Help-Seeking Behaviors Among Athletic Training Students in the Clinical Education Setting: A Pilot Study

INTRODUCTION

Athletic training students (ATSs) spend numerous hours mastering the art and science of athletic training, first by acquiring clinical knowledge and skills in classroom and laboratory settings, and then by integrating, applying, and mastering these skills in the clinical education setting.¹ Clinical education is defined as “the application of athletic training knowledge, skills, and clinical abilities on an actual patient base that is evaluated and feedback provided by a preceptor.”^2(p19) It provides students with opportunities to integrate knowledge and practice skills related to athletic training, while honing decision making and professional behaviors.² The importance of clinical education to health care professionals' academic preparation is acknowledged in the literature,^3–5 is fundamental to their professional identity creation,⁴ and gives exposure to real-life patient care that cannot be replaced elsewhere.⁵

Throughout their educational experience, ATSs' learning is guided by the Athletic Training Educational Competencies, which list the minimum requirements for students' professional education.⁶ Students must transfer knowledge learned through formal classroom and laboratory instruction to real-life situations in the clinical setting² to solidify clinical decision-making skills and allow safe and efficient treatment of patients. To do this, students must first learn how to recognize, gather, analyze, synthesize, and use information.⁷ However, the gap between theory and practice, in which content learned in the classroom is not necessarily connecting to clinical settings, is well documented.^8–11 For example, nursing students have reported difficulties translating theoretical knowledge into practice.¹² Because the athletic training educational model is similar to that of nursing,¹³ it is reasonable to assume that ATSs would also experience difficulties transferring classroom knowledge into clinical practice and may have trouble connecting the two settings. When an ATS encounters a problem, the student should be able to ask their preceptor for help. According to the Commission on Accreditation of Athletic Training Education (CAATE) Standards, the preceptor provides instruction and learning opportunities to allow students to develop communication and clinical decision-making skills during actual patient care.² However, students often do not use their preceptor as a resource when a task is overly challenging. Instead, many students give up prematurely, passively wait for help, or persist at the task unsuccessfully on their own rather than asking for help.¹⁴ This fear that their need for help will indicate a lack of ability¹⁵ can be problematic, because it may lead them to continue doing something incorrectly or not do anything at all.

Many years ago, help-seeking was viewed simply as an indicator of incompetence, but researchers have now differentiated help-seeking that indicates overdependence from help-seeking intended to strive for mastery and long-term autonomy.¹⁶ Currently, help-seeking is considered an important self-regulatory strategy related to student learning and academic achievement.^17,18 Past studies have reported that students who effectively sought help when faced with academic difficulties were more successful in overcoming those difficulties compared to non–help-seekers.^18,19 Nelson-LeGall initially distinguished between two help seeking styles²⁰: 1) instrumental help-seeking that involved help-seekers' requests for others to demonstrate or explain the problem-solving method, allowing the help-seeker to actually solve the problem,²⁰ and 2) executive help-seeking that involved help-seekers' requests for others to solve the problem for them.²¹ The goal of instrumental help-seeking is to improve understanding or capabilities that lead to autonomy, whereas executive help-seeking is considered effort avoidant, because the goal is to get by without necessarily increasing one's knowledge base.²² In addition to these two styles, studies on avoidance of help-seeking and the perceived benefit of help-seeking were also found in the literature.²³

Avoidance of help-seeking refers to instances where a student needs help but does not seek it because the perceived benefits do not outweigh the consequences of not seeking help for the task at hand.¹⁹ When the relationship between help-seeking and academic achievement was investigated, typically instrumental help-seeking and perceived benefits of help-seeking were linked to increased academic motivation and achievement. On the other hand, executive help-seeking and avoidance of help-seeking were linked to decreased motivation and achievement.^15,19,24

One of the problems with help-seeking is that students do not actively seek help when needed.^25–28 The primary reason for this behavior might be the inverse relationship between help-seeking and the perceived threat to self-esteem^19,29; learners with low academic self-efficacy (whether the person thinks he or she can or cannot complete a task)³⁰ are less likely to seek help.¹⁹ There is evidence that low self-efficacious learners fail to seek help because they fear being identified as less competent by their instructors or being ridiculed by their peers when they cannot complete the task. For example, a student may not ask the meaning of a word, even though it may be critical to solve the problem, if they feel that they would be labeled foolish. On the other hand, high-efficacious learners appear not to be threatened by asking for help and using it to improve skills or academic performance.¹⁹ One researcher found that these students' behaviors were positively related to adaptive help-seeking and negatively related to avoidance help-seeking.²⁷ Adaptive help-seeking was defined as asking for help necessary to learn independently,³¹ which is similar to instrumental help-seeking.

In the field of athletic training, students may not seek help for various reasons. For example, they might be worried about negative judgments from their preceptors, peers, or athletes regarding their abilities and related perceived incompetence^19,32 or about their self-image, because the desire to maintain a positive self-image conflicts with the action of seeking help.³³ Help-seeking is a show of weakness or flaw; thus, it damages their self-image. Unfortunately, although the importance of help-seeking is recognized in other health care professions,³³ research on help-seeking behaviors in clinical education is scarce, with only one published study investigating its relationship to academic performance among nursing students.³⁴ Because help-seeking is an important learning behavior, students who fail to seek help can be disadvantaged when trying to reach their academic goals.³⁴ Furthermore, even when students ask for help, the nature of the help requested may not be valuable for their learning.³⁵ Therefore, instrumental help-seeking is an important skill for ATSs to possess, because successful learning often depends on their ability to ask for necessary help. The role of help-seeking behaviors in athletic training education has not been investigated; therefore, the purpose of this study was to conduct a pilot investigation of the type of help-seeking behaviors used by ATSs in the clinical setting and their relationship to self-efficacy and achievement in an athletic training program (ATP) as determined by successfully passing a competency examination. It was hypothesized that high-achieving students and those with higher self-efficacy scores would engage in more instrumental help-seeking and less executive and avoidance help-seeking behaviors.

METHODS

Participants

Thirty-eight students currently enrolled in a CAATE-accredited ATP in the far West region of the United States participated in the study. The host institution's Institutional Review Board approved the study's use of human subjects. Of the 38 participants, 52.6% (n = 20) were first-semester students in a four-semester ATP (the program starts their junior year in the university), while the remaining 47.4% (n = 18) were third-semester students. The gender distribution was roughly 2:1, with 63.2% (n = 24) female and 36.8% (n = 14) male. The subjects' ethnicity, age, mean grade point average (GPA), and competency exam score are presented in Table 1.

Table 1. Breakdown of Demographic Variables by Group

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Statistical Analysis

The SPSS software (PASW Statistics for Windows, version 18.0; SPSS Inc, Chicago, IL) was used to analyze descriptive statistics and group differences. Pearson product moment correlation coefficients (Pearson correlations) assessed the relationship between the four help-seeking subscales, the general self-efficacy scale, GPA, and the competency exam score percentage. In addition, multivariate analysis of variance (MANOVA) and multivariate analysis of covariance (MANCOVA) calculations were used to investigate the differences in help-seeking subscale scores between groups based on gender, ethnicity, semester in program, and achievement in ATP as defined by passing of the competency exam (ie, achieving a score of 70% or higher). Self-efficacy was the covariate for the MANCOVA analysis. In addition, a univariate analysis used the same variables as the MANOVA, with self-efficacy as the dependent variable. All statistical analyses were calculated with a confidence level of P ≤ .05.

RESULTS

Of the 40 e-mails that were sent, 38 ATSs responded (95% response rate) to the online survey without follow-up procedures, perhaps due to the survey only being distributed to 1 university. Preliminary analysis examined differences in the independent variables (ie, semester of the students [semester], results of the competency exam [pass]) based on gender, ethnicity, GPA, the 4 help-seeking scales (instrumental, executive, avoidance, and perceived benefit), and general self-efficacy. Chi-square analyses yielded a significant difference for pass by semester only (χ²₁ = 11.916, P = .001), with no differences for gender by semester (χ²₁ = 0.062, P = .804), ethnicity by semester (χ²₅ = 3.858, P = .570), gender by pass (χ²₁ = 0.064, P = .800), or ethnicity by pass (χ²₅ = 7.184, P = .207). Independent t tests found no between-group differences in regards to semester for pass, GPA, help-seeking scales, or general self-efficacy.

Pearson correlations showed that instrumental help-seeking had a moderate negative relationship with both executive help-seeking (r = −0.568, P = .000) and avoidance help-seeking (r = −0.352, P = .030), whereas instrumental help-seeking had a moderate positive relationship with perceived benefit of help-seeking (r = 0.457, P = .004). Lastly, executive help-seeking had a moderate positive relationship with avoidance help-seeking (r = 0.462, P = .003), but a moderate negative relationship with perceived benefit of help-seeking (r = −0.497, P = .001). With the exception of overall GPA and exam score percentage, additional Pearson correlations showed significant moderate-to-weak correlations between all of the dependent variables (Table 2). However, of the independent variables, only self-efficacy was positively correlated with perceived benefits of help-seeking (r = 0.470, P = .003).

Table 2. Correlations of the Variables

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Multiple 2 × 4-factorial MANOVAs using different pairs of independent variables and using the 4 subscales of the help-seeking scale entered as the dependent variable were calculated. An additional 2 × 4-factorial MANCOVA using the self-efficacy score as the covariate was also calculated, and this increased the F value, partial η², and observed power (Table 3). Therefore, the MANCOVA results were reported here. A nonsignificant Box M test indicated homogeneity of the covariance matrices of the dependent variable across the participants (P = .168). However, a significant result was obtained when pass (P = .034) and semester (P = .001) were entered as the independent variables. In addition, there was an interaction effect (P = .007) for which follow-up univariate analysis determined a significant main effect of both pass (P = .002) and semester (P = .000) for avoidance help-seeking (Table 4). Lastly, univariate interaction also found significance between pass and semester on the avoidance help-seeking scale (P = .001). Although the α level was below .05 for the main effects of semester obtained for executive help-seeking (P = .025) and interaction effects between pass and semester on executive help-seeking (P = .046), the criterion for univariate analysis was reduced to .012 after considering Bonferroni adjustment, thus yielding nonsignificant results.

Table 3. MANOVA and MANCOVA Results for Main and Interaction Effect of Competency Exam Results and Semester on Help-Seeking Scales

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Table 4. Univarate Analysis of Main and Interaction Effect of Competency Exam Results and Semester on Help-Seeking Scales

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Next, post hoc analyses determined significant group differences on the avoidance help-seeking scale (Table 5). These results indicated that first-semester students who passed had significantly lower scores for avoidance help-seeking (x̄ = 1.229 ± 0.282) compared to those who didn't pass (x̄ = 1.994 ± 0.079, mean difference = 0.754, P = .004). On the other hand, first-semester students who did not pass had significantly higher scores for avoidance help-seeking (M = 1.994 ± 0.079) compared to third-semester students, who both did (M = 1.089 ± 0.092, mean difference = 0.855, P = .000) and did not pass (M = 1.070 ± 0.114, mean difference = 0.873, P = .000). There was no significant difference between third-semester students who passed and those who did not pass the competency exam.

Table 5. Post Hoc Analysis for Interaction Effect of Competency Exam Results and Semester on Avoidance of Help-Seeking Scale

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Lastly, 2-way MANOVAs with different pairs of variables (ie, semester and passing) entered as independent variables and with the general self-efficacy scale entered as the dependent variable were calculated. A significant result was obtained only when gender and semester were the independent variables (Table 6). A follow-up univariate analysis also found a significant interaction effect for gender and semester (P = .012). Post hoc analysis determined group differences on the general self-efficacy scale (Table 7), with first-semester male students reporting significantly lower scores of self-efficacy (x̄ = 3.814 ± 0.487) compared to those of first-semester female students (x̄ = 4.358 ± 0.372, mean difference = 0.544, P = .041).

Table 6. Univariate Analysis for Interaction Effect of Gender and Semester on Self-Efficacy Scale

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Table 7. Post Hoc Analysis for Interaction Effect of Gender and Semester on Self-Efficacy Scale

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DISCUSSION

This study examined the types of help-seeking behaviors ATSs use during their clinical education and the relationship of these behaviors to self-efficacy. The study also examined whether certain help-seeking behaviors relate to student achievement as determined by passing a competency exam. This is the first study of which we are aware to examine the role of help-seeking and self-efficacy in the field of athletic training.

In general, the ATSs engaged in more instrumental help-seeking than executive help-seeking (Table 1). This is encouraging because it implies that students were not looking for quick answers, but rather for opportunities to enhance their learning by asking questions that do not directly lead to only the answers. However, the results also showed that students who engaged in executive help-seeking tended to have decreased instrumental help-seeking and avoid help-seeking altogether. Because students who do not value the importance of help-seeking may not be proactively engaged in their learning, their possibilities to absorb knowledge and skills may be limited.³⁵

Because we measured achievement solely by passing status on the competency exam, it is possible that the results would have been more variable if a different assessment was used. However, using the competency exam supports our conceptualization that help-seeking influences at least one component of student achievement, and because the competency exam is directly associated with the competency packet and lists all the competencies for which ATSs need to become proficient during that semester, it adequately represents student progress at a single point in time. Therefore, the study results provide partial support for our hypothesis that achievement is related to help-seeking behaviors and self-efficacy in the ATP. For example, first-semester students who failed the ATP competency exam showed higher avoidance help-seeking scores than those who passed. However, no statistical significances were observed for the other help-seeking scales (ie, instrumental, executive, and perceived benefit). Interestingly, when self-efficacy scores were controlled, the statistical difference between low-achieving and high-achieving students remained the same. This corresponds to past research that showed positive relationships between students' help-seeking behaviors and achievement.^18,19 However, according to the Wilks λ values, close to 60% of the data variance is still not explained. Therefore, the results should be interpreted with caution, as there are presumably many variables that were unaccounted for in this study.

Previous literature has suggested that help-seeking involves both cognitive and social engagement, encompassing learning strategies and social interactions with others.¹⁵ Students look for familiarity and friendship when asking for help,⁴² and when there is mutual affection with the teacher, students are more likely to ask for help in the classroom setting.⁴³ Therefore, both social relationships¹⁵ and the social climate of the classroom seem to influence students' help-seeking behavior.^44,45 Ryan and Pintrich⁴⁵ also showed that avoiding help-seeking was related to students' perceptions of classroom goal structure and that emphasis on relative ability was associated with higher levels of avoidance. Therefore, it is possible that first-semester students may not have established the social relationships necessary to confidently seek help in the athletic training clinic. These inexperienced ATSs may also have perceived the clinical setting as performance-oriented rather than mastery-oriented and, therefore, engaged in avoidance behaviors.^45,46 Additionally, new ATSs may not have established a confident relationship with their preceptor and, therefore, may have been unsure of their motivational support.²⁸ Therefore, in order to reveal why help-seeking behavior differences existed between first- and third-semester ATSs, it is important for future research to investigate contextual factors, including goal structures, social climate, and preceptor support.

In addition to the differences between help-seeking behaviors, there was also a gender difference in the self-efficacy scores. Among the first-semester students, female students had higher self-efficacy scores than males. The reason why this difference existed for first-semester students and not for third-semester students cannot be determined by this study. However, the variance may be due to how self-efficacy is formed.^30,47 According to past research,³⁰ people form their self-efficacy perceptions by interpreting 4 major sources of information: mastery experiences, vicarious experiences, social persuasions, and physiological indexes. It has been suggested that men and women develop self-efficacy beliefs differently.^47,48 Typically, past performance accomplishments (mastery experiences) are the most significant source for developing self-efficacy.³⁰ However, through qualitative methodology, Zeldin and Pajares⁴⁷ concluded that social persuasion and vicarious experiences are critical sources for women's self-efficacy beliefs. Their study showed that familial, academic, peer, and work-related influences, in the form of encouragement or vicarious experiences, nurtured women's beliefs. Other researchers have suggested that, for women, social persuasion and vicarious experiences might be stronger self-efficacy building blocks, especially in a male-dominated domain.⁴⁸

Similar to this research,^47,48 in our study, female students at the end of the first semester may have shown increased self-efficacy due to positive comments received during the semester. On the other hand, male students often base their self-efficacy on mastery experiences,³⁰ and first-semester students, in general, have few opportunities to achieve mastery status, because of program progressions that plan for increasing clinical responsibility across semesters.² This might explain both why female students showed higher self-efficacy scores at the end of the first semester and why gender differences diminished at the end of the third semester.³⁰

Although self-efficacy did not have a direct relationship to achievement in the ATP in this research study, abundant past research shows the importance of self-efficacy on student achievement.^30,47,48 Therefore, it is important to note the possible gender differences when promoting students' self-efficacy. Although both are equally important sources of developing one's self-efficacy, female students may tend to benefit from verbal praises and male students from opportunities for success.

Implications for Practice

Based on partial support from the results of this study and findings from past educational research,^{14–16,18,22,34,35,45,46} students are more successful when engaging in instrumental help-seeking behaviors than in executive help-seeking or avoidance of help-seeking behaviors. Student guidance, especially to novices, should include types of questioning strategies that would benefit their learning experience and give them the tools to engage in instrumental help-seeking rather than executive help-seeking. Furthermore, the athletic training clinic social climate should promote a mastery-oriented environment, rather than a performance-oriented environment.^44–46 This would promote instrumental help-seeking from students. In addition, preceptors should know how self-efficacy develops in both male and female students, so that by being informed, they can provide appropriate feedback and opportunities to maximize their students' self-efficacy development.

Limitations of the Study and Recommendations for Future Research

This study was the first to investigate the importance of help-seeking behaviors among ATSs and their relationship to ATP achievement. Although the study provided some valuable data showing relationships between certain help-seeking behaviors and student success, it had limitations. For example, one limitation was the small number of participants. Because this study involved only one CAATE-accredited ATP, the results cannot be generalized to students at different institutions. Therefore, future studies should include more students from various ATPs to provide more conclusive information.

Variable measurement was also a limitation. First, help-seeking behaviors were only measured by self-reported score. Because there were no observational data, there is no way to determine whether the students who reported that they engage in instrumental help-seeking behaviors were actually using it. Future studies should evaluate help-seeking behavior via direct observation to truly discern what type of help-seeking behaviors students are using. Second, the way self-efficacy was measured in this study may have been problematic, because the results were inconclusive regarding its relationship to student success and help-seeking. Self-efficacy was originally proposed as a domain-specific construct,³⁰ and the General Self-Efficacy scales used in this study may not have captured the actual self-efficacy students have regarding their clinical abilities. Unfortunately, there is currently no specific self-efficacy scale used in athletic training clinical education. Lastly, ATP achievement was assessed using a competency exam pass/fail rate, which may not accurately represent student achievement. Although the competency exam encompassed all of the content with which the ATSs were to become proficient during the semester, it was computerized and, therefore, could not measure students' actual skills. Because ATP success includes more than academic content, and important aspects such as professional behavior⁶ cannot be fully assessed through a written competency exam, future studies should measure ATP achievement in different ways, including Board of Certification Examination scores, formative evaluations from preceptors, and other indicators of student success in the athletic training educational setting.

Perhaps the largest limitation for this study was the fact that only limited components of help-seeking behaviors were measured. As mentioned earlier, help-seeking behavior is related to contextual factors, such as goal structures, social climate, and preceptor support.^44–46 The current study only investigated the relationship between help-seeking behavior, self-efficacy, and student achievement. In the future, additional variables such as the role of preceptors,⁴⁵ achievement goal structure,²⁶ and perception of the athletic training clinic environment⁴⁶ should be included for a more robust understanding of help-seeking behaviors in ATSs.