those who were 1 year from graduation was to capitalize on participants' reflections regarding their experiences. Inclusion of both criteria also allowed us to triangulate the data, gaining both an immediate evaluation of the programs' performance as well as the benefit of a year to reflect upon those experiences.

Future Research

Future research should evaluate the effectiveness of the use of more realistic instructional methods and hands-on practice. Areas of interest may include specific educational techniques, including contrived laboratory situations, problem-based learning, and practice in the clinical setting. In conjunction with looking at ATSs' education in the clinical setting, additional research can be performed that examines how preceptors teach in the clinical setting while still providing care to athletes.

Another area for further investigation is the general satisfaction regarding educational preparedness. This can be accomplished with a prospective study using ATSs, following them for an amount of time through their careers in order to see how their perspectives change with regard to their professional education and how their education as ATSs has affected them as professionals in the field.