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THE IMPORTANCE AND MEASURABILITY OF SELECTED NATA
EDUCATIONAL COMPETENCIES AS PERCEIVED BY CERTIFIED
ATHLETIC TRAINERS AND TEAM PHYSICIANS

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Sally Eaves Nogle

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_ __(._ .—.___

THE IMPORTANCE AND MEASURABILITY OF SELECTED NATA
EDUCATIONAL COMPETENCIES AS PERCEIVED BY CERTIFIED
ATHLETIC TRAINERS AND TEAM PHYSICIANS

By

Sally Eaves Nogle

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Kinesiology

2001

ABSTRACT
THE IMPORTANCE AND MEASURABILITY OF SELECTED NATA
EDUCATIONAL COMPETENCIES AS PERCEIVED BY CERTIFIED ATHLETIC
TRAINERS AND TEAM PHYSICIANS
By

Sally Eaves Nogle

The purpose of this study was to describe the measurability and importance of the
competencies in the general medical conditions and disabilities content area of the
National Athletic Trainers’ Association educational competencies as perceived by
athletic trainers and team physicians. This content area is only one of twelve content
areas that define the competencies necessary for the entry-level athletic trainer.

Four research questions guided this study: (a) the extent to which stakeholders
perceive that the educational competency statements in the general medical conditions
and disabilities content area are measurable; (b) the extent to which the stakeholder
groups differ on the perceived measurability of each of these competencies; (c) the extent
to which stakeholders perceive these competencies as important; and (d) the extent to
which the stakeholder groups differ on the perceived importance of the competency
statements.

The instrument included the competencies, paired with 4-point Likert-type scales
for rating both importance and measurability. The stakeholder groups included 420
certified athletic trainers (ATC) from college and university settings; 384 “professional”
ATCS from high school, clinic, industrial, and professional sports settings; and 122 team
physicians who were members of the American Society of Sports Medicine or the

American Orthopedic Society of Sports Medicine.

The results of the study revealed that participants had a wide range of perceptions
about the measurability and importance of these competencies; however, there were no
statistical differences in perceived measurability or importance across stakeholder groups.
Overall, the measurability of the competencies was perceived to range from “somewhat
measurable” to “measurable.” The competency perceived to be the easiest to measure
was “assessing vital signs,” and the least measurable was “supporting the moral and
ethical behavior of athletic trainers in dealing with diseases for the persons who are
physically active”. Measurability issues occur because a competency is not easily
observed, it involves uncommon conditions or situations, it is difficult to simulate, and/or
the competency statement is unclear.

The ratings for importance demonstrated that overall, the affective domain and
psychomotor assessment competencies were perceived as the most essential. The
competency perceived to be the most important was “recognizing postconcussional
syndrome,” while the least important was “describing common conditions of the breast”.
Some of the less important competencies may be beyond the scope of duty for the entry-
level ATC.

Overall, 37% of the 57 competencies were rated low in both measurability and
importance. Further breakdown of these competencies revealed that 49% of the
cognitive, 25% of the psychomotor assessment, 11% of the psychomotor treatment, and
none of the affective competencies were in the “low-low” category. The results of this
study demonstrate a need to further evaluate the NATA educational competencies since
they are the basis for the accreditation of athletic training programs and the certification

of athletic trainers.

ACKNOWLEDGEMENTS

There are many people who contributed to my completion of graduate school and
this dissertation. I would like to thank them for their support.

The members of my dissertation committee are appreciated for all their time and
efforts. I thank Dr. John Haubenstricker, Dr. Paul Vogel, and Dr. Stephen Yelon for
sticking with me through these many years as an integral part of my graduate experience.
A thank you to Dr. Edward Wolfe, the statistical whiz, without whom I would still be
making calculations. A special thank you to my advisor, Dr. Gail Dummer, who spent
countless hours advising me on my dissertation and who went above and beyond the call
of duty with her expediency and support.

I thank my coworkers and many friends who have been willing to listen to me and
provide me with their wisdom and assistance throughout graduate school. A special
thank you to Dave Carrier, George Glazer, Jo Ann Janes, Holly and Dr. Michael
Kasavana, Tom Mackowiak, Carrie Murphy, and Gale and Dr. Larry Schiamberg who
have always been there for me and constantly encouraged me with their unending
support. Also, a special thank you to Jeff Monroe, who allowed me to pursue this dream
and supported me throughout the entire process.

To my parents, Jackson and Pat Eaves, I thank you from the bottom of my heart
for the love and encouragement that has always been there for me.

Finally, but most importantly, thank you to my husband, Carlton, and children
Bryce and Tracy, who have sacrificed often to allow me time to complete my work. I
appreciate your patience and I love you.

All of you have made this dream a possibility and I cannot thank you enough.

iv

TABLE OF CONTENTS

LIST OF TABLES .......................................................................................................... viii
LIST OF FIGURES .......................................................................................................... ix
CHAPTER 1
INTRODUCTION .............................................................................................................. 1
Statement of Purpose ................................................................................................... 5
Significance of the Study ............................................................................................. 5
Research Questions ...................................................................................................... 7
Assumptions ................................................................................................................ 8
Limitations ................................................................................................................... 8
Definition of Terms ................................................................................................... 10
CHAPTER 2
REVIEW OF RELATED LITERATURE ........................................................................ 12
Accreditation of Educational Programs ..................................................................... 12
ProgramAccreditation ........................................................................................ 13
Importance of Accreditation in Health Fields .................................................... 15
Accreditation of Athletic Training Education Programs .................................... 18
Educational Models in Allied Health and Medical Education .................................. 23
Traditional Model .............................................................................................. 23
Medical Model .................................................................................................... 24
Problem-Based Learning Model ......................................................................... 24
Competency-Based Education ........................................................................... 25
Competency-Based Education ................................................................................... 26
Critical Elements of CBE .................................................................................. 27
Explicit learning outcomes ........................................................................... 27
Flexible time parameters and varied instructional approaches ................... 29
Criterion-referenced evaluation ................................................................... 31
Theoretical Bases of CBE .................................................................................. 35
Experimentalism .......................................................................................... 35
Novice to expert theory .............................................................................. 36
Adult learner theory .................................................................................... 37
Competencies ............................................................................................................ 39
Competencies in Health and Medical Education ............................................... 40
Competencies in Athletic Training .................................................................... 42
Summary .................................................................................................................... 49
CHAPTER 3
METHODOLOGY .......................................................................................................... 52
Sample ....................................................................................................................... 53
Stakeholder Groups ............................................................................................ 53
Data Collection Procedures ....................................................................................... 57

Sample Size ........................................................................................................ 59

Sample Characteristics ...................................................................................... 60
Instrumentation .......................................................................................................... 62
Instrument Development .................................................................................... 64
Pilot Test to Determine Instrument Reliability .................................................. 65
Psychometric Properties ............................................................................................ 66
Dirnensionality ................................................................................................... 66
Rating Scale Structure ........................................................................................ 7O
Reliability ........................................................................................................... 72
Fit Analysis ......................................................................................................... 73
Data Analyses ........................................................................................................... 77
Research Questions 1 and 3 ................................................................................ 78
Research Questions 2 and 4 ................................................................................ 78
CHAPTER 4
RESULTS ......................................................................................................................... 80
Research Question 1 ................................................................................................... 80
Research Question 2 ................................................................................................ 102
Research Question 3 ................................................................................................ 102
Research Question 4 ................................................................................................ 107
Conclusions .............................................................................................................. 108
CHAPTER 5
DISCUSSION, RECOMMENDATIONS, CONCLUSION .......................................... 109
Discussion ....................................................................................................................... 109
Measurability ........................................................................................................... 111
Easiest to measure competencies ........................................................................ 112
Difficult to measure competencies ...................................................................... 1 14
Importance ............................................................................................................... 1 19
Characteristics of more important competency statements ................................ 120
Characteristics of less important competency statements ................................... 121
Limitations ....................................................................................................................... 132
Recommendations ........................................................................................................... 1 3 3
Conclusions ..................................................................................................................... 1 34
APPENDICES
Appendix A: F ollow-up Letter to Non-responders .................................................. 136
Appendix B: Survey Instrument ............................................................................. 138
Appendix C: IRB Approval for Pilot Study ........................................................... 150
Appendix D: IRB Approval for Study .................................................................... 153
Appendix E: Pilot Study Data .................................................................................. 155
Appendix F: Measurability and Importance Data .................................................... 168
REFERENCES ............................................................................................................... 170

vi

Table 1:

Table 2:

Table 3:

Table 4:

Table 5:

Table 6:

Table 7:

Table 8:

Table 9:

Table 10:

Table 11:

Table 12:

Table 13:

Table 14:

LIST OF TABLES

Distribution of NATA Educational

Competencies by Domain ................................................................................. 47
Demographic Characteristics of Sample .......................................................... 61
Primary Factor Loading Summary ................................................................... 68
Measurability Rating Scale Summary .............................................................. 71
Importance Rating Scale Summary .................................................................. 72
Measurability Item Fit Summary ...................................................................... 74
Measurability Person Fit Summary .................................................................. 75
Importance Item Fit Summary .......................................................................... 76
Importance Person Fit Summary .............. 77
Frequencies and Means for Importance and Measurability

of NATA Competencies ................................................................................... 81
Mean Logits for Measurability and Importance Ratings .................................. 95

Distribution of Numbered Competency Statements
by Mean Values for Measurability .................................................................. 99

Distribution of Numbered Competency Statements
By Mean Values for Importance .................................................................... 105

Importance and Measurability Ratings for
Rounds 1 and 2 of the Pilot Study ................................................................. 156

vii

Figure 1:
Figure 2:
Figure 3:
Figure 4:
Figure 5:

Figure 6:

Figure 7:

Figure 8:

LIST OF FIGURES

Scree Plot for Measurability Scale ................................................................... 67
Item Difficulty Plot for Measurability Scale .................................................. 101
Item Difficulty Plot for Importance Scale ...................................................... 104
Scatterplots of Measurability and Importance ................................................ 127
Scatterplot for Measurability and Importance of Cognitive Items ................. 128
Scatterplot for Measurability and Importance of

Psychomotor Assessment Items ....................................................................... 129
Scatterplot for Measurability and Importance of

Psychomotor Treatment Items ......................................................................... 130
Scatterplot for Measurability and Importance of Affective Items ................. 131

viii

CHAPTER 1
INTRODUCTION

The educational competencies of the National Athletic Trainers’ Association
(NATA) represent the key knowledge and Skills needed by entry-level certified athletic
trainers. The educational competencies have been revised and expanded numerous times
since the 1980’s; however, they have not undergone rigorous evaluation to determine if
the outcomes are measurable and essential. This evaluation is crucial because these
competencies are receiving increased attention as the basis for the accreditation of athletic
training education programs and the associated revisions of athletic training curricula
nationwide. In addition, the educational competencies are the foundation for the national
athletic training certification examination. Accordingly, the evaluation and refinement of
these competencies would provide a means to assure a level of quality critical to the
profession.

The first edition of the NATA competencies was developed in the 1980’s after the
completion of a professional role delineation study (Grace, 1999). Subsequent editions
were written as repeated role delineation studies were completed with the results
documented as revised competencies. In 1999, the NATA competencies were increased
from 191 to 542 with the addition of 696 clinical proficiencies (NATA, 1996; NATA,
1999). The 542 competencies that appear on the revised list represent a huge amount of
content to be covered in an athletic training educational program.

Furthermore, the National Athletic Trainers’ Association Board of Certification
(NATABOC) recently mandated that beginning in 2004 to be eligible to qualify for the

National Athletic Trainers’ Association (NATA) certification exam, a student must have

graduated from an accredited program (Hunt, 1998; McMullan, 1997; NATA Education
Task Force, 1997). This mandate effectively eliminates the former internship route to
certification, thereby altering the educational methodology currently used to educate
athletic trainers at most universities. Instead of working as mentors to student athletic
trainers in an internship arrangement where a minimum of 1500 hours of apprenticeship
were required, athletic training educators must focus more on formal coursework under
the new requirements. Many collegiate athletic training educators will restructure the
educational programs at their institutions to conform to accreditation guidelines as
specified by Commission on Accreditation of Allied Health Education Programs
(CAAHEP) of the American Medical Association (AMA). In most cases, this will lead to
an escalation of the number of athletic training courses taught at participant institutions.
As athletic training programs are restructured, their curricula must include the NATA
educational competencies (NATA, 1999).

Athletic training educators face challenges when attempting to implement the
NATA competencies into the university curriculum. There are concerns about the number
of competencies required. This was illustrated by comments posted on the athletic
training education listserv that discussed the concerns about how to teach and develop
competence in all these areas. Some thought that the competencies have gone beyond
“entry-level.” One person referred to this problem as “competency overflow.” Another
commented “. .. I look at the competencies which have been put forth and wonder how it
can be done in 4-5 years of school. I think that many of the proponents of these new
competencies, most with 10-20 years of experience, didn’t learn all of the stuff they say

kids should learn, in school. . ..” A student listserv respondent even discussed his

frustration when presenting information on one Specific competency for a class project
and found the amount of instructional time necessary to teach the implied competency
overwhelming. He had presented, but not developed competence in only half of one of
the general medical conditions and disabilities competencies in 1.5 hours. His concern
was that the time it would take to truly develop competency in only half of that
competency would preclude the students from learning some other competencies that he
felt were more important. These comments illustrate common concern over both the
number and the importance of the NATA competencies.

There are a limited number of credits and curricular opportunities in every
educational program. It is imperative that the importance of the competencies is
identified so that high priority content will be emphasized in the curriculum. Therefore, a
critical issue of the study is to determine the importance of competencies proposed for
inclusion in a program. The NATA has done a good job of delineating competencies, but
with the concerns voiced, it is time to take a realistic look to determine if all of the
current competencies are truly essential for the entry-level certified athletic trainer.

In addition to the number of competencies, there is concern about the potential
variability of interpretation of each competency by athletic trainers. A competency must
be clearly written to achieve interpretability and measurability. When competencies can
be accurately measured, a standardized understanding of the most important knowledge
and skills necessary for becoming a successful athletic trainer can be established. This, in
turn, contributes to the educational process because programs can be designed to achieve
intended curricular outcomes. Conversely, if a competency’s standards of achievement

are variable across athletic trainers or sports medicine physicians, the competency

statement must be revised to provide its intended curricular guidance function. Hence,
curriculum development and evaluation standards will be stronger and more purposeful
with measurable competencies.

An example of a problem in this area occurred when the investigator tried to
develop a rubric for the affective domain competency concerning “supporting the moral
and ethical behavior of athletic trainers when dealing with diseases of athletics and
physical activity.” In attempting to help standardize student evaluation within the staff
members at her institution, it was found that there was a lack of consensus on the
meaning of the competency statement. Therefore, it was not possible to develop a rubric
because everyone wanted to measure something different. A lack of measurability may
be due to the vagueness of a statement or, the difficulty in measuring some competency
areas. Both difficulties are aided, however, by addressing the measurability of each
competency statement.

The NATA’S revised educational competencies specify the outcomes that students
should possess upon completion of an accredited athletic training educational program.
Competencies are grouped into twelve content areas: (a) risk management and injury
prevention; (b) pathology of injuries and illnesses; (c) assessment and evaluation; ((1)
acute care of injury and illness; (e) pharmacology; (f) therapeutic modalities; (g)
therapeutic exercise; (h) general medical conditions and disabilities; (i) nutritional aspects
of injury and illness; (j) psychological intervention and referral; (k) health care
administration; and (1) professional development and responsibilities. Within each

content area the competencies are distributed among three domains: cognitive,

psychomotor, and affective. One content area, general medical conditions and
disabilities, is the focus of this study.

The general medical conditions and disabilities area was chosen because it
includes a wide range of competencies in which both athletic trainers and sports medicine
physicians have been educated. In addition, several concerns have been expressed about
this area on the athletic training educators listserv. Some athletic trainers feel the
competencies in this content area are outside the scope of athletic training, and that they
are better left for the team physician. Also, there is concern that some competencies
require a great deal of time to develop proficiency and that they are of low importance.
Such competencies may need to be deleted to prevent detracting from some of the
competencies perceived as more important. Where educational resources are insufficient
to address all the competencies currently contained in the NATA document.

These issues demonstrate the need to identify the importance of these
competencies for the entry-level athletic trainer. Research can also help to identify poorly
defined competency statements, thus facilitating their future revisions.

Statement of Purpose

 

The purpose of this study is to describe the measurability and importance of the
competencies in the general medical conditions and disabilities section of the NATA
educational competencies as perceived by athletic trainers and sports medicine
physicians.

Significance of the Study
The identification of the most important competencies, and subsequently

developing methods of teaching and evaluating that content, is critical to the health and

well-being of athletes, patients, and clients that athletic trainers will serve in their
professional lives. Conversely, a lack of knowledge and Skills may actually exacerbate the
severity of injuries, illnesses, or medical conditions of clients. Both can be detrimental to
the credibility of the athletic training profession. Additionally, the consequences of
insufficient knowledge or skills enable additional liability risk because of possible harm
to the patient.

The fact that NATA educational competencies are used by thousands of athletic
trainers representing over 200 college and university athletic training programs across the
country contributes to the Si gnificance of this problem. Athletic training educators at
every one of these programs are faced with the challenge of implementing the.
competencies and clinical proficiencies in a coursework emphasis program. This problem
is exacerbated when considering the limited instructional time available to athletic
training programs. For example, most programs require approximately 30 semester credit
hours in the major area of study. This converts to 450 hours of classroom time to teach,
develop, and evaluate 542 educational competencies, an average of only 50 minutes per
competency. These values do not include the time needed for student attainment of the
696 clinical proficiencies that are to be developed in the clinical education program.
Accordingly, much work is needed to establish measurability and importance of the
competencies to aid in managing this merger between content and instructional resources.

This study will identify the importance of each of the general medical conditions
and disabilities educational competencies as rated by certified athletic trainers and sports

medicine physicians. The results will help determine which competencies are essential

for the entry-level ATC and provide a foundation for further research of the other 1 1
content areas.

Competencies that are clearly stated and those that are not directly measurable
will also be identified. This study was designed to identify competencies that need
modification and/or clarification. Such information will help educators in athletic training
programs to focus their curricula on high priority, clearly stated, measurable
competencies. Educators may waste time trying to define the competency and even
worse, they may teach unnecessary content, wasting time for both the students and
instructors. The identification of competency measurability may also give rise to the
establishment of better tools for student evaluation.

These issues need to be addressed expediently because in 2002 CAAHEP is
requesting a competency matrix from each institution that will display when students are
taught a competency, when they are evaluated, and how often they are evaluated as part of
the accreditation process. Additionally, by 2004, all athletic training programs are to be
accredited based on the degree to which they are in alignment with the competencies.
Research Questions

This study focused on the general medical conditions and disabilities content area
of the NATA Athletic Training Educational Competencies (NATA, 1999). The following
research questions guided this study:

1. To what extent do stakeholders perceive that the educational competency

statements in the general medical conditions and disabilities content area are measurable?

2. To what extent do college/university athletic trainers, professional athletic I
trainers, and sports medicine physicians differ on the perceived measurability of the
general medical conditions and disabilities educational competency statements?

3. What importance do stakeholders assign to each of the competencies in the
general medical conditions and disabilities area?

4. To what extent do college/university athletic trainers, professional athletic
trainers, and sports medicine physicians differ on the perceived importance of the
competency statements in the general medical conditions and disabilities area?

In addition to these research questions, the influence of demographic variables
such as gender, employment status, and teaching responsibilities will be explored.

Assumptions

 

The assumption was made that the participants had sufficient knowledge and
experience in the athletic training field to rate each competencies measurability and
importance. Additionally, it was assumed that the participants gave a good faith effort
when rating each competency. Another assumption was that when a stakeholder rated a
competency, he/She was interpreting it as intended.

Limitations

Any misunderstanding of the content of a specific competency could influence the
stakeholder’s perception of its measurability, creating a limitation in the ratings for both
importance and measurability. In addition, if the results Show that the competency is not
easily measured, the importance ratings for that competency will be suspect. For
example, one participant noted that for competency # 57, accepts the roles of medical and

allied health personnel in the referral of those physically active people suffering from

medical conditions, that if the interpretation is “accepts the roles of other medical
personnel” he would rate it as a “1 , nonessential”; however, if the interpretation is
“accepts referral to other medical personnel” then the rating would be a “4, very
essential.” Therefore, the stakeholder’s interpretation and perception of the intent of the
competency, even if erroneous, affects his/her rating.

Another limitation is that the sample may not be representative of all athletic
trainers, because it may be postulated that the athletic trainers who returned the
questionnaires are atypical. Those who volunteered to complete and return the surveys
may be different from those who did not participate in this research, creating a self-
selection bias.

Only one content area of the educational competencies was evaluated. Each
content area covers different competencies of the athletic training profession and is
dissimilar from the other content areas. Therefore, the results from the general medical
conditions and disabilities section may not be an appropriate representation of the other
content areas. For instance, this content area may have clearly written and thus easily
measured competencies, which would give the impression that, in general, all the
competencies are measurable. Conversely, the general medical conditions and disability
content area may have many ambiguous and unmeasurable competencies that would give
the impression of major problems. Therefore, it is important that these results not be

generalized to the other content areas.

Definition of Terms

 

1. Athletic training. An allied health profession that applies the art and science of
Sports medicine for the prevention and management of injuries for those who are
physically active.

2. CAAHEP. The Commission on Accreditation of Allied Health Education
Programs, the accrediting body for the American Medical Association (AMA) of athletic
training educational programs.

3. Certified Athletic Trainer (ATC). A Certified Athletic Trainer. He/She has
passed the National Athletic Trainers’ Association Board of Certification exam.

4. Competencies. The knowledge, skills and attitudes that a person must
demonstrate to be competent in a given area.

5. Entry-level certified athletic trainer. An athletic training program graduate
who has recently passed the NATABOC exam.

6. Internship. An educational experience where students learn the skills
necessary for the profession by working with certified athletic trainers in a clinical
setting.

7. JRC-AT. The Joint Review Committee-Athletic Training is the committee that
validates whether or not a program is in compliance with the required educational
standards required for accreditation by CAAHEP.

8. NATA. National Athletic Trainers’ Association, the national governing body

for athletic trainers, founded in 1950.

10

9. NATABOC. National Athletic Trainers’ Association Board ofCertification, the
organization that establishes the requirements for eligibility for the certification exam and
certifies athletic trainers.

10. Program or curriculum director. The person responsible for the day—to-day
operation, implementation, management, and evaluation of a CAAHEP accredited
athletic training educational curriculum.

1 1. Role-delineation study. Role delineation studies focus on the tasks that are
performed on the job, the importance of the tasks, the frequency of the tasks, and how
critical the tasks are for the entry-level athletic trainer (NATA Education Council, 1999b;
Grace & Ledderman, 1982).

12. Sports medicine physician. A doctor who is working with athletic trainers and
athletic teams and is listed as a member in either the American Medical Society for Sports
Medicine or the American Orthopedic Society for Sports Medicine.

13. Stakeholders. Individuals who are involved in the athletic training profession
as certified athletic trainers or team physicians. For this study they include a) Sports
medicine physicians, b) ATC’S working at the collegiate level, and c) ATC’s employed at

high schools, clinics, industrial, or other settings.

11

CHAPTER 2
REVIEW OF RELATED LITERATURE

The purpose of this study was to establish the perceived measurability and
importance of the general medical conditions and disabilities content area of the NATA
educational competencies. The following topics will be reviewed in this chapter: (a)
accreditation of programs in athletic training, allied health and medical fields (b)
accreditation of athletic training education programs; (c) educational models in allied
health and medical education; (d) competency-based education, especially in relation to
allied health and medical fields; (e) competencies; and (f) athletic training competencies.

Accreditation of Educational Programs

The education of athletic trainers has evolved into accreditation of the programs
that are responsible for producing students who are competent and qualified to become
certified athletic trainers. In exploring accreditation in athletic training, it is important to
understand general philosophies and practices related to accreditation. General
accreditation once was perceived as a threat to the freedom of colleges and universities,
but has now become widely accepted by those institutions (Selden, 1960). The once held
belief that accrediting organizations Should not interfere with higher education has
changed to the point where accreditation has become the accepted standard. The purpose
of accreditation in higher education is to inform the public through certification that an
institution is of acceptable quality, and to support institutions in improving their

educational programs (Commission on Institutions of Higher Education, 1984-1985).

12

According to Selden (1960), accreditation is the process by which an organization
or agency grants a college, university, or program of study as having met specific
standards. The accreditation process focuses on two concerns: (a) educational quality,
defined and interpreted through a comparison of the institution’s own statements of scope
and purpose with those of similar institutions; and (b) institutional integrity, that the
institution or program is accurate in describing its goals and abilities as well as the
capability to complete set tasks (Young, Chambers, Kells, & Associates, 1983).
Accreditation can improve the institution or program by forcing it to focus on internal
issues.

Progam Accreditation

 

Apart from the accreditation of the general university, many programs within the
institution participate in separate, individual program accreditation. Program
accreditation, also identified as specialized accreditation or professional accreditation, is
primarily relevant to the approval of programs, entry-level curricula, disciplines, or units
within institutions of postsecondary education (Commission on Institutions of Higher
Education, 1984-1985; Harcleroad, 1980; Stull, 1989). Program accreditation examines
the curricula and the Specified student outcomes within the specialized program in an
institutional setting. The American Physical Therapy Association (APTA, 2001) defines
specialized accreditation as “a system for recognizing professional education programs
for a level of performance, integrity, and quality that entitles them to the confidence of the
educational community and the public they serve. Accreditation status signifies that the
program meets established and nationally accepted standards of scope, quality and

relevance.”

13

The charge of accreditation is to assure quality education through the official
accreditation process (Fauser, 1992; Shirer, 1987). The accreditation process requires the
following essential elements: (a) clearly stated educational intentions by the program; (b)
performance of a self study focused on the achievement of these intentions; (c) an on-site
evaluation by a selected group of peers; and (d) a decision by an independent accrediting
commission that, in light of its standards, the institution or specialized unit is worthy of
accreditation (Young et al., 1983). Therefore, an outside group visits the institution to
perform an evaluation and arrive at an independent judgment verifying or denying that the
program is substantially accomplishing its objectives and that the quality of education
meets the acceptable standards. Conditions that are believed to be necessary and desirable
to produce educational quality (input, resources, and process) are encouraged and
evaluated by assessing evidence that the program does indeed achieve educational
quality, as stated in the purpose and goals.

In order to evaluate itself objectively, the institution uses a self-study process.
This process will identify the strengths and weaknesses of the program, (Dummer,
Reuschlein, Haubenstricker, Vogel, & Cavanaugh, 1993). The information provided
from the institution’s self-study is presented to the accrediting body for validation. The
self-study must have measurable verification that the students who have completed the
program have achieved the outcomes described. This process is rigorous, but necessary
for the specialized program within the institution to attain accreditation. Gelmon (1996)
notes that the primary purpose of the self-study should not, however, just be
accreditation; each institution should use the results to improve the educational quality of

the program.

14

Importance of Accreditation in Health Fields

Program accreditation was first developed by the professions of medicine and law
as a means of raising educational standards in their respective fields of study (Harcleroad,
1980; Selden, 1960). The need for specialized accreditation for medical schools was
generated from the concern over the abilities of the graduating practitioners. The
variance of programs and inconsistency in knowledge and skills of graduates created the
need to improve the quality of their educational programs, which accreditation could help
accomplish (Selden, I960). The institutions, along with the profession, did not want
graduates regarded as incompetent. In addition, the public should have the assurance that
a person who graduates with a medical or allied health degree will be competent in
his/her field (Gelmon, 1996; Young et a1., 1983). Young et a1. postulated that there is no
need to argue about society’s need for quality assurance in the education of practitioners
in health related fields; it is an obvious necessity.

Although seemingly necessary for quality assurance and endorsed by the
individual allied health professions, program accreditation has not been embraced by all
institutional leaders (Selden, 1960). Some felt the institutional accreditation for the
university already was achieved and should be satisfactory. Accreditation also has been
viewed as an expensive, time consuming, bureaucratic activity with possible disciplinary
repercussions (Gelmon, 1996; Kniffel, 1999). Mangan (1999) researched accreditation
for health programs and found unfavorable results. She reported that a university’s
Center for Health Professions Committee found site visitors fi'om accrediting bodies to be
rigid with poor inter-rater reliability. The committee also found that the process was time

consuming and expensive. In addition, Bruhn (1993), writing about the need to abolish

15

individual allied health program accreditation, noted that the accreditation process still
focuses on monitoring details and instilling standardization and conformity. He suggested
that accrediting agencies often are more concerned with the way things are done in the
program rather than with the outcomes, creating a prescriptive educational program with
little room for program variation or innovation. These are important concerns because
the whole accreditation process places large time demands on program personnel to
gather the information for the self-study. Therefore, if the accreditation process is not
founded on the outcomes necessary for the students, it may be a waste of everyone’s time
and energy. The profession, and ultimately the public, should have assurance that the
graduates of an accredited allied health care program are qualified entry-level workers.
One of the chief causes of tension between institutional leaders and the specialized
accreditation advocates is the question of who is being served by the accreditation
process, the institution or the profession (Knight, 1991). The best result is to identify a
balance between the two. Appropriate professional standards must be upheld, not only in
the interest of the profession, but also for the good of society. In general, specialized
accreditation acknowledges that mission as its primary function. Currently the beliefis
that all accreditations, institutional or specialized, should have educational outcomes as
their primary focus.

Contrary to those who believe accreditation is an expensive, time consuming,
bureaucratic activity, Young et a1. (1983) expressed optimism that specialized accrediting
bodies have been attempting to further improve their operations, with several agencies
making enormous efforts to study and validate their standards. The key is the

establishment of these standards and expected outcomes so that the accreditation process

16

is not a random event depending on who is evaluating the program. In allied health fields,
the Committee on Allied Health Education and Accreditation (CAHEA) is trying to help
improve the accreditation process by supporting succinct, cost effective reports as long as
the professional requisites are maintained (Fauser, 1990). In addition, Healy (1999)
recently pointed out that the United States Education Department is proposing rules to
provide more flexibility to institutions of higher education by decreasing the demands on
branch campuses, as well as improving their review of an institution’s standards. Also,
the Higher Education Amendments of 1998 and the proposed regulations described
accreditors as retreating towards their traditional function as assessors of educational
quality and agencies trying to help institutions improve their programs (Healy, 1999).

Program accreditation lends credibility to the institution’s educational program
and to the profession. Therefore, many institutions and programs participate in voluntary
accreditation because of the credibility and prestige it provides. If a program achieves
accreditation, the public thinks of a certified program as “good” (Shirer, 1987). Young et
al. (1983) asserted that the enhancement of a profession must be through the structure for
accrediting educational programs. A member of the NATA Board of Directors supported
that assertion when he stated that athletic trainer educational reform and proposed
program accreditation “will further enhance our credibility, help us keep abreast of
current techniques and better qualify our members to perform their functions of caring for
the physically active” (McMullan, 1997, p. 4). As for the many professions that struggle
for recognition, accreditation can supply it instantly.

Accreditation is mandatory for several programs in order for the graduating

students to be eligible for a professional certification or licensure exam (Fauser, 1992;

17

Harcleroad, 1980; Roberts, Cordova & Saxe, 1978). Young et al. (1983) stated that for a
few professions, graduation from an accredited program is the only accepted route toward
licensure. This has recently become the case for the athletic training profession.
Therefore, there are numerous quality reasons why institutions voluntarily seek
accreditation. The accreditation process has become widely accepted by many
professions and the public. Despite some of the concerns about program accreditation by
institutional administrators, it has garnered a strong foothold in numerous allied health
care fields, including athletic training.
Accreditation of Athletic Training Education Programs

"Specialized accreditation was born out of the concern of a profession about the
quality of educational programs that were preparing its practitioners" (Young et al., 1983;
p. 187). This statement summarizes the need for program accreditation and resonates for
the profession of athletic training because of the need to ensure educational quality. The
athletic training profession has grown and progressed towards accreditation for its
educational programs because of the need for standardized quality educational programs,
and to generate professional credibility (McMullan, 1996; Peer & Rakich, 2000).
Credibility is created when the public has confidence in the educational programs and
certification process. This credibility improves the patient’s trust of the ATC with the
assurance that every ATC has the knowledge and skills to treat their conditions.

It has taken approximately 50 years for the profession to reach its current status of
mandatory program accreditation for students to be eligible for the National Athletic
Trainers’ Association Board of Certification (NATABOC) exam. Athletic trainers took

the first step toward professionalism by forming the National Athletic Trainers’

18

Association (NATA) in 1950 (Ebel, 1999). The NATA was created by a group of men
who worked with a variety of institutions providing health care for their athletes while
labeling themselves athletic trainers. Essentially, this group founded the profession since
there was no recognized formal education in the field and no set curriculum for students
interested in athletic training as a profession. At this time, students interested in an
athletic training career would pursue a college degree in any discipline and obtain
experience through internship training with an athletic team or an apprenticeship with an
athletic trainer.

The founders of the NATA realized the need for a strong educational foundation
in order for the profession to become a legitimate allied health care field, and therefore
formed a committee to establish a professional preparation program for students
(Delforge & Behnke, 1999; Hunt, 1998; Rawlinson, 1961, as cited in Zylks, 1988). In
1969, the Professional Education Committee of the NATA established the curriculum
requirements necessary to have a NATA-approved undergraduate athletic training
education program (Delforge & Behnke, 1999; Zylks, 1988). In addition to a curriculum,
they agreed to institute a certification process, the first stages of accreditation (McLean,
1999).

The previously established internship route to certification was allowed to
continue in tandem with the NATA-approved cuniculums specifying the number of
internship hours as the key requirement. Eventually seven core courses (human anatomy,
physiology of exercise, human physiology, kinesiology/biomechanics, health, basic
athletic training, and advanced athletic training) were identified as essential preparation

for students, along with the required clinical hours. Therefore, under the current

19

certification eligibility requirements, a student can graduate from an approved curriculum
along with 800 clinical hours, or follow the internship route of seven core courses and
1500 clinical hours, to be eligible for the NATA certification exam. To balance the lack
of standards for the internship route to certification, a larger number of internship hours
are required. The view was that with more internship hours, the student would have a
better chance of gaining the knowledge and skills required for the certification exam and
ultimately for an entry-level job.

The problem with the internship route is the lack of standardization of educational
outcomes (McMullan, 1996; Peer & Rakich, 2000). The student who graduated via the
internship route was dependent on the certified athletic trainers who were responsible for
the instruction, including clinical instruction, in the athletic training program. These
educators could decide what to teach based on their own preferences instead of what the
profession deemed important or necessary to know. They were not required to teach any
specific competencies or proficiencies. Some ATCs did not take the time to teach in the
clinical setting, but instead used the students to perform menial tasks. In fact, Turocy,
Comfort, Perrin and Gieck (2000) illustrated this when they examined the clinical
experience hours performed by students and compared them to the passing rate on the
NATABOC exam. The results demonstrated that the amount of clinical hours had no
relationship to passing rates. Thus, more internship hours for the students did not translate
into more knowledge or skills, and ultimately certification. It would seem logical that if
learning were occurring in the athletic training room, then more hours would result in

higher passing rates.

20

An important aspect of the athletic training education evolution occurred when the
American Medical Association (AMA) agreed to oversee the educational programs for
athletic trainers (Delforge & Behnke, 1999). Originally, the Committee on Allied Health
Education Accreditation (CAHEA) (currently, the Commission on Accreditation of
Allied Health Education Programs or CAAHEP) was the accrediting body of athletic
training education (Delforge & Behnke, 1999; Hunt, 1998; Mathies, Denegar, & Amhold,
1995; Weithaus & Fauser, 1991). Formed in 1976, CAHEA was one of the early
specialized accreditation units under the umbrella of the AMA. In fact, the AMA was
one of the first professional organizations to develop an umbrella approach to
accreditation (Harcleroad, 1980). CAHEA addressed the need for coordination and
cooperation in the accreditation of health-related educational programs, taking over a
function previously performed by the AMA (Fauser, 1992; Gupta & Hendrick, 1990).
CAAHEP currently recognizes 18 professions, including athletic training (CAAHEP,
2001; JRC-AT, 2001).

The Joint Review Committee—Athletic Training (JRC-AT) is the athletic training
arm of CAAHEP that helps validate institutional compliance with J RC-AT educational
standards. Its role is “to promote and ensure quality of the institutional programs"
(NATA Education Council, 1999a, p. 2). To achieve this quality, a single route to
certification for all students was developed to ensure the standardization of athletic
training education (McMullan, 1996).

A mandate was issued by the NATABOC that beginning in 2004 a student must
have graduated from a CAAHEP-accredited program in order to be eligible for the

NATABOC exam (Hunt, 1998; McMullan, 1997; NATA Education Task Force, 1997).

21

Therefore, the previous internship route to certification was eliminated, thereby requiring
all students to graduate from an accredited athletic training program in order to be eligible
for the NATABOC exam. In accredited athletic training programs, the educators must
demonstrate the educational process, content, and outcomes. The termination of the
internship route was initiated to eliminate the variance among athletic training programs
and to standardize athletic training education.

The CAAHEP accreditation preamble in the CAAHEP standards and guidelines
describes the joint efforts of the American Academy of Family Physicians, the American
Academy of Pediatrics, the American Orthopaedic Society for Sports Medicine,
CAAHEP, and the NATA to “establish, maintain, and promote appropriate standards of
quality for educational programs in athletic training and to provide recognition for
educational programs that meet or exceed the minimum standards outlined in these
standards” (CAAHEP, 2001). These standards include the educational competencies that
are the heart of an athletic training program and ultimately of certification. Thus, it was
imperative for the NATA and NATABOC to establish updated competencies so that
students will know what is expected of them during their studies in an athletic training
educational program, as they prepare for the certification exam, and as they enter the field
of athletic training.

The NATA educational competencies drive the educational program at each
institution and are tested on the NATABOC exam. The newly revised competencies are
the standards by which accreditation will be granted starting in 2002 (NATA Education
Council, 1999c; NATA, 2000, 2001b). The accreditation process requires the curriculum

director to document and demonstrate proof regarding where in the program these

22

competencies are taught and when the students are demonstrating competence
(NATABOC, 2000b). Therefore, the competencies, along with the accreditation process,
are currently driving the curriculum in every athletic training program. These
competencies are the key to the educational program for the student athletic trainer, and
they demonstrate the knowledge and skills needed to be a competent entry level certified
athletic trainer.
Educational Models in Allied Health and Medical Education

A variety of educational models have been used in the allied health and medical
fields to educate students. An educational model may be chosen due to the accreditation
process that drives the curriculum for many allied health fields. With the majority of
medical and allied health fields involved in some type of accreditation, the influence of
accreditation on curricula is profound. This influence was evident when Bruhn (1993)
discussed how often a set of specific courses must be offered within a program in order to
achieve accreditation. He asserted that the programs seeking accreditation necessitate
curricula that are carefully sequenced with required courses. However, there are a variety
of models that can be used to educate allied health professionals. When seeking
accreditation in medical or allied health fields, most curriculum programs follow the
traditional model of education, the medical model, problem-based learning, or
competency-based education (Conger, Baldwin, Abegglen, & Callister, 1999; Hart, 1976;
Heestand, Templeton, & Adams, 1989; Posey, 1983).
Traditional Model

The traditional model of higher education requires students to follow the required

courses in general education, the required courses within the major, possibly some

23

electives, and clinical experiences (Hart, 1976; Young & Van Mondfrans, 1972). The
courses are usually teacher driven with the information given to all students at the same
pace regardless of student comprehension. Yet the goals and areas stressed are those
valued by individual teachers

Medical Model

 

The medical model, which stresses the basic medical sciences, demands that
graduates complete an undergraduate program, two to three years of post-graduate work,
clinical rotations, and a residency program (Ebert & Ginzberg, I988; Ende & Davidoff,
1992; Hunt, 1991; McGaghie, Miller, Sajid, & Telder, 1978; Moore-West, Regan-Smith,
Dietrich, & Kollisch, 1990; Posey, 1983). Some graduates may want to further their
expertise and complete fellowship training in their specialized area. The assumption of
the traditional and medical models is that if the student completes and passes the
specified courses and experiences, he/she is ready to sit for the certification/licensure or
national exam and is ready to practice his/her profession (Hart, 1976; Posey, 1983). This
assumption was the same one used for the internship route of the athletic training
educational model. Students took specific courses then gained experience through
clinical rotations prior to being eligible for the NATABOC exam.

Problem-Based Learning Model

The problem-based learning (PBL) model was first introduced into the medical
school curriculum in the mid 1960’s (Caplow, Donaldson, Kardash & Hosokawa, I997;
Heestand, et al., 1989; Moore-West, et al., 1990). Albanese and Mitchell (1993) have
defined PBL as a method for students to learn problem-solving skills and acquire

knowledge about the basic clinical sciences through the use of patient problems. In PBL

24

the problem is presented prior to the student’s acquisition of the necessary science or
clinical knowledge to solve the problem. The educational goals of PBL are: (a) the
structure of clinical contents and acquisition of knowledge; (b) the development of
critical thinking and problem solving; (c) the improvement of individual learning
abilities; and (d) the improvement of personal motivation (Barrows, 1986; Caplow et al.,
1997; Moore-West et al., 1990). The methodology used to achieve these goals mainly
incorporates small group work. The groups are given a problem that they discuss as a
group, research individually, and then further discuss as a group. Therefore, the analysis
of patient cases through group discussion and independent research educates the students
in the knowledge and skills they need. This model could be incorporated into some of the
other models as a pedagogical method.

Competency-Based Education

 

In contrast to the previous models, the field of athletic training has chosen to use
competencies as the basis for the educational process. In fact, the J RC-AT asserted that
no courses are required; however, a demonstration of student competence in the NATA
educational competencies is required (J RC-AT, 2001). The JRC-AT affirmed this
assertion by declaring, “this is a competency-based program where an institution has the
academic freedom to determine where and how it presents the ‘competencies’ in its own
unique setting. Although there are no ‘required’ courses, each of the competencies must
be formally instructed, meaning taught in a classroom setting” (JRC-AT, 2001). This
may still create a sequenced, high credit course load curriculum for athletic training

students, but the teaching is based on the NATA educational competencies.

25

Other medical and allied health fields have started using competencies as a means
to ensure that their students possess the requisites for entry—level professional
performance (Bensley, 1990; Roberts et al., 1978). Therefore, even though the medical
model or PBL is used in many of the medical and allied health fields, there is also a trend
toward the development of competencies to help define and guarantee that graduates in a
Specific field will possess specific knowledge and skills. Once the competencies are
developed, a profession may choose to use the competency-based education (CBE) model
in the education of their students. Competency-based education has been found to be a
viable model in the health care fields to prepare individuals for their profession. (Barris,
I978; Broski et al., 1977; Chidley & Kisner, 1979; del Bueno, Barker, & Christmyer,
1980; DeWald & McCann, 1999; Hinojosa, 1985; Menne, I975; Moncur, 1985; Roberts,
et al., 1978; Russell & Weinstein, 1978).

Competency-Based Education

CBE, sometimes known as outcome-based education, performance-based
education, and mastery learning, originated in the 19303 and slowly evolved during the
19605 as a method for teacher education (Bell, Kozakowski, & Winter, 1997; Block,
1971; Houston & Warner, 1977; Jarrett, 1977; Lane & Ross, 1994a; Scott, 1982). In
teacher education, CBE was a term created by promoters of a movement that sought to
base teacher education on behaviorally stated objectives related to teacher effectiveness
(Houston & Warner, 1977). The objectives would be known, specific, and completely
connected to their roles as teachers. These objectives would drive the instructional
activities and the evaluation criteria would relate directly to the stated objectives. These

CBE features for teacher education are almost synonymous to those described for mastery

26

learning. For instance, Bell et al. (1997) defined the primary features of mastery learning
as unambiguous definitions of the competencies that must be mastered for successful
completion of a curriculum, use of formative evaluation instruments that facilitate the
assessment of students and teachers throughout the program, variable time frame to
accommodate all learners, and a variety of teaching strategies. CBE, mastery learning,
and outcome-based education have their roots in teacher education, but have expanded to
other disciplines.

Critical Elements of CBE

 

Certain critical elements must be included for an educational program to be
defined as CBE. These elements include explicit learning outcomes or statements of
behavior, flexible time parameters, a variety of instructional approaches with learning
opportunities, and criterion-referenced evaluation (Alspach, 1984; Bell, 1976; Burns &
Klingstedt, 1972; Fearon, 1998; Moncur, 1985; Schuldenfrei, I993; Spady, 1977).

Explicit learning outcomes. Explicit learning outcomes imply that the instructor

 

and student both understand what the student needs to know or be able to do at the end of
the lesson, course, and/or program. Jarrett (1977), discussing the use of CBE in the liberal
arts, stated that CBE focuses on outcomes in the educational process, hence the name
outcome-based education.

In the nursing education field, Beare (1985) claimed that CBE specifically defines
the process of education and the outcomes of the learning process. Scott (1982) also
discussed the use of CBE for nursing curriculums because she feels it provides the
programs with explicit goals and standards within a systematic framework. Therefore, the

focus of CBE shifts from the teacher and teaching process to the learner and learning

27

process, with the emphasis placed on the needs and accomplishments of the student
(Beare, 1985; Elam, 1971; Hart, 1976; Schmaus, 1987; Young et al., 1983; Young & Van
Mondfrans, 1972). This shifi is defined by Banis (1978) as an emphasis on exit
requirements. Entrance requirements are not as important since the goals are focusing on
what the student will be able to do at the end of the program. Mager (1962) also stressed
the necessity to be explicit about educational objectives and defining the exit behaviors.
He discussed the importance of educators knowing the direction they are going with
instruction or else they may end up somewhere unexpected. Defining the exit behaviors
provides goals for the instructors and learners. The exit or outcome requirements are
presented as competencies.

In CBE the most valued outcomes or content are represented in the competency
statements. Therefore, a key to competency-based education is the establishment of the
essential competencies required for the specified profession. These competency
statements must be explicit and inform the learner which behaviors are necessary for each
domain (cognitive, psychomotor and affective) in order to complete the program
successfully (Beare, 1985; Bell, 1976; Burns, 1972; Fearon, 1998; Roberts et al., 1978).

The establishment of the competencies must be through a rigorous process.
Fearon (1998) discussed how the content to be included in a competency should be
developed through research of the best practice and clinical experience available along
with the interpersonal skills needed to perform the activity to an agreed standard. Others
have used role delineation studies to determine content of the competencies (Bruess,

Hedricks, Poehler, & Redford, 1987; Ebel, 1999; Golaszewski, Couzelis, Corry, Baun, &

28

Eickhoff-Shemek, 1994; Grace, 1999; Grace & Ledderman, 1982; Henderson, McIntosh
& Schaller, 1981; Schmidt & Beall, 1988).

Once the content of the competencies is decided, the next step is to compose well-
written and easily interpreted competency statements. According to Bell (1976) a
competency statement must include the behavior the student is to acquire, specifically
what the student will be capable of doing upon completion of the learning period or
course. Besides the behavior, the statement should also include the area of life or context
in which behavior will be conducted. This is important because these statements will
guide all learning experiences and establish the foundation for evaluating student
achievement (Lutrell, Lenburg, Scherubel, Jacob, & Koch, 1999). Outcomes have often
been written in vague terms, so proponents of CBE have stressed the need for more
specific, behavioral type objectives (Klingstedt, 1972). Some of the essential
characteristics of a competency statement as described by Alspach (1984) are: (a)
describes a general category of behavior; (b) learner oriented; (c) behavioral and
measurable; and ((1) expert validated. Luttrell et al. (1999) pointed out that when writing a
competency statement, “to be effective they must be worded deliberately in realistic,
practice-based and measurable terms” (p. 136). Easily interpreted or clearly written
competencies allow the educator and learner to understand the outcome they are striving
toward.

Flexible time parameters and varied instructional approaches. Other requirements
of competency-based education are flexible time parameters and varied instructional
approaches. The students must have multiple opportunities for achieving and

demonstrating competence (Spady, 1977).

29

Beare (1985) discussed that when using CBE in nursing education, the focus is on
creating alternative teaching strategies to achieve learning goals. These alternative
strategies are necessary because in a true competency-based program, students move on
to the next area of study if they have developed competence in the current content area.
Conversely, if a student does not achieve competence quickly, he/She needs to be given
additional time to attain mastery (Bell, 1976; Bell et al., 1997). Therefore, students will
move through the curriculum at various rates. The flexible time parameter creates a
classroom of students who may all be studying different areas at a given time. Thus, the
instructor must learn how to facilitate the learning experience instead of preparing
lectures to give to the whole class. The diversity of instructional strategies to teach the
different competencies is important since there is variability in the competencies.
Competencies come from a variety of domains, which make them prone to different
instructional methods.

In addition, a variety of teaching strategies for those who require additional
instruction must be available so that strategies can be matched to learner styles (Bell,
1976; Bell et al., 1997). The instructor’s ability to implement a variety of methodologies
is important, however, the instructor may not have control over the time frame in which
to use these methods.

In theory, a variable time frame may be a good concept, but in practice this may
be a problem because most curricula are developed by the time frame of the university.
Courses traditionally start at the beginning of the semester and finish at the end. Colleges
and universities do not allow for students to change to a different course midway through

the semester. A true competency-based program at the higher education level will require

30

that some changes be made to the current system. The traditional time frame may have to
be adjusted, and instructors must also be educated in how to teach when students are
working on different competencies at the same time. Within this flexible time parameter
is the underlying assumption that every student has the potential to become competent.
This assumption may be true if the program admission requirements are stringent and
ensure only the entry of students who are capable of developing competence. This belief
is seen in physical therapy, nursing, and medical schools where the prerequisites for
admittance into the program are stringent enough to only accept students who all have the
capability of learning the competencies required (McGaghie et al., 1978).

Athletic training programs are in the process of incorporating the flexible time
parameter into athletic training clinical experiences. The historically mandated 800-hour
requirement for students who graduate from an accredited program was discontinued in
favor of the development of clinical proficiencies. Therefore, the time necessary to
develop and demonstrate proficiency will vary for each individual student as long as
he/she has developed the skills over a minimum of two years (NATA, 2001b). The issue
remains that the competencies must be taught in courses, but they are usually restricted in
time to the semester or quarter framework of the institution.

Criterion-referenced evaluation. Another requirement of competency-based
education is the use of criterion-referenced measurement. The students are not compared
to each other, but are evaluated according to a pre-set standard of knowledge or
performance (Schuldenfrei, I993; Shanklin & Beach, 1980). Criterion-referenced
measurement is an excellent evaluation method when the goal is to assess student

competence and not student ranking (Tumbull, 1989). Criterion-referenced measurement

31

is supported in the use of competency assessment in medical and allied health education
(del Bueno & Altano, 1984; Shanklin & Beach, 1980; Tumbull, I989). The goal of
medical and allied health education is to produce qualified professionals; therefore, it is
imperative that the assessment of knowledge, skills, and attitude determines competence.
CBE emphasizes the specific knowledge or skills required by the student within clearly
articulated performance standards. This was declared by McGaghie (1991) in terms of
fitness for practice. If there is not an explicit understanding about what is professional
competence, then determining who is ready to practice is impossible. Thus competency
in the context of higher education has been defined by Bell (1976) as the minimum
knowledge, skills, and/or affective behavior that an individual needs to possess at a set
level of expectations. The key to the objectives or competency statements is the addition
of a standard (Burns, 1972). This pre-set standard is one that every student must meet in
order to be deemed competent.

These standards may require the student to demonstrate competence in simulated
or real life situations. Many feel the competencies Should relate to real life situations so
that the students will be able to function independently in their first job (Beare, 1985;
Chambers, 1995; Chambers, Gilmore, Maillet, & Mitchell, 1996; Lutrell et al., 1999;
Mitchell, 1990; Spady, 1977; Spady & Mitchell, 1977). The need for entry level
practitioners to be able to function adeptly in real life situations is seen when McGaghie
(1991) stated, “competence evaluations are defined as measurements and subsequent
interpretation of data derived from measurements that result in a judgment that an
individual is fit to practice a profession autonomously”(p. 3). Senior (1976) discussed the

issues of determining whether or not a physician is competent. He noted that a key to

32

being deemed competent is when an evaluator judges the physician as demonstrating the
knowledge and Skills necessary for a good performance in his/her future practice.
Therefore, the judgment against a standard for each specific competency to determine
competence is crucial in CBE. However, the evaluation of competencies is a struggle in
CBE programs due to the difficulty in delineating clearly understood competencies and
defining the appropriate minimum level of competence.

One way to deal with the interpretation of a competency is to divide broad
competencies into smaller closed competencies that are easily defined and measured.
Spady (1977) stated that as CBE programs strive for high quality evidence as a basis for
certification of competency, the more the objectives will have to be narrowed and
simplified so as to correspond to existing test technology. These competencies must be
clearly demonstrable and the criteria for demonstration explicitly stated in order for valid
and reliable testing of competence to take place. The establishment of measurable
competencies is a difficult task.

The definition of the standard and thus the testing to determine competence has
been lacking in some fields (Scott, 1982). For instance, this problem of measurement has
received an enormous amount of consideration in the literature for the nursing field
(Scott, 1982). In addition, Reilly, Barclay and Culbertson (1977) have referred to the
measurement of competence in CBE programs as the “Achilles heel.” This view was
supported by others and is attributed mainly to the inadequacy, weak validity, and
questionable reliability of the measurement tools (Barr, 1977; DeWald & McCann, 1999;
Elam, 1971; Hanken, 1979; Houston & Warner, 1977, Lane & Ross, 1994b; Lane &

Ross, 1998; Lane, Ross, Parkinson, & Chen, 1995). Competencies within the affective

33

domain have been observed to be very difficult to measure (Harbeck, 1972). Therefore,
the concern is that the assessment approaches have not evolved along with the teaching
and learning philosophies of CBE (Spady, 1977).

The lack of reliability and validity of a competency statement, along with a lack of
consensus on a standard for competence, creates the need to establish measurable
competencies. The issue of explicit outcomes and minimal standards for criterion-
referenced evaluation needs to be addressed. The developers of the competencies need to
ensure that every instructor and learner interprets the competency as it was intended or
else there will not be any standardization of educational outcomes.

The field of preventive medicine has acknowledged this lack of reliability and
validity (Lane & Ross, 1998; Lane, Ross, Parkinson, & Chen, 1995). Extensive work has
been done to alleviate this problem in the CBE programs for preventive medicine
physicians. To evaluate the competencies, they have identified performance indicators
for each competency. These indicators are then used to develop measures to assess
competency achievement. They also have stressed the need to assess the performance by
direct observation if possible; otherwise, they suggest simulations.

In athletic training there should be a common understanding of what the entry-
level athletic trainer should know and be able to do. The knowledge, skills, and attitudes
necessary to be an entry-level athletic trainer have been determined, but there may be
disagreement as to the interpretation of what each competency statement intends and what
defines competence. To help resolve this problem, the NATA competency statements
need to be written so they are easily interpreted. Educators need to know what to teach

while students need to recognize when they have achieved competence. Also, to decrease

34

ambiguity among students, teachers, and programs, there is a need to develop standards,
criteria, or what constitutes “competent.” These are important aspects of a CBE program.

Theoretical Bases of CBE

 

The origin of CBE has been attributed to several theoretical bases. The
components of CBE (explicit outcomes, flexible time parameters, variable teaching
strategies, and criterion-referenced evaluation) within an educational program are similar
to other educational models, which may be the foundation of CBE. Three of these
theoretical bases are: (a) experimentalism (Burns & Klingstedt, 1972; Klingstedt, 1972;
Moncur, 1985); (b) novice to expert theory (Chambers et al., 1996); and (c) adult learner
education (Schmaus, 1987).

Experimentalism. The underpinnings of experimentalism focus on the scientific

 

study of human behavior. The belief is that learning is defined as a change in behavior.
Some of the fundamental ideas associated with experimentalism are that the world is in
constant change, that learning takes place when one experiences, observes, and reflects on
the outcomes or consequences of his/her behavior (Hallet, 1997; Regan-Smith, 1998;
Schmaus, 1987). John Dewey, the founder of experimentalism, maintained that children
learned best from experimenting, followed by observing the outcome of their actions.

The opinion that CBE grew out of experimentalism is because of the emphasis on change
in the learner and his or her behavior or performance. Dewey also stressed the importance
of a clearly defined purpose that will guide the educational process and help promote
growth (Hallet, 1997; Schmaus, 1987). The relationship to competency-based education

is seen in the similarities of clearly defined purposes in the intended competencies, and

35

growth of the learner occurs as he or she develops competence. One of the benefits of
CBE is the proof that a student has developed competence in the stated areas.

In addition, experimentalists discuss the need to use new altematives when
educating, to use a variety of teaching strategies, and to be flexible in their routine. Hallet
(1997) noted how learning from experience is better than sitting in a classroom and
learning only from didactic techniques. CBE follows this prescription by providing
alternative methods to in order to accommodate all learning styles. A variety of teaching
strategies is also necessary because students would be able to concurrently work on a
variety of competencies.

Novice to expert theom Novice to expert literature is attributed by some to be the

 

theory behind the development of CBE (Chambers et al., 1996). Chambers et al. defined
competency as the midpoint on a scale of professional growth that typically extends over
10 to 12 years. There are five stages a person must progress through to advance from
novice to expert. The stages that range from 1 to 5 are novice, beginner, competence,
proficiency, and expertise or mastery (Bruer, 1993; Chambers et al., 1996). The years of
learning in the formal school setting take the student from novice to competence. The
proficiency and expertise/mastery stage occur sometime during the person’s professional
career. Chambers (1995) defined competency as the stage where a learner has achieved
enough understanding, skill, and appropriate values to continue professional growth
independently.

Both the novice to expert model and CBE has been used in physical therapy and
nursing practice (Benner, 1984; Farrell, 1996; Jensen, Shepherd, & Hack, 1990;

Minghella & Benson, 1995; Nuccio et al., 1996). Benner (1984) originally developed the

36

novice to expert domains for the stages of nursing development from interviews and
observations of clinical nursing practice. Other studies have supported her definitions of
each stage of nursing practice (Minghella & Benson, 1995; Nuccio et al., 1996).

In the profession of physical therapy, Jensen et al. (1990) studied novice and
expert physical therapists and found that experts learned to manage their patient care time
better, thus more time was actually spent working closely with the patient. They also
found that expert therapists were better able to respond to their patient's thoughts and
concerns while the novice worked in a more mechanical and procedural manner. These
studies demonstrated that competence occurs in the middle or at stage 3 of the novice to
expert model. At that time they are ready to practice their profession without much
guidance. The relationship of the novice to expert theory to CBE is noted through the
focus on competence. In CBE, a student must have exhibited an acceptable level of
competence in the stated competencies in order to ultimately graduate and/or become
certified. As the certified athletic trainers enter the work force as entry-level practitioners
they will continue to learn and grow as they practice, develop their skills, and continue to
attain more knowledge. Thus, this component of CBE is a parallel to the novice to expert
model.

Adult learner theory. The final theory claimed by some to be the basis for CBE is
adult learner theory (Price, Swartz & Thum, 1983; Schmaus, 1987). Adult learner theory,
often called andragogy, has been described extensively by Knowles (1980, 1984). Some
of the primary assumptions regarding adult learners are: (a) adult learners perceive
themselves as responsible for their Ieaming and are self-directed; (b) adults use the

immense quantity of knowledge they have amassed as a learning resource; (c) adults are

37

motivated to learn when they recognize that the knowledge or skill will help them with
real-life tasks or problems; and ((1) adult learners consider education as a lifelong process
that will help them realize their full potential (Knowles, 1980, 1984; Schmaus, 1987).
CBE may be derived from adult learner theory because it has similar assumptions within
its structure. One similarity is that adult learners are said to be self-directed learners.
CBE is described as self-directed instead of instructor-centered in view of the fact that
when the learner has attained the knowledge or skills for a specific competency he/she
continue on to another competency.

Another likeness is seen when Beare (1985) discussed CBE in nursing education
and noted that the trend is to focus on methods to develop self-motivated life long
learners. This goal matches up to the belief that adult learners consider learning a life
long process. Lastly, adult learners are motivated when they realize the knowledge or
Skill they are learning is related to real life tasks (Regan-Smith, 1998; Knowles, 1980,
1984). Regan—Smith described a workshop for primary care practitioner educators where
the importance of adult learning theory was evident. She felt the most compelling aspect
relating to adult learning was the learner's intrinsic need to know. This motivation was
necessary for learning to take place. One aspect of motivation is the realization that
learning will be needed in the future, that the knowledge and/or skill relate to real life.
This real life aspect is found in CBE, since role delineation studies often become the basis
for competency development. Thus, CBE competencies are directly relevant to job
performance. CBE is designed to have competencies that are related to real life tasks.

Each of these theories may have contributed to the development of CBE. The

ultimate outcome is the assistance CBE provides educators in all fields of study by

38

providing accountability through the measurement of outcomes in a systematic and
objective manner (Beare, 1985). Thus, the outcomes or competencies on which CBE are
based are very important for each profession because they will be used in all the
educational programs, in the accreditation process, and will define to society what
knowledge and Skills students have attained. Importance is also realized because the
competencies are actually needed by professionals in the field to perform their job, and
their patients value these competencies.

Competencies

 

Curriculum development, often driven by accreditation, is concerned with the
central issue of determining which content is of most value (Allen, 1998; Ende &
Davidoff, 1992; Walker, 1990). This holds true for all curricula, including those in the
allied health fields. When determining the content of curricula for allied health
professions, there are some general professional competencies advocated for all health
education settings (Doyle, Woods, & Deming, 1995; Luebke & Bohnenblust, 1994). In
addition, in preparing for the future, the Pew Health Professions Commission (1995) has
established competencies and strategies for all allied health care practitioners starting in
2005 (Buck, Tilson, & Andersen, 1999; Fauser, 1992; Gelmon, 1997; Starkey, 1997).
These competencies are related to promoting a healthy America and include such areas as
improving primary care, promoting healthy lifestyles, and coordinating health services.
The Pew Health Professions Commission feels that the task at hand is the development of
outcome measures for each allied health field in order to assess how members will attain

these competencies.

39

Competencies in Health and Medical Education

 

In addition to these general guidelines, each health profession must develop
competencies that define to society and the profession what knowledge and skills a
graduate of an accredited program and certified member of the profession will possess.
Many medical and allied health fields have realized the need for the development of
competency statements (Ali, Hogan, & Blanchard, I992; Chidley & Kisner, 1979;
Deming, Doyle, & Woods, 1993; DeWald & McCann, 1999; Edwards & Keeley, 1998;
Hinojosa, 1985; Holmes, 1982; Weinstein & Russell, 1976; Young, Weser, McBride,
Page, & Littlefield, 1983). Some of the specific professions include family practice,
preventive medicine, dietetics, nursing, and athletic training (Barris, 1978; Bell et al.,
1997; Dunn, Hamilton, & Harden, 1985; Grace, 1999; Luebke & Bohnenblust, 1994;
Pololi et al., 1994; Scott, 1982; Stephens, 1999). Some of these professions are farther
along than others Since they have already identified their essential competencies, while
other professions are still grappling with this issue.

Nursing is one field that has developed competencies and has used them in CBE
and novice to expert education models (Beare, 1985; del Bueno & Altano, 1984; Rice &
Rapson, 1999; Stephens, 1999). The need for clarity and accountability along with
increasing costs created the interest in CBE for the nursing profession (Rossel & Kakta,
1990). Although competencies were developed for nursing, everyone did not support
them. Stephens (1999) discussed the tensions in the development of nursing
competencies when he pointed out that some members objected to the apparent reduction
of nursing to a series of tasks while others thought that delineation of tasks would help

clarify and identify skills that must be included in educational programs.

40

DeWald and McCann (1999) discussed the three-step process used to develop a
C BE curriculum for a dental hygiene program at the Caruth School of Dental Hygiene.
Determining the program competencies was the first step. Experts in that department
initially developed the ideal curriculum, and then adjusted it to a realistic curriculum in
terms of the essentials for an entry-level hygienist and the available time frame. The next
steps were the establishment of the teaching and measurement techniques for these
competencies.

Preventive medicine specialists realized the need for competency development
when there was confusion by colleagues, program applicants, and employers about their
roles (Lane & Ross, 1994a). There was also a great amount of variance among programs
that needed to be diminished (Lane & Ross, 1994a). In addition to competencies that
define the field of preventive medicine to others, competencies for the preventive
medicine curriculum for all medical schools in teaching have been discussed (Pololi et
al., 1994; Seagall et al., 1981). These competencies were developed to increase effective
use of limited curriculum time and resources by reducing the arbitrary component of
teaching programs in preventive medicine.

In the 1980’s the charge was given to dietetic programs to identify competencies
that relate to the philosophy and goals of their institutions, as well as the general needs for
all competent practitioners (Shanklin & Beach, 1980). Studies were performed to
determine the general competencies for an entry-level generalist dietitian (Holmes, 1982;
Loyd & Vaden, 1977). Holmes (1982) advanced the competencies in the dietetics field
with her research on competency ratings by dietetic educators. As the essential

competencies were identified, the need to continually update the competencies to meet

41

the current needs of society was realized. Thus, the profession of dietetics has developed
and continually revises competencies for CBE programs within the field.

While the professions of nursing and dietetics have already established
competencies, the field of family practice also has identified the need to do so, but does
not have unanimous support from its practitioners. Bell et al. (1997) stated that there are
no standardized definitions of what is a competent family practice physician. He called
for the need to establish these competencies for family practice despite the resistance of
some who feel the “art of family practice” is impossible to define.

The development of competencies varies for the many health care fields. There is
a mixture of stages of competency development with some professions very advanced and
using them extensively while others are in their infancy of the development process.

Competencies in Athletic Training

 

The profession of athletic training grappled with competency development many
years ago and has evaluated and revised its competencies several times. The NATA
educational committees and the NATABOC made the determination of what was
important through role delineation studies (Grace, 1999; Grace & Ledderman, 1982;
NATA, 1996).

Role delineation studies focus on the tasks that are performed on the job, the
importance of the tasks, the frequency of the tasks, and how critical the tasks are for the
entry-level athletic trainer (NATA Education Council, 1999b; Grace & Ledderman,
1982). Role delineation studies also have been used to help define other allied health

fields including health education and worksite wellness programs (Bruess, et al., 1987;

42

Golaszewski et al., 1994; Henderson et al., 1981; McMahon, Bruess, & Lohrrnan, 1987;
Schmidt & Beall, 1988).

Henderson et al. (1981) discussed the role delineation process undertaken for
entry-level health educators. A role delineation study was performed to help establish the
definition and competencies for entry-level health educators, which in turn would
establish standardized curricula. The goal was to develop core competencies needed by
all entry-level health educators regardless of their employment settings. They were able
to determine seven areas of responsibilities.

The profession of athletic training conducted its first role delineation study in
1982 to assess the profession and determine the validity of the content of the National
Athletic Trainers’ Association Certification Exam (Ebel, 1999; Grace, 1999; Grace &
Ledderman, 1982). The exam content was validated through this study by determining
the tasks performed by entry-level athletic trainers and comparing them to the
certification exam content (NATABOC, 20003; Grace, 1999). The role delineation
studies have been repeated approximately every five years with the latest study completed
in 1999 (NATA Education Council, 1999b; NATABOC, 1999). It is important to repeat
and update the role delineation studies because of the continuing changes in the field and
practice settings of athletic training (NATABOC, 2000a). Some of the progress has been
made in the technological and surgical areas that affect the knowledge and skills required
for athletic trainers. In addition, athletic trainers have gone from working only with
athletic teams in the "traditional" settings of colleges/universities, professional sports, and
high schools to practicing in clinics, hospitals, and industrial settings. Also, the increase

in participation by women, persons with disability, children, and older adults in

43

competitive sports has changed the role of the ATC. The role delineation studies are
critical to the athletic training profession because they provide the framework for the
academic program for entry-level preparation (McMullan, 1996).

The latest role delineation study commenced with a panel of athletic training
experts from diverse backgrounds (NATABOC, 1999). They developed the major
performance domains and the tasks associated within each domain. After a pilot study,
the questionnaire was distributed to a national sample of 2000 certified athletic trainers.
The results, based on a 36% return rate, were published as the current role delineation
study (NATABOC, 1999).

Role delineation studies provided an analysis of the tasks that are utilized by
certified athletic trainers. The NATA Education Council used the results of the role
delineation study to delineate competency statements (Grace, 1999; NATA, 1999). The
Education Council has stated that the competencies are slightly broader and more specific
than the content found in the role delineation study to help ensure growth of the
profession (NATA, 1999). These competencies then became the foundation for
curriculum development. It should be noted that the NATA educational and certification
committees were wise to realize the need to establish competencies that would be the
basis for both educational programs and the certification exam. They recognized that
athletic training educational programs and the certification exam should be founded on
one set of competencies. As the foundation for the profession, the NATA educational
competencies need to be developed and stated in full alignment with the literature

delineating high quality competency statements.

44

The NATA educational competencies have emerged as the field of athletic
training has advanced into a profession over the past thirty years. The field of athletic
training is similar to its original profession, yet advanced due to research and progress in
such areas as the prevention, evaluation, treatment and rehabilitation of injuries. Role
delineation studies have been performed to determine the NATA competencies necessary
for an athletic training curriculum. Koehneke (1999) emphasized this when he stated,
"JRC-AT/CAAHEP Standards and Guidelines and the NATA Athletic Training
Educational Competencies must be the basis of a curriculum" (p. 16). AS the foundation
of the curriculum, the fiJtUI’C requirement for accreditation is to use a competency matrix
to document where each competency is taught, how it is evaluated, and when the student
will be evaluated (NATA Education Council, 1999a; 1999c).

Interestingly, the investigator found only one other study that evaluated the
importance of the athletic training competencies (Zylks, 1988). In that study 300 certified
athletic trainers were asked to rate the importance of the NATA competencies that were
in existence in 1988. At that time, there were 175 competencies in 7 content areas. The
sample was divided into three groups, including program directors of NATA-approved
educational programs, clinical instructors, and ATCs from the general membership. The
participants rated the competencies on importance with a 5-point Likert scale. Zylks
identified the competencies that received a “5 - “very important” or a “4 - important”
ratings only. Only a few of the competencies received average ratings of “4” of “5” from
instructors and program directors. The general membership (N = 179) did not rate any of
the competencies with only “5’8” and “4’s.” Therefore, there was variability in the

perceived importance of the competencies by the participants.

45

In addition to examining competencies considered as important or very important,
Zylks also noted competencies that 50% or more of the respondents rated as less than
“important,” a “3” or below rating. Five competencies had 50% or more of the ratings
below “important.” The content areas were two in education, one in counseling and
guidance, and two in prevention of athletic injuries and illnesses. The competency
statements in this study have since been revised two times.

The Education Council’s Competencies Committee, using the previously
published competencies and current role delineation studies as their guideline, developed
the current competency statements. The 542 NATA Athletic Training Educational
Competencies are organized into 12 content areas (NATA, 1999). There are three
domains within each content area: cognitive, psychomotor, and affective. The 12 content
areas and the distribution of the competencies by domain are presented in Table l. A
panel of experts and several NATA educational committees reviewed the first draft
(Starkey, 1998). The draft of competencies was then placed on the Education Council
web site for public review and comments. The resultant 542 NATA educational
competencies (NATA, 1999), are a contrast in number to the previous edition of NATA
competencies, which included only 191 competencies (NATA, 1996).

Some of this enormous increase in the number of competencies may be due to a
better definition of the competencies. Rewriting the competencies into more discrete
statements would help clarify the competencies, but would create a larger number of
them. This method has been suggested by Spady (1977) as a way to help increase the

measurability and understanding of each competency statement.

46

Table 1

Distribution of NATA Educational Competencies by Domain

 

 

 

Content Area Domains
Cognitive Psychomotor Affective Total

Risk Management and 25 12 12 49
Injury Prevention
Pathology of Injuries 19 0 5 24
and Illnesses
Assessment and Evaluation 27 17 7 5]
Acute Care of Injury 46 21 16 83
and Illness
Pharmacology 25 7 9 41
Therapeutic Modalities 22 10 5 37
Therapeutic Exercise 16 7 4 27
General Medical Conditions 37 17 3 57
and Disabilities
Nutritional Aspects of Injuries 27 4 4 35
and Illnesses
Psychosocial Intervention 25 6 l 0 41
and Referral
Health Care Administration 46 8 12 66
Professional Development 16 3 12 3 l
and Responsibilities
Total 33 l 1 12 99 542

 

Note. These values represent the number of competencies for each domain in every

content area.

47

Another explanation for the increase may be the perceived competency needs of
athletic trainers due to the changes in the profession. As the profession has advanced, the
population served has expanded from athletes to other physically active persons, and the
practice settings have increased in scope from the athletic training room to clinical and
industrial settings. The diversity of the patient population including physically active
men, women, persons with disability, children, and older adults, in addition to more
practice settings over the years may have changed the duties of the athletic trainer. The
population has grown from athletes in the high school, collegiate, and professional
settings to any physically active person regardless of age and profession. Therefore,
besides athletes in the training room setting, the population served by athletic trainers
includes people who work on the assembly line, people who are physically active only on
weekends, or people who are training for a marathon. Each of these people has different
needs. This diversity helped shape the outcomes of the recent role delineation study,
which ultimately affect the competency statements.

It must be noted, that in addition to the competencies, clinical proficiencies for
each content area have been identified. These proficiencies are used concurrently with
the competencies, but they are taught and demonstrated in the clinical portion of athletic
training education. The proficiencies provide an outcome-based qualitative approach to
the student’s clinical education as compared to the previous hour or quantitative approach
(NATA, 1999). The proficiencies are another area that can be examined, but they are
beyond the scope of this study.

Although these competencies have been determined, the question arises

concerning the practicality of a student accomplishing all these competencies in the

48

limited time of a typical undergraduate educational program. Realistically, there is a
limited amount of time in each course or program, contrary to the CBE philosophy of
flexible time parameters (Ali et al., 1992; Aston-McCrimmon, 1986). Therefore, it is
imperative to identify which competencies are truly necessary for the entry-level athletic
trainer. There may be some competencies that would be “nice to know” but are not
essential for the entry-level athletic trainer to perform his/her first job.

Summag

Program accreditation, along with professional certification, strengthens a
profession’s credibility and defines to the public the knowledge and skills the
professional will possess. The profession of athletic training has evolved to an
accreditation of its educational programs after many years of allowing the existence of
two routes to certification, curriculum and internship. The internship route was the
original method of educating students; however, this route to certification will be
eliminated by 2004. The switch to an accredited program based upon coursework that
emphasizes the NATA competencies will facilitate the education of athletic training
students to become standardized.

Athletic training educators across the country are striving for J RC-AT
accreditation of their programs. As accreditation is sought, a self-study must be
undertaken to evaluate the program. Required for the self-study, and a key component to
the educational process, are the NATA educational competencies (NATA, 1999).
Teaching these competencies creates an opportunity to use the CBE model to educate

students.

49

CBE, with its elements of explicit learning outcomes, flexible time parameters,
varied instructional approaches, and criterion referenced evaluations, has been used in
other allied health fields. The elements of CBE can help strengthen the education of
athletic training students, but attention must be given to the explicit learning outcomes
and criterion-reference evaluations. The competencies that define the outcomes need to
be clearly understood and evaluated in comparison to a pre-set Standard. This can be
summarized as measurability.

The measurable competencies are then incorporated into a CBE program. For
athletic training, the competencies developed from the NATABOC role delineation
studies were recently revised and increased in number from 191 to 542. The large
increase has created a concern about the amount of time available to develop a student’s
competence in each competency. Currently, if calculated for the credit hours available in
most programs, there is less than one hour of class time in which to teach each
competency. In addition, the athletic training educators need to document the student’s
competence for each of these competency statements. If there are 30 students in a
program, the educator must perform 16,260 competency evaluations during the time these
students are in the program. This large amount of competency evaluations is to only
document each student’s competence one time for each competency statement. The
evaluations will be done over the three years the students are in the program, so there will
be approximately 5400 competency assessments a year. This does not include the fact
that each competency should be evaluated more than once to demonstrate competence

over time. Since these competencies are an integral part of athletic training educational

50

programs, it is time to examine the competencies in terms of importance and

measurability to help produce competent, professional certified athletic trainers.

51

CHAPTER 3
METHODOLOGY

The measurability and importance of the general medical conditions and
disabilities content area of the National Athletic Trainers’ Association educational
competencies (NATA, 1999) were the focus of this study. The content matter in the
general medical conditions and disabilities competencies includes: (a) common illnesses;
(b) cardiopulmonary conditions; (c) ear, nose, throat, and eye pathologies; and ((1) Skin
disorders and organ infections. The general medical conditions and disabilities content
area consists of 37 cognitive, l7 psychomotor, and 3 affective competency statements, for
a total of 57 competencies. In this study, three stakeholder groups rated each of these
competencies on two different dimensions, importance and measurability. The three
stakeholder groups were the university/college athletic trainers, professional athletic
trainers, and sports medicine physicians.

The general purpose of this study was twofold: (a) to identify stakeholder beliefs
in the measurability of the general medical conditions and disabilities competencies of the
NATA educational competencies (1999) and (b) to identify stakeholder perceptions of the
importance of these same competency statements. The following research questions
guided the study:

I. To what extent do stakeholders perceive that the educational competency
statements in the general medical conditions and disabilities content area are measurable?

2. To what extent do college/university athletic trainers, professional athletic
trainers, and sports medicine physicians differ on the perceived measurability of the

general medical conditions and disabilities educational competency statements?

52

3. What importance do the stakeholders assign to each of the competencies in the
general medical conditions and disabilities area?

4. To what extent do college/university athletic trainers, professional athletic
trainers, and Sports medicine physicians differ on the perceived importance of the
competency statements in the general medical conditions and disabilities area?

53mm?

Three stakeholder groups participated in this study. There were two groups of
athletic trainers, all NATA certified, and one group of sports medicine physicians.
The sample size and characteristics of the stakeholder groups will be discussed in the
following section. The methods of sample selection and informed consent will be
discussed under the “Data Collection Procedures” heading in this chapter.
Stakeholder Groups

0 College/university athletic trainers. The participants in this group were certified

 

athletic trainers (ATC) who worked at Division I, II, or 11] institutions or junior
colleges as classified by the National Collegiate Athletic Association (NCAA) or
the National Association of Intercollegiate Athletics (NAIA). These athletic
trainers were working in an athletic training room setting with athletic teams at
their respective institutions and/or were educators of athletic training students at
these institutions.

0 Professional athletic trainers. Certified athletic trainers in high school, clinical,
industrial, or "other" settings were included in this group. The ATCs who work in
high schools were one group of participants in this category. These athletic

trainers were full time high school athletic trainers, teacher/athletic trainers, or

53

clinical/athletic trainers. The clinical or industrial athletic trainers were people
who spent the majority of their time working in a clinical setting such as a sports
medicine or physical therapy clinic, or those who work in an industrial setting.
The "other" category includes athletic trainers who were working with
professional sports, hospital settings, or any other setting that would not be
included in any of the previously listed categories.

Sports medicine physicians. The physicians are doctors who specialize in sports
medicine and are listed in the directory of either the American Society of Sports
Medicine or the American Orthopedic Society of Sports Medicine. These
physicians usually work with athletes and athletic trainers. The physicians could
specialize in family practice, orthopedics, sports medicine, or any other area, as
long as they were listed in one of these sports medicine directories.

The rationale for the grouping of the athletic trainers based on employment is due

to the task variance at each of the employment settings. For example, athletic trainers

who work in the college or university setting usually have a specific team physician and

often work with student athletic trainers. Working with the same physician each day,

week, or year establishes a strong athletic trainer/physician relationship. The physician

who knows the Skills and knowledge of the athletic trainer may ask him/her to perform

different or additional duties as compared to athletic trainers who do not have this close

working relationship. In addition, athletic trainers in the collegiate setting are working

with a relatively homogenous population of healthy 17-22 year old athletes, while ATCs

at other settings usually have a more diverse population. Another difference is that the

athletic trainers who work in the college settings often work with student athletic trainers

S4

who are earning hours or developing clinical proficiencies towards NATA certification.
These students may be involved in the athletic training curriculum at the university or
they may be on rotation from the athletic training program at another school. This student
involvement requires many athletic trainers at the collegiate setting to be involved in the
education of the student athletic trainers by teaching athletic training classes and/or
teaching in the clinical setting of the athletic training room.

In contrast, athletic trainers who work in high school, industrial, or clinical
settings often work with a variety of physicians who may or may not have a sports
medicine background. The community physicians who do not commonly work with
athletes and athletic trainers may not understand the competencies of athletic trainers.
High school athletic trainers are also dealing with different issues compared to college
athletic trainers, since they are treating minors and must include the parents or guardians
in any major decisions. High school athletic trainers were placed in the “professional”
category because they often work in a clinical setting in the morning prior to going to the
high school or when the schools are not in session.

The competencies necessary to work in the non-traditional clinical or industrial
settings may be different from those needed in the traditional setting. The traditional
setting for an athletic trainer is in a training room working with athletes who compete for
the school or organization. The need and desire to return to work or play may be different
for the assembly line worker, youth athlete, adult athlete, or recreational participant as
compared to the college athlete. Also, many skills, such as the pre-participation exam,
pre-game preparation, taping, and emergency management, are not used frequently in

non-traditional settings. The clinical and industrial settings are businesses that need to

55

control costs and make money, which may influence the skills that are necessary in this
setting. Also, many of the clinical and industrial athletic trainers do not work with
students, but they understand the knowledge and skill needed for athletic trainers in their
employment settings.

The “other” category may include athletic trainers who work for professional
sports, hospitals, or other agencies not included in the previous categories. Even though
athletic trainers who work in the professional setting may have a team physician, the
demands of the professional athlete are different than those of the collegiate athlete.
Since the professional athlete’s livelihood depends upon his or her health, the team
physician may be more involved than at the collegiate level. Additionally, the
professional athlete has the means to seek second opinions, specialized rehabilitation, or
alternative therapies outside the athletic training room. The professional athletic trainers
may perceive different competencies as important to help them keep the athlete within
their system. These athletic trainers also rarely work with student athletic trainers for an
extended period of time. The athletic trainers who are also included in the “other”
category may work in hospitals or other settings, but have moved out of the traditional
setting. The work required of them may be similar to athletic trainers in other settings or
it may require unique knowledge and Skills. Therefore, the professional sport athletic
trainer and those in unique settings have been placed into the “other” category. The
“other” category, expected to have low participant numbers, was grouped with the high
school, clinical, and industrial athletic trainers into the professional category because each
of these groups has unique features that are distinctive from the college/university athletic

trainers.

56

Data Collection Procedures

 

A list of ATCS was obtained by completing the NATA request for labels and
returning it to the NATA District 4 secretary. A request for a list of all certified athletic
trainers was then forwarded to the NATA headquarters. The NATA office provided the
names, addresses, and employment status in a database format for each certified athletic
trainer (ATC) in the United States. The employment was listed by the worksite codes:
CL=clinical, CS= College Student, CO= Corporate, HS: High School, HC= High
School/Clinic, HO= Hospital, IN= Industrial, JC= Junior College, PB: Pro Basketball,
PF: Pro Football, PG= Pro Golf, PH: Pro Hockey, PS= Pro Soccer, PT= Pro Tennis,
PX= Pro Baseball, OP= Other Professional, and UC= University and College. Certified
student athletic trainers were included on the list, but these people were not included in
the sample. The database was converted to a Microsoft Excel file to facilitate the
selection of a random sample of 1200 college and university athletic trainers and 1200
other athletic trainers who were included in the professional group. The college and
university group included any athletic trainer who was listed in the directory as college or
university (UC) or junior college (JC). The professional group included clinical (CL),
industrial (IN), high school (HS), high school/clinical (HC), or other (CO, HO, PB, PF ,
PG, PH, PS, PT, PX, OP) athletic trainers. The names of this stratified randomized
sample were then printed in label form.

To help maintain confidentiality, a code was written only on the return envelope.
When the questionnaire was returned, this code number was used to delete an individual’s
name from the master list, then the envelope was thrown away and the survey placed in a

holding bin. This procedure permitted the master list to be updated so that follow-up

57

letters could be sent to non-responders. A cover letter and questionnaire were mailed to
1200 athletic trainers in each of the groups, college and professional. A follow-up letter
was mailed three weeks later to all the athletic trainers who were non-responders
(Appendix E).

The physicians were selected through two listings of sports medicine physicians.
Two societies of sports medicine physicians are the American Society of Sports
Medicine, which includes primary practice physicians, and the American Orthopedic
Society of Sports Medicine, which includes orthopedic surgeons who specialize in sports
medicine. Every physician listed in the American Society of Sports Medicine roster was
given a number while in the American Orthopedic Society of Sports Medicine roster the
physicians who were listed as “active” were given a number. There were a total of 664
physicians in the American Society of Sports Medicine and 999 active members of the
American Society of Orthopedic Sports Medicine. Therefore, the physicians were
numbered from 1 through 1663. A statistical randomization of all the numbers was then
performed and the first 600 physicians whose numbers were selected were included in the
mailing. The investigator sent a cover letter, questionnaire, results sheet, and return
envelope to each physician requesting his or her participation. A follow—up letter was not
mailed to the physicians. This decision was made because the investigator believed the
yield from a follow up mailing to physician non-responders would be very low. This
decision was reached after speaking with a team physician about the possible reasons for
non-response. For example, a secretary may screen the physicians mail and throw out the
survey without the physician’s knowledge. Another reason may be that the physician is a

sports medicine doctor, but may not work with an athletic trainer. Lastly, many physicians

58

have large time demands so they may not take the time to complete a survey not
specifically related to physicians. Therefore, to save time and money, they were only sent
one questionnaire.

Each participant was asked to rate the measurability and importance of each
competency statement in the general medical conditions and disabilities content area
using the definitions provided in the instructions. The cover letter contained an
explanation that informed consent was implied if the survey was completed and returned.
Sample Size

The profession of athletic training has approximately 21,000 ATCS. The sample
size goal for the athletic trainer groups was 300 as recommended by Krejcie & Morgan,
1970. The Sports medicine physician goal was 50 because it was the minimum number
needed for statistical comparisons and because this goal was practical.

The potential sample size fiom the NATA directory listing included p = 1200
ATCS randomly selected from the college/university employment settings, p = 1200
ATCS randomly selected from the employment settings in the professional category, and
g = 600 physicians randomly selected from the sports medicine physician directories.

The actual sample size included 420 for the college/university ATCS (return rate
35%), 384 for professional ATCS (return rate 32%), and 122 for sports medicine
physicians (return rate of 20%). An additional five participants did not include their
employment setting, thus the total was 931 participants. This sample size was sufficient
for statistical analysis according to the recommendations provided by Krejcie and Morgan

(1970).

59

Sample Characteristics

 

The participants were asked to identify their place of employment. These areas
included: (a) athletic trainer at division 1 university; (b) athletic trainer at division 11
university; (c) athletic trainer at division III university; ((1) athletic trainer at junior
college; (e) athletic trainer at high school; (f) athletic trainer at clinical or industrial
setting; (g) athletic trainer-other; and (h) team physician. Overall the ATC participants
were fairly evenly distributed across all employment settings. The athletic trainers were
then grouped into the two stakeholder groups, college/university and professional,
discussed previously.

Demographic characteristics including employment status, gender, education, and
years of certification or licensure are reported in Table 2. Overall, teaching
responsibilities were reported by approximately half (47%) of the athletic trainers while
only 10% of them reported that they were curriculum directors. Also, only a third of the
participants overall, and 37% of athletic trainers reported that they had used the NATA
competencies in their curriculum development; however, of those who indicated that they I
were curriculum/program directors at their institutions, 92% stated that they used the

NATA Athletic Training Educational Competencies in planning their curricula.

60

Table 2

Demographic Characteristics of Sample

 

 

University/ Sports
College Professional Medicine
ATCS ATCS Physicians Overall
(2:421) (9:388) (2:122) (9:931)

Gender:

Female 40% 53% 7% 39%

Male 60% 47% 93% 61%
Highest Degree Earned:

BA/BS 8% 37% 20%

MA/MS 82% 58% 61%

EdD/PhD 1 0% 5% 6%

MD/DO 100% 13%

Year of Certification
or Licensure:

Prior to 1960 0% 0% 2% 1%
1961—1970 1% 1% 12% 2%
1971 — I980 16% 7% 30% 14%
1981 — 1990 32% 30% 35% 32%
1991-2000 51% 62% 21% 51%
ATC Educator 70% 23% 43% 47%
ATC Curriculum Director 18% 2% 1% 9%
Read NATA Competencies 77% 45% 16% 55%
Used NATA Competencies 57% 15% 8% 33%

 

61

This sample of athletic trainers is similar to the total athletic training population
when compared to a recent NATA membership profile survey (NATA, 2001a). The
NATA survey found 35% of the membership employed at the college level, 23% in the
high schools, 14% within the clinical setting, and an additional 1 1% working at both high
schools and clinics. Thus 10% more of athletic trainers (45%) in the collegiate setting
responded to this study when compared to the NATA membership profile survey. This
study did not separate those who work in clinics and high schools, so it is difficult to
compare directly to the NATA membership. When compared to the membership study,
the participants in this study were more educated. The membership study showed that
60% of athletic trainers have attained a master’s degree or higher compared to 81% in this
study, and 32 % hold a bachelors degree versus 19% in the current study. The slightly
higher percent with bachelor’s degree only in the NATA study was expected because
prior to selecting the sample those who declared themselves as students were eliminated
from this study. Therefore, certified athletic trainers currently in a masters program were
not included because they were identified as students. In the NATA database 43% of the
members are female; whereas there was a 46% female ATC participant rate in the current
study.

Instrumentation

The Competency Evaluation Survey was developed by the investigator and
contained several components. The instrument (Appendix A) was structured as follows:

1. Cover sheet. The cover sheet provided the details of the study, including the
importance of the study, participation time, confidentiality, and informed consent

information.

62

2. Demographic information. The participants were asked to provide
demographic information including gender, work setting, specialty, year of certification
or medical degree, educational background, teaching and/or curriculum director
experience, familiarity with the competencies, and use of the competencies within the
curriculum.

3. Instructions for rating the competencies. The participants were provided with
an instruction sheet to help them rate the competencies. Definitions for both the
measurability and importance scales were provided to the participants.

4. Competency statements. The actual questionnaire included the competency
statements presented exactly as printed in the general medical conditions and disabilities
content area of the NATA educational competencies (NATA, 1999) accompanied by
Likert scales. Each competency statement was rated twice, once for measurability and
once for importance.

5. Likert scales. The Likert scales were defined for the participants in the rating
instructions. The 4-point Likert scale for importance ranged from 1 “non-essential” to 4
“extremely essential.” The 4-point Likert scale for measurability ranged from 1
“unmeasurable” to 4 “easily measurable.” Full definitions of the scales and ratings can be
found with the survey in Appendix A.

6. Results address form. To help insure confidentiality, a separate address sheet
was provided so the participant could request the results of the survey independent of
submitting the questionnaire.

7. Return envelope. A stamped, addressed return envelope was also included to

help encourage the return of the questionnaire.

63

Instrument Development

The original investigator-developed survey was pilot tested after the University
Committee on Research Involving Human Subjects (UCRIHS) approval (Appendix B) in
May 2000 to determine any problems with the survey. A selected group of certified
athletic trainers and sports medicine physicians were participants in the first pilot study.
The investigator asked athletic trainers and sports medicine physicians who worked in the
Greater Lansing Area if they were interested in participating in a study. If they were
interested in participating, the investigator either hand delivered or mailed a questionnaire
to them. Thirty questionnaires were delivered to potential participants, and 24 (80%)
completed surveys were returned. The results of this survey suggested that a few changes
be made in the original questionnaire. The Likert scales were changed from an end point
of “5” to “4” because of a concern over the number of responses for each point. In the
pilot study the participants had a propensity to choose options near the middle of the scale
leaving the ends of the scale with very few ratings. It was thought that a better
discrimination would take place with no middle value. The statement for measurability
was changed from the original end points of 1 “not clear” and 5 “very clear” to the current
measurability statements of “unmeasurable” and “easily measurable,” respectively. This
change was made because after the participants voiced concerns about the definitions of
clarity. After discussions with athletic trainers and experts in the field of education, it
was decided that clarity would be better defined as measurability. If a competency
statement is clearly written, then it is measurable. If a competency can be measured, then

the statement clearly indicates outcomes that are observable.

64

Pilot Test to Determine Instrument Reliability

After the changes, and further IRB approval (Appendix C), the revised
questionnaire was pilot tested. This second pilot study was performed to check for any
issues with the new scale, wording, and to verify rater stability. The investigator recruited
athletic training participants at the NATA national convention in Nashville, TN, in June
2000. The investigator identified an individual as a certified athletic trainer (ATC) by the
color of his/her name badge. The ATCs who were in the exhibit arena or lobby area of
the convention center during the meeting breaks were approached by the investigator and
were asked to participate in the study. They were given a cover letter explaining the
importance of the study for the athletic training profession and what their participation
would require, especially noting the requirement to respond to the survey on two separate
occasions. Athletic trainers (g = 30) who agreed to participate were provided a
questionnaire that included consent provisions. Informed consent was implied if subjects
completed and submitted the survey. A second survey was hand delivered or mailed to
each of the participants five months later. They were informed in advance that the study
would require them to complete the Likert scales for the competency statements two
different times, several months apart. This was explained to them in the survey cover
sheet along with the consent procedures. Since the pilot study was done to establish
stability, it was important for them to realize the need to complete the questionnaire
twice.

The results of the pilot study were analyzed using a test-retest reliability procedure
to establish the stability of the rater responses. Twenty-two of the original 30 participants

(73%) completed both sets of surveys. The pilot study yielded acceptable, moderate test-

65

retest reliability with a correlation of r = .67 Data from the pilot study can be found in
Appendix D.

Psychometric Properties

 

The analyses of the Competency Evaluation Survey focused on four
characteristics. First, a dimensionality analyses was performed to determine the degree to
which measurability and importance are distinct and cohesive constructs as defined by the
items. Second, the structure of each rating scale was evaluated to determine whether the
categorizations that were utilized by athletic trainers were sufficiently defined. Third,
each scale was analyzed to determine its reliability. Fourth, fit analyses were done to
determine the quality of individual items within each scale.

Dimensionalitv. Factor analyses to evaluate the dimensionality of the instrument

 

were conducted. Specifically, an exploratory factor analysis was performed on the raw
scores from both scales simultaneously (measurability and importance). Promax rotation
was used to determine whether the empirical factor loadings were logical considering the
content of the competencies. An item was declared to have a primary loading on the
factor for which the rotated factor loading was the largest. An item was declared to have a
cross-loading if it had rotated factor loadings greater than .40 on two factors.

The first step of the analyses was to evaluate the factor structure of the data to
determine whether it is reasonable to generate different scores for measurability and
importance, and whether it is reasonable to generate different subscales within these sets
for cognitive, psychomotor, and affective items. A scree plot was used to evaluate the
number of useful dimensions by identifying the location at which the eigenvalues show

negligible change with additional subsequent factors. Also, factors were eliminated from

66

consideration if no items exhibited a rotated factor loading greater than .40. A relatively
flat line that appears for each point to the right of the fifth factor is noted on the x-axis.
Therefore, based on the scree plot of the eigenvalues of each extracted factor (see Figure

l), substantive interpretations of the first five extracted factors will be conducted.

30.00 —
25.00 7

20.00 1

Eigenvalue

15.00 A
10.00 -

5.00 - ~ .-,_.

 

000 T T I I T I 1 I I I
Factor

 

Figure I. Scree plot for measurability scale

The exploratory factor analysis of raw scores using Promax rotation produced
substantively interpretable factor loadings for virtually all items on these five factors.
Table 3 shows the number (and percent) of items in each item category that had primary
loadings on the first five factors. These factor loadings demonstrate that the first, third,
and fifth extracted factors are defined exclusively by measurability items, and the second
and fourth factors are defined exclusively by importance items. It is important to note that
there are no large cross-loadings between the three factors defined by the measurability

items and the two factors defined by the importance items.

67

Table 3

Primary Factor Loading Summary

 

 

 

 

Construct/Category Factor
I 2 3 4 5
Measurability

Cognitive 32 0 5 0 0
(86%) (0%) (14%) (0%) (0%)

Psychomotor/Treatment 0 0 8 0 0
(0%) (0%) ( 100%) (0%) (0%)

Psychomotor/Assessment 0 0 l 0 8
(0%) (0%) (l 1%) (0%) (89%)

Affective O 0 3 0 0
(0%) (0%) ( 100%) (0%) (0%)

Importance

Cognitive 0 29 0 8 0
(0%) (78%) (0%) (22%) (0%)

Psychomotor/Treatment 0 l 0 7 0
(0%) (13%) (0%) (88%) (0%)

Psychomotor/ Assessment 0 4 0 5 0
(0%) (44%) (0%) (55%) (0%)

Affective 0 0 0 3 0
(0%) (0%) (0%) ( l 00%) (0%)

 

Note. There are a total of 57 items for each construct—37 cognitive, 8 psychomotor

treatment, 9 psychomotor assessment, and 3 affective. The values shown are the number

(and percent) of items within each of these categories that have a primary loading on each

of the first five extracted factors.

68

The largest potential cross-loading equals .20 for measurability items loading on
importance factors and .34 for importance items loading on measurability factors. In both
cases, the average potential cross-loading was very low (.01 for measurability items
loading on importance factors and .02 for importance items loading on measurability
factors).

The three measurability factors are defined by cognitive items, psychomotor
treatment and affective items, and psychomotor assessment items (the first, third, and
fifth extracted factors, respectively). Only one item, psychomotor item #54, exhibited a
cross—loading between the measurability factors (i.e., had loadings on multiple factors that
were greater than .40). This item had a primary loading on the assessment factor and a
secondary loading on the cognitive factor. This competency includes the demonstration
of a peak-flow meter for the assessment of asthmatic physically active people. This
competency is very similar to competency #8, a cognitive competency that requires the
athletic trainer to describe the use of the peak-flow meter in the evaluation and
management of respiratory conditions. Therefore, it may have been perceived that the
demonstration of this skill will require the cognitive abilities to explain as they
demonstrate, creating a cross-loading.

In addition, three cognitive measurability items had weak primary loadings (i.e.,
the largest factor loading was < .40), although the lowest primary factor loading was still
reasonably strong (.29). Competencies #4, recognition of common eye pathologies, #5,
recognition of common ear pathologies, and #6, recognition of common mouth, sinus,

and nose pathologies all involve the recognition of pathologies in the facial region.

69

The two importance factors separate items into two substantively meaningful
subsets. One subset defined primarily by cognitive and psychomotor assessment items,
and the other is defined primarily by psychomotor treatment and affective items.

The ratings of importance did not separate into three subsets like the measurability
ratings. This may be due to the fact that the psychomotor assessment competencies are
skills that are based heavily on the cognitive knowledge in order to execute the skills.
The psychomotor treatment and affective competencies discuss more recognition and
management of conditions. In evaluating these competencies it is thought that most of
the conditions described in the psychomotor treatment will require the athletic trainer to
make a referral to a physician.

There were no between factor cross-loadings for the importance items. However,
ten importance items had weak primary loadings (i.e., the largest factor loading was <
.40), although the lowest primary factor loading was still reasonably strong (.33).

The results of the analyses of the two scales demonstrate that they measure
separate constructs and the subscales of cognitive, psychomotor, and affective are
unidimensional measures.

Rating scale structure. The structure of the Likert rating scales was evaluated by

 

using six criteria proposed by Linacre (1999). First, the minimum of IO observations in
each category was verified. Second, a unimodal shaped rating scale distribution was
confirmed. Third, it was ensured that the average category measures increase with the
rating scale categories. Fourth, it was determined that the outfit mean square statistics lie
within a reasonable range of values (between 0.8 and 1.4 for this study). F ifih, it was

confirmed that category thresholds (Ix) increase with the rating scale categories. Sixth, it

70

was verified that the category thresholds are at least 1.4 logits apart and no more than 5‘
logits apart.

Measurability rating scale structure. The pertinent rating scale evaluation
statistics are shown in Table 4. From these indices, it is apparent that the rating scale is
functioning as intended. There are sufficient ratings within each category, and the
category distribution is unimodal. Additionally, the average measure (Mean 0) and
threshold values (Ix) increase with rating scale categories. Finally, the magnitudes of the

outfit mean square statistics are all reasonable.

Table 4

Measurability Rating Scale Summary

 

 

 

Category Index
N Mean 9 w r.
l - Unmeasurable 1,609 -0.10 1.2
2 — Somewhat Measurable 10,432 0.39 1.1 -1.80
3 — Measurable 21,648 1.05 0.9 -0.02
4 — Easily Measurable 18,053 2.37 1.0 1.81

 

Note. N indicates the number of ratings in each category, Mean 0 indicates the average
measurability estimate of trainers using that category, MS Outfit indices that unweighted

mean square residual, and IX indicates the value of the rating scale threshold.

Importance rating scale structure. The relevant rating scale evaluation statistics
are presented in Table 5. These indices unmistakably demonstrate that the rating scale is

functioning as intended. The category distribution is unimodal; there are sufficient ratings

71'

within each category, and the average measure (Mean 0) and threshold values (1,)
increase with rating scale categories. Finally, the magnitudes of the outfit mean square

statistics are all reasonable.

Table 5

Importance Rating Scale Summary

 

 

 

Category Index
N Mean 0 PM rx
1 - Unessential 2,384 -0.77 1.1
2 — Somewhat Essential 1 1,387 0.12 1.0 -l .91
3 — Essential 18,368 1.19 0.9 0.16
4 — Very Essential 20,503 2.59 1.0 1.74

 

Note. N indicates the number of ratings in each category, Mean 0 indicates the average
importance estimate of trainers using that category, MS Outfit indices that unweighted

mean square residual, and IX indicates the value of the rating scale threshold.

Reliability. Four indices were computed to evaluate the reliability ofmeasures
from each of the two scales and the relevant subscales. First, the computation of the
a coefficient was based on the raw scores. Second, the raw score point-biserial
correlations were computed on the raw scores. Third, Rasch scaled scores were used to
compute the reliability of separation for persons and for items. Lastly, the average Rasch

equivalent of the point-bisen'al correlation was examined.

72

Measurability scale reliabilitv. The measurability scale exhibits strong
unidimensional trends, however, the subscales exhibit sufficient distinct cohesiveness to
create substantively interesting distinctions.

Coefficient or for the measurability raw scores equals .96. Coefficient or for the
cognitive, behavioral, and affective raw score subscales for measurability equals .96, .90,
and .93, respectively. The average raw score point-biserial correlations for the
measurability scale and for the cognitive, behavioral, and affective subscales equal .56,
.63, .55, and .85, respectively. The reliability of separation for the measurability scale
equals .96, and the average scaled score point-biserial correlation equals .55. All of these
indices support the conclusions that were based upon the dimensionality evaluations.

Importance scale reliability. The importance scale also exhibits fairly strong
unidimensional trends with distinct subscales. Coefficient or for the importance raw
scores equals .96. The coefficient a for the cognitive, behavioral, and affective raw score
subscales for importance equals .94, .85, and .78, respectively. The average raw score
point-biserial correlations for the importance scale and for the cognitive, behavioral, and
affective subscales equal .48, .53, .46, and .63, respectively.

The reliability of separation for the importance scale equals .95, and the average
scaled score point-biserial correlation equals .49. All of these indices support the
conclusions that were based upon the dimensionality evaluations, that the importance
scale exhibits fairly strong unidimensional trends, but that the subscales exhibit sufficient
distinct cohesiveness to be substantively interesting distinctions.

Fit analyses. The fit of items to the underlying scale was evaluated by examining

the Rasch mean-square infit and outfit indices. The purpose of this was to determine

73

whether item responses exhibited reasonable consistency with the Rasch-based
expectations. The criterion used was established through the work of Wright and Linacre
(1994). That is, fit indices were considered moderately large if greater than 1.4 and very
large if greater then 2.0. Likewise, applying the same criteria to person infit and outfit
indices assessed the fit of persons to the underlying scale.

Measurability scale fit analyses. Descriptive statistics for the Rasch-based infit
and outfit statistics for the items in the measurability scale are shown in Table 6. These
statistics indicate that each item appears to function well as a measure of the common
construct. In addition, the evidence supports that response vectors for individual items are
in line with the expected values from the Rasch rating scale model as seen by the average
mean square fit values around 1 and maximum values for infit and outfit indices less than

2.2.

Table 6

Measurability Item Fit Summary

 

 

 

Statistic Index
Mean Square Infit Mean Square Outfit

Mean 1.00 1.01
SD 0.32 0.34
Minimum 0.65 0.64
Maximum 2.14 2.19
N > 1.4 6 6

% > 1.4 1 1% 1 1%

 

Note. There are a total of 57 items.

74

Only 1 1% of the total infit and outfit items exhibited fit values greater than 1.4.
Although these values are not ideal, they provide evidence that there was not substantial
item misfit on the measurability scale.

Descriptive statistics for the Rasch-based person infit and outfit statistics are
presented in Table 7. These statistics indicate that there is some evidence that response
vectors for individual people may be out of line with the expected values from the Rasch
rating scale model as evidenced by the maximum values in the range of 4.5. However, the
average mean square fit values around 1 indicate that this is not a pervasive trend. The
percentage of persons who exhibited misfit values greater than 1.4 confirm that there is
some concern about misfit at the person-level. There are approximately 19% of the

people exhibiting large infit statistics and 16% exhibiting large outfit statistics.

Table 7

Measurability Person Fit Summary

 

 

 

Statistic Index
Mean Square Infit Mean Square Outfit
Mean 1.03 1.01
SD 0.50 0.48
Minimum 0. 14 0. 1 5
Maximum 4.42 4.78
N > 1.4 175 151
% > 1.4 19% 16%

 

Note. There are a total of 930 participants, 15 are non-measurable due to extreme data.

75

Importance scale fit analvses. Descriptive statistics for the Rasch-based infit and
outfit statistics for the items in the Importance scale are shown in Table 8. These statistics
indicate that response vectors for individual items are in line with the expected values
from the Rasch rating scale model as evidenced by the average mean square fit values
around 1 and maximum values for infit and outfit indices less than 1.50. Only 4% of both
the infit and outfit items exhibited fit values greater than 1.4. These values confirm that

there was little item misfit on the importance scale.

Table 8

Importance Item Fit Summary

 

 

 

Statistic Index
Mean Square Infit Mean Square Outfit

Mean 1.02 1.01
SD 0.21 0.22
Minimum 0.59 0.60
Maximum 1.50 1.51
N > 1.4 2 2

% > 1.4 4% 5%

 

Note: There are a total of 57 items.

Descriptive statistics for the Rasch-based person Importance scale infit and outfit
statistics are shown in Table 9. These statistics suggest that there is some evidence that
response vectors for individual people may be out of line with the expected values from

the Rasch rating scale model as evidenced by the maximum values in the range of 4. 1 5 to

76

7.02. Overall, about 12% of the person response vectors exhibited noteworthy misfit on

both the infit and outfit indices.

Table 9

Importance Person Fit Summary

 

 

 

Statistic Index
Mean Square Infit Mean Square Outfit
Mean 1.00 1.01
SD 0.37 0.44
Minimum 0.33 0.34
Maximum 4. 15 7.02
N > 1.4 1 10 109
% > 1.4 12% 12%

 

Note: There are a total of 930 participants, 16 are non-measurable due to extreme data.

Data Analyses

To perform the analyses two types of scores were used, raw scores and Rasch
scaled scores. The raw scores were the responses observed for each participant on each
item. Summing responses for each item of these scales produced measurability and
importance composite raw scores. Scaled Rasch scores were formed by fitting the Rasch
rating scale model to the raw scores using FACETS (Linacre, 1994).

The Rasch rating scale model is an additive linear model that describes the
probability that a participant will give a particular response to a Likert type questionnaire

item (Wolfe, Chiu, & Reckase, 1999). Therefore, in this study, it will determine the

77

probability that a specific athletic trainer or physician will rate a particular competency.
using a specific rating scale category. In addition, the probability that a specific
competency item will receive a particular rating is ascertained. This model is useful for
this study because it is able to compensate for missing data, evaluate the stability of
individual participant responses and instrument items, and create interval measures that
can be subjected to further statistical analysis such as analysis of variance (ANOVA).

For purposes of data analyses, the 57 competencies were categorized as cognitive
(37 items—1 through 37 in the instrument), psychomotor (17 items—38 through 54 in the
instrument), or affective competencies (3 items—55 through 57 in the instrument). The
data were analyzed for each research question as follows.

Research Questions 1 and 3. The first and third research question were concerned
about the stakeholder’s perceptions of measurability and importance of the competency
statements. For these questions the frequencies of rating scores for each competency
statement were tabulated. Scaled Rasch scores were used to calculate the means and
standard deviations for each competency. These numbers were then analyzed to
determine the measurability and importance of each competency. The competencies that
have the highest ratings and are most often perceived “easily measurable” and
“extremely essential” are discussed. Also those competencies that were on the low end of
ratings and are perceived to be more “unmeasurable” and “nonessential” are discussed.

Research Questions 2 and 4. The remaining two research questions were

 

concerned with the differences in stakeholder group perceptions of the measurability and
importance of the competencies. The responses of the various groups of participants

were evaluated to determine whether there were any correlations between particular

78

persons and their responses. Specifically, the mean ratings of the stakeholder groups,
namely college/university athletic trainers, professional athletic trainers, and team
physicians, were compared to establish any differences in their perceptions of
measurability and importance for each of the general medical conditions and disabilities
educational competency statements. Second, a comparison was made of the mean ratings
assigned by individuals who were curriculum directors, were teachers, and those who had
no teaching responsibilities. Third, a comparison of the mean scaled scores of females
and males was completed. Fourth, a correlation of the certification year with ratings was
executed.

The data were analyzed by an analysis of variance (ANOVA) to determine any
differences among stakeholder groups or demographic characteristics for perceived

measurability (p < .05). There were no post-hoe analyses conducted.

79

CHAPTER 4
RESULTS

Results are presented separately for each research question. In general, the results
showed that there are concerns about the measurability of certain competencies and that
many of the competencies are not considered to be essential for the entry-level certified
athletic trainer (ATC).

Research Question 1

The first research question was concerned with the extent to which stakeholders
perceive that the educational competency statements in the general medical conditions
and disabilities content area are measurable. Descriptive results showing the frequencies,
means, and standard deviations for measurability for each competency are presented in
Table 10. Descriptive results showing the mean logits for measurability associated with
each competency are presented in Table 11. The reader can think of logits as
standardized means, with positive numbers representing better measurability, and
negative numbers representing less measurability. Further statistics for each competency
are presented in Appendix F.

The ratings for the measurability scale range from the easiest to measure
competency (#52) about assessing vital signs (M = 3.80, SD = .44, M103“: 2.34) to the
hardest to measure competency (#55) supporting the moral and ethical behavior of
athletic trainers in dealing with diseases for the persons who are physically active (M =
2.50, S_D = 1.04, Mm“ = -1.32). Overall, the majority of the competencies were in the

“somewhat measurable” to “measurable” range.

80

 

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Table 11

Mean Logits for Measurability and ImporLance Ratings

 

 

Competency Measurability Importance

Number (Mlogit) (Mlogit)
1 - .18 -.94
2 - .18 - .04
3 .49 .66
4 .22 .28
5 —.34 - .64
6 -.48 - .85
7 .21 - .41
8 .27 - 1.82
9 .32 .08
10 - .29 - .98
11 .07 .58
12 .57 .23
13 .41 .01
14 .28 .05
15 - .14 - .82
16 - .20 - .27
17 - .41 - 1.38
18 .13 - .30
19 - .28 - 1.24
20 - .19 - 1.42

95

Table 11, continued

 

 

Competency Measurability Importance
Number (Mlogit) (Mlogit)
21 - .35 - 1.69
22 - .36 - 1.69
23 - .66 - 2.18
24 - .06 - .23
25 - .57 - 1.83
26 .12 - .87
27 - .01 .47
28 .23 1.38
29 - .31 .04
30 .01 .23
31 - .10 1.28
32 - .04 - .14
33 .45 2.87
34 - .27 - .30
35 .22 - .27
36 - .29 - 1.04
37 .22 .37
38 - .66 - .13
39 - .14 1.38
40 - .04 1.63
41 - .78 - .87

96

Table 11, continued

 

 

Competency Measurability Importance

Number (.Mlogit) (Miogn)
42 .07 1.36
43 - .21 1.32
44 .23 1.65
45 - .38 .45
46 - .06 - 1.71
47 .36 - 1.79
48 1.57 1.90
49 .70 91
50 .05 - .82
51 2.16 1.47
52 2.34 2.79
53 - .53 .34
54 .33 - 1.07
55 - 1.32 1.21
56 - 1.14 .97
57 - 1.05 1.83

 

97

In examining the frequency of measurability ratings, it is interesting to note that
only one competency, assesses body temperature (# 51) was rated by all participants as

99 ‘6

“somewhat measurable, measurable,” or “easily measurable,” no respondents rated this
competency as “unmeasurable.” Competency #52 only has one respondent perceiving the
competency as unmeasurable. Otherwise, surprisingly, respondents used all of the
categories, from “unmeasurable” to “easily measurable,” to characterize the remaining
competencies.

Table 12 indicates the distribution of competencies by relative measurability.
This table shows that most of the competencies are in the “somewhat measurable” to
“measurable” categories.

The relative ratings within the measurability scale by domain are displayed in
Figure 2. This figure shows the four item types by position on the Y-axis and the location
the parameter estimate in logits for each item on the x-axis. The difference between the
means of the three subscales is statistically significant with a large effect size, E(2,56) =
8.95, p = .0004, B: = .25. From this figure, it is clear that, overall, the affective items
were believed to be the least measurable of the items (M1031, = -1.17). For example, the
three competencies that participants rated as least measurable focused on maintaining
ethical behavior in issues dealing with diseases of athletes (# 55, M: 2.51, S_D = 1.04,
M108“ = -1.32 ), maintaining ethical behavior when taking situational control in the
containment of contagious diseases (# 56, M = 2.60, _S_D__== 0.99, Mm" = -1.14), and
accepting the roles of medical personnel in the treatment of the medical conditions of

athletes (# 57, M = 2.64, §__D_ = 1.04, M103“ = -1.05).

98

 

 

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The next two competencies that were difficult to measure were from the
psychomotor treatment area. Competency #41 concerning the recognition and
management of gastrointestinal disorders had a mean rating of 2.76, (S_D = 0.76, M109, = «-
.78), while Competency #38 which included the assessment of patients for abnormalities,
disabilities, or diseases had a mean rating of 2.82 (S_D: 0.79, M109, = -.66 ).

The cognitive and psychomotor treatment items were of about the same level of
measurability, at the threshold between being rated “measurable” and “somewhat
measurable” with means of -0.04 and -0.23 logits, respectively. Overall, the psychomotor
assessment competencies (IL/Log“ = 0.76) were considered to be more easily measured than
competencies in the cognitive (ll/Log“ = -0.04 ) and psychomotor treatment (M1091: 0.23)
areas. Four of the competencies that were rated easiest to measure were within the
psychomotor assessment area. These competencies focused on assessing vital signs
(# 52), assessing body temperature (# 51), using a penlight to examine pupil
responsiveness (# 48), and palpating abdominal quadrants for rigidity and tenderness
(# 49). These competencies had mean ratings that ranged from 3.80 to 3.39. An
interesting outcome was the larger range of item difficulties for the psychomotor
assessment items. These competencies vary considerably in the degree to which
participants believed them to be amenable to observation. The psychomotor assessment
competencies ranged from the easiest to measure, #52, assessing vital signs (M = 3.80,
52 = .44, M103“: 2.34) to the hardest to measure, #53, referring an individual with

genitourinary or reproductive disorders (M = 2.88, §I_) = 0.89, M10“: -.53).

100

 

 

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(Somewhat Measurable) (Measurable) (Easily Measurable)

Item Parameter Estimate (Logit)

Figure 2. Item Difficulty Plot for Measurability Scale

The final competency rated in the top five for measurability was a cognitive
domain competency, #12, the recognition and relationship between changes in blood
pressure and activity levels. The cognitive domain competencies all clustered in the
“somewhat measurable” to “measurable” range. The cognitive competencies ranged from
the easiest to measure, #12, recognizing the relationship between blood pressure changes
and exercise (M = 3.34, $2 = 0.78, M108“ = .57) to the hardest to measure, #23, describing
conditions of the breast (M = 2.83, §_D_= 0.88, M103“ = -.66). The cognitive competencies

are usually amenable to paper and pencil tests for evaluation of competence.

101

Research Question 2

The second research question analyzed the extent to which the stakeholder groups
differed on the perceived measurability of each of the general medical conditions and
disabilities educational competency statements. Ratings were analyzed for differences
across stakeholder groups (ATC college/university, ATC professional, MD/DO), gender,
years of certification or licensure, and teaching responsibility.

The analyses of the data determined that there are only small differences in the
means of these groups. ANOVAs were not statistically significant for stakeholder groups
E(2,914) = 1.15, p = .32; teaching responsibility E(2,906) = 0.01, p = .99; or gender
_P_‘(2,905) = 0.00, p_= 0.98. In addition, the correlations between years since certification
and scaled measurability scores were weak for athletic trainers (r_= -.O6, p_= .12),
physicians (_r_' = -.18, p_= .05), and for both groups combined (1 = -.09, p = .01). Although
the p value for some of the correlations are statistically significant, the effect size is
miniscule and therefore not meaningfirl. Therefore it can be concluded that years since
certification or licensure is not related to perceived measurability of competency items.
All of these statistics suggest that the ratings are fairly consistent across the subgroups of
athletic trainers. Consequently, there is no perceived need for firrther consideration of
demographic variables when examining the measurability of the NATA educational
competencies.

Research Question 3

The third research question was concerned with the extent to which stakeholders

perceive that the educational competency statements in the general medical conditions

and disabilities content area are important. Descriptive results showing the frequencies,

102

means, and standard deviations for the importance of each competency are presented in
Table 10. Mean logits for the importance assigned to each competency are presented in
Table 11. Additional statistics for each competency are presented in Appendix F.

The results revealed that the mean values for importance ranged from 3.89 (SD:
0.33, M108“ = 2.87 ) for competency # 33, about recognizing postconcussional syndrome,
to 2.12 (812 = 0.79, M103“ = -2.18) for competency #23, about describing common
conditions of the breast. Thus, the mean importance ratings of the competencies range
from “very essential” to “nonessential.” Table 13 indicates the distribution of
competencies by importance. This table shows that the competencies are spread across
all rating categories.

The relative ratings within the importance scale by domain are displayed in Figure
3. This figure demonstrates the four item domain types by position on the Y-axis and the
location of each item’s parameter estimate in logits on the x-axis. The difference between
the means of the three subscales is statistically significant with a moderately large effect
size, E(2,56) = 5.75, p = .005, 1:: .18. From this figure, it is apparent that overall, the
affective items were perceived to be among the most important competencies (Mm-t =
1.34). The psychomotor treatment items were rated slightly lower, on average, with a
mean of 0.85 logits. The competencies perceived to be the least important were the items
in the cognitive and psychomotor assessment domains with means of - 0.35 and 0.22
logits, respectively. A notable element is the wide dispersion of items within each of
these categories, much wider than for the measurability scale. For example the
psychomotor assessment competencies ranged from the “somewhat essential”

competency #41, about recognizing and managing gastrointestinal disorders (M = 2.74,

103

$2 = 0.79, M103" = -.87) to the “essential” competency # 42, about recognizing and
treating diabetic issues M = 3.63, SD = 0.64, Mlog" = 1.36). The psychomotor treatment
competencies ranged from the “essential” competency #53, refers individuals with
genitourinary complaints M = 3.29, S_D = 0.81, Mlogn = .34) to the “very essential”
competency #52, assesses vital signs M = 3.88, SD = 0.34, Mlogit = 2.79). The cognitive
competencies had the largest distribution ranging from the lowest rated, “nonessential”
competency #23, describes conditions of the breast M = 2.12, S_D = 0.79, Mlogn = -2.18)
to the highest rated, “very essential” competency #33, about recognizing

postconcussional syndrome M = 3.89, S_D = 0.33, M102," = 2.87).

Atfective

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(Unessential) (Somewhat Essential) (Essential) (Very Essential)

Item Parameter Estimate (Logit)

Figge 3. Item Difficulty Plot for Importance Scale

104

 

 

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The five competencies rated as most important represent all four of the item type

categories. These competencies had mean ratings that ranged from 3.89 (M109. = 2.87) to

3.70 (M108, = 1.63)

Item #3, recognizes postconcussional syndrome (cognitive)

Item #52, assesses vital signs (psychomotor assessment)

Item #48, uses a penlight to examine pupil responsiveness (psychomotor
assessment)

Item #57, accepts roles of medical and allied health personnel in treatment of
athletes suffering form general medical conditions (affective)

Item #40, recognizes and refers individuals with symptoms of

cardiopulmonary conditions to medical authorities (psychomotor treatment)

The five competencies rated least important fell into the cognitive and

psychomotor assessment categories. These competencies had mean ratings that ranged

from 2.33 (Mlogit = -l .71) to 2.11 (Mlogit = ~2.18).

Item #23, describes common conditions of the breast (cognitive)

Item #25, identifies physiological effects of pregnancy (cognitive)

Item #8, describes the use of peak-flow meters in the management of
respiratory conditions (cognitive)

Item #47, uses and interprets urine diagnostic chemsticks (psychomotor
assessment)

Item #46, uses an otoscope correctly to examine the ear and nasal passages

(psychomotor assessement)

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In examining the frequency of importance ratings, only competency #33,
recognizes postconcussional syndrome, was rated by all respondents as “somewhat
essential,” “essential,” and “very essential.” No respondents rated it as “nonessential.” A
few other competencies, #28, identifies contagious skin infections, #39, manages acute
asthma attacks, #40, recognizes individuals with cardiopulmonary conditions, #43, acts
quickly to contain skin infections, #48, uses a penlight to examine pupils, #51, assesses
body temperature, #52, assesses vital signs, and #57, accepts the role as an allied health
personnel, had three or fewer respondents rating them as “nonessential.” Therefore, each
of the remaining competencies had a minimum of four respondents for each rating
category, from “nonessential” to “very essential.”

Research Question 4

The extent that stakeholder groups differ on the perceived importance of the
competency statements in the general medical conditions and disabilities area was
examined in Research Question 4. Ratings were analyzed for differences across
stakeholder groups (ATC college/university, ATC professional, MD/DQ), gender, years
of certification or licensure, and teaching responsibility.

The analyses of the data determined that there are only small differences in the
means of these groups. ANOVAs were not statistically significant for any of these
variables: stakeholder group E(2,928) = 0.45, p_ = .64; teaching responsibilities £0,920) =
1.54, p = .22; and gender E(2,917) = 0.64, p = 0.42. Furthermore, the correlations
between years since certification and ratings were weak and statistically non significant
for athletic trainers (r = -.03, p = .44), physicians (r = -.13, p = .14), and for both groups

combined (r = -.04, p = .27). All of these statistics suggest that the ratings are fairly

107

consistent across the subgroups of athletic trainers. Consequently, there is no perceived
need for further consideration of demographic variables when examining the importance
of athletic training competencies.

Conclusions

There is considerable variability in the perceptions of measurability of the general
medical conditions and disabilities competencies by athletic trainers and team physicians.
The overall results showed most of the competencies to be in the “somewhat measurable”
to “measurable” range. However, there are some competencies that are suspect with
respect to measurability, especially those in the affective domain.

The results also yielded a wide range of perceptions concerning the importance of
these competencies. The overall range of perceptions for importance was larger than that
found for measurability. Most of the competencies were perceived to be in the
“somewhat essential” to “essential” range. However, these results demonstrated that
some of the competencies that are considered “nonessential” or only “somewhat
essential” in the general medical conditions and disabilities content area of the NATA

Athletic Training Educational Competencies.

108

CHAPTER 5

DISCUSSION, RECOMMENDATIONS, CONCLUSION

This study focused on one of twelve parts of the National Athletic Trainers’
Association (NATA) Educational Competencies (1999). Specifically, the dimension of
general medical conditions and disabilities was the section evaluated. The educational
competencies are presented in three domains, cognitive, psychomotor, and affective. For
this study, the psychomotor competencies were subdivided into treatment and assessment
areas. Athletic trainers and team physicians rated each of the competencies for their
measurability and importance.

The results of this study demonstrate that the NATA educational competencies
should be further refined to focus only on the essential knowledge and skills deemed
necessary for the entry-level certified athletic trainer (ATC). This study provides
evidence that the importance of some of the competencies need to be further evaluated.
In addition, some competencies need to be evaluated and refined to increase their clarity,
which in turn would improve their measurability. Improving the clarity and
measurability of the statements is important to defining entry-level ATC knowledge and
skills. These strategies will help athletic training educators develop appropriate curricula
and educational experiences for athletic training students. The results of these proposed
changes should also improve the competence level of entry-level athletic trainers since
educators can focus intensely and directly on the knowledge and skills deemed essential.

mm
In this study the NATA competency statements were evaluated for their perceived

measurability. The term measurability describes how clearly the competency statement

109

indicates what the entry-level ATC should know or be able to do. In turn, it is the
knowledge and skills that educators should teach and evaluate in an athletic training
program. More specifically, measurability refers to the specific outcomes that can be
observed in order to determine competence.

NATA competencies were designed for use as criterion-referenced measurements,
which compare student performance with a pre-set standard to determine competence,
rather than comparing students to one another (Schuldenfrei, 1993; Shanklin & Beach,
1980). These measurements are a key component to competency-based education, which
requires clearly written competency statements to define outcomes that are measurable.

In addition to measurability, the importance of the competencies was also
addressed in this study. Importance is the degree to which a competency statement
represents a critical knowledge or skill, or one that is frequently used by entry-level
ATCS. The term critical refers to the extent to which the health and well being of the
athlete or physically active person depends upon an ATC’s knowledge, skill, or attitude
for addressing client health. As well, an ATC skill is critical if an athlete might suffer
serious consequences if the ATC does not posses that knowledge or skill, specified in the
competency. In addition, the ATC knowledge, skills, or attitudes are important if they are
used by an entry-level ATC on a regular basis.

The measurability and importance of the competencies were studied because
athletic training professionals have not effectively considered the measurability of the
competencies nor have standards been published for the evaluation of competence. The
issue of measurability is vital to the athletic training profession because the goal of

athletic training education programs is to produce competent entry-level athletic trainers.

110

Thus, it is important to be able to determine when a student has achieved competence in
each specific knowledge or skill. There are questions that need to be answered to ensure
consistency in the interpretation of the competencies. For example, does each person
understand which knowledge or skills were intended by the competency? If different
ATCS were to evaluate a student, would they agree on the student’s competence level?
An inconsistency in the interpretation of the NATA educational competencies makes it
difficult to establish valid and reliable evaluation tools and creates variance across
programs. Each athletic training educator individually interprets each competency,
develops evaluation tools, and determines the standards on which to evaluate students.
Autonomy for every program is desired, but this can effectively occur in the instructional
strategies used to educate students, it cannot occur in the outcome standards.

In addition to the measurability of the competencies, the perceived importance of
these competencies has not been investigated. The athletic training profession is defined
by these competencies, so it is imperative that the profession is founded on competencies
that are deemed important.

Measurability

 

There is a wide range of perceptions among ATC professionals and team
physicians on the effectiveness of the competency statements as useful tools for
measuring athletic training student competence. This variability in measurability ratings
is apparent in the frequency values in Table 10. Variability is noted because there is only
one competency (out of the 57) that did not have at least one entry in each of the four
rating categories. However, despite such overall variability, the majority of competencies

are considered to be “measurable” or “somewhat measurable.”

111

Easiest to measure competencies. Two psychomotor assessment competencies are
considered as the easiest to measure. Competencies #51, regarding assessment of body
temperature (M = 3.77, S_D = 0.47, Mlogn = 2.16) and #52, regarding assessment of vital
signs (M = 3.80, S_D = 0.44, Mlogi. = 2.34) are thought to be easy to measure. They are
easy to measure because they are succinct, clearly stated, and involve common readily
observable skills. These skills can be taught and evaluated easily in the classroom setting.
The only apparent ambiguity is which specific method is required or how many
techniques are necessary for an ATC to be deemed competent in assessing body
temperature or vital signs. Nonetheless for these measurements, the most common
methods are easily understood and easy to evaluate.

The competency next easiest to measure is #48, which involves using a penlight
to examine the pupils of the eyes (M = 3.65, S_D = 0.58, M108" = 1.57). Again, that
competency is stated succinctly, is clearly written, and specifies the exact skills required.
Therefore, competencies which are perceived to be easily measured are broken down into
discrete statements and, as a result, are easy to assess or observe. That outcome was
anticipated because it is consistent with the findings of previous research which points to
increased understanding and ease of evaluation by breaking competencies into more
specific, discrete statements (Klingstedt, 1972; Lutrell et al., 1999).

In general, the psychomotor assessment competencies were rated as more
measurable than the psychomotor treatment competencies. The assessment competencies
are thought to be easier to measure because they represent more specific behaviors and
are easier to observe. For example, as noted earlier, using a penlight (#48), assessing

body temperature (#51), and assessing vital signs (#52) are some of the treatment

112

competencies. The psychomotor assessment competency with the lowest measurability
involves referral to a physician. Competency #53 requires the ATC to refer an individual
who has genitourinary or reproductive issues to a physician (M = 2.88, S_D = .89, Mlogi. =
.34). This competency is different from the other assessment competencies because it is
not a specific or observable skill that can be easily measured in the classroom. This
competency is therefore comparable, and its rating similar, to the psychomotor treatment
competencies, which are rated lower than the psychomotor assessment competencies. In
addition, many of the psychomotor treatment competencies are conceptually broader and
involve more than one action, including “recognizes and manages,” or “manages and
takes appropriate steps.” Therefore, they are more complex than the psychomotor
assessment competencies.

In addition, the conditions or situational content of the psychomotor treatment
competencies need to be simulated, whereas, the techniques in the psychomotor
assessment area can be performed and evaluated on anyone. For example, the
psychomotor assessment competency of assessing a temperature can be performed on any
individual; however, the psychomotor treatment competency of demonstrating how to
manage and take appropriate steps of a diabetic coma is more complex and must involve
a simulation of a diabetic emergency in the classroom.

Overall, psychomotor assessment competencies may be perceived as easier to
measure than other competency statements; however, there was a variation in the ratings
for these competencies when compared to the others. This larger range may be due to the
variety of the competency statements in this area. For instance, as discussed earlier,

some of these competencies are very succinct and involve only one skill such as “assesses

113

temperature” while others involve more skills such as “correctly auscultates the heart,
lung and bowels.” In addition, competency #53, as pointed out earlier, is the lowest rated
in the psychomotor assessment area and is very similar to the competencies in the
psychomotor treatment area.

Difficult to measure competencies. Some competencies are difficult to measure

 

because the competency is not easily observed. This is especially true when evaluating a
person’s attitudes and moral beliefs. The affective domain competencies are very difficult
to measure because a person’s moral development or true intentions are not easily
observed and measured (Harbeck, 1972). This perception held true in this study with all
three affective domain competencies rated low or only “somewhat measurable.” These
three difficult to measure competencies include #55, maintaining ethical behavior in
issues dealing with diseases of athletes (M: 2.50, S_D = 1.04, Mlog" = -1.32), #56,
maintaining ethical behavior when taking situational control in the containment of
contagious diseases (M: 2.59, S_D = .99, Mlog" = -l .14), and #57, accepting the roles of
medical personnel in the treatment of medical conditions of athletes (M = 2.64, S_D

=1 .04, Mmgi. = -l .05).

Although the affective domain competencies are all in the “somewhat
measurable” category, the participants have rated these competencies as some of the most
important in the general medical conditions and disabilities content area. Since these
competencies are deemed to be very important, it is essential to include them in an
athletic training curriculum and, as well, to develop an effective method for measuring

them.

114

There are other competencies that may also be difficult to measure because the
conditions are uncommon and because the situation or athlete condition in which the
competency is needed may not present itself. Competencies in the psychomotor
treatment domain that require skills to be demonstrated in the management of various
conditions or disabilities may never truly be tested due to the inability to create that
condition. For example, many student athletic trainers may never encounter a person with
a diabetic reaction or one who is experiencing a seizure. Because a patient with the actual
conditions or disabilities may not be available, and because clearly it is unethical to
create an injury, illness, or disability for the purposes of assessing the skills of an athletic
training student, a measurement difficulty is created. This concern was voiced when one
respondent commented that the only way the psychomotor treatment competencies can be
measured is “if they a see an athlete with the condition” listed. In addition, these
competencies are to be taught and evaluated in the classroom setting where these
conditions will not be observed. This creates a measurement difficulty in the classroom
setting that must be addressed.

To overcome this limitation, sometimes a simulation can be created representing
the real life setting. Simulations can be created in a variety of ways, including role-
playing, videotapes, or through computerized simulations. With a simulation the student
can demonstrate his or her competence and an evaluation by an instructor can occur. The
evaluation of competence needs to be related, as closely as possible, to real life situations
so that students can demonstrate the independent performance of the athletic training
competencies (Beare, 1985; Chambers, 1995; Chambers et al., 1996; Lutrell et al., 1999;

Mitchell, 1990; Spady, 1977; Spady & Mitchell, 1977). Although, simulations may be

115

difficult to create for some competencies they are useful and need to be developed for
evaluating student competence.

Another reason for decreased measurability is if the expected outcome of the
competency is not clear. Clarity and thus measurability may be an issue if the
competency is too broad or the language unclear. Vague language creates a problem
because the desired outcome is difficult to determine. If a competency is explicitly stated,
its measurability increases.

Some of the athletic training competencies, as discussed previously, were
perceived to be only “somewhat measurable.” Although this may be due to the difficulty
in observing behavior, there is also some confusion in the interpretation of the
competencies. In examining competency #3 8, which requires the athletic trainer to
“assess the patient for congenital or acquired abnormalities, physical disabilities, and
diseases that would predispose him or her to other injury or illness, or would exacerbate
the existing condition(s),” the wording is broad with no distinctions as to which
abnormalities, disabilities, and diseases need to be included. This imprecision may create
variability in what is perceived as essential to teach and learn. The confusion in
interpreting competencies is illustrated when one respondent commented that the ability
to rate one competency depended on how it is interpreted. The respondent illustrated the
point by writing two different interpretations of one competency, rating each one at
opposite ends of the Likert scale. The respondent noted that for competency #57, accepts
the roles of medical and allied health personnel in the referral of those physically active
people suffering from medical conditions, that if the interpretation were “accepts the

roles of other medical personnel,” he would rate it as a “l-nonessential.” However, if the

116

interpretation were “accepts referral to other medical personnel,” then the rating would be
a “4-very essential.” Thus, the interpretation and perception of the intent of the
competency may be variable across the athletic training profession.

This difficulty in measuring competencies is not unexpected since the
measurement of competence has been a weak area within competency-based education
(CBE) in other fields (Harbeck, 1972; Lane & Ross, 1994b; Lane & Ross, 1998; Reilly et
al., 1977; Scott, 1982). The difficulty in evaluating competence has been referred to as
the “Achilles heel” of CBE (Reilly et al., 1977). Some health care professions, including
preventive medicine, dental hygiene, and dietetics, have recognized this lack of reliability
and validity and, in turn, have taken steps to improve the understanding and evaluation of
their professional competency statements (Lane et al., 1995; Lane & Ross, 1998; Scott,
1982)

The preventive medicine profession has acknowledged this lack of reliability and
validity and made advances in alleviating the problem (Lane & Ross, 1998; Lane et al.,
1995). Performance indicators have been identified for each competency necessary for
preventive medicine physicians. These indicators define the interpretation of the
competency such that educators and students will not interpret a competency in varied or
differing of ways. These performance indicators provide a template for developing
measures to assess competency achievement.

McGaghie (1991) discusses the competence level in terms of whether or not a
person is “fit to practice.” In theory, when student athletic trainers pass all the
competencies during their educational experience they should also be capable of passing

the NATABOC exam and be capable of practicing as entry-level certified athletic

117

trainers. Conversely, if an ATC does not posses the basic knowledge and skills, the
patient may suffer. Accreditation, along with certification, offers an assurance of
minimal competency (Gelmon, 1996; Young et al., 1983). ATC certification protects the
athlete or client and maintains the integrity of the profession.

In addition, liability may be an issue if the athletic trainer cannot perform tasks
correctly or does not perform a skill they are expected to administer as the established
standard of care for athletic trainers (Amheim & Prentice, 1997). Therefore, if the ATC
cannot perform a competency, the ATC may be legally responsible for any harm caused
to the person. Thus, it is extremely important that every athletic trainer is educated in
what is considered the knowledge and skills of a professional in the field of athletic
training so that he or she can provide the expected standard of care.

Variability across programs cannot be tolerated because uniformity of
understanding of each competency statement is necessary for every athletic training
educator and student to know the expectations for entering the profession. This reliability
within and across athletic training programs has to date not been effectively addressed
within the profession. The mandated accreditation/curriculum route has created the need
for increased course work and demonstration of teaching the NATA Educational
Competencies (NATA, 1999). Current educators from internship routes now need to
increase or revise class content and courses within their programs in order to meet the
accreditation requirements. This creates a concern because these educators may not have
the experience or knowledge of pedagogical and evaluation techniques to understand how
to measure certain competencies. If there is a lack of understanding, the profession needs

to ensure that there are opportunities to educate athletic trainers in measuring

118

competencies. Athletic training professionals have made many positive strides in this
area through more offerings of lectures, seminars, workshops, and conferences for
athletic training educators. However, there are many ATCS who cannot or do not take
advantage of these opportunities, so other avenues need to be explored to minimize
variance across programs.

Lastly, because the athletic training profession is eliminating the internship route
to certification and is focusing on more structured classroom instruction, it is important
that the essential and “somewhat measurable” competencies are evaluated. Improvement
in clarity of the competency statements will help increase the measurability of the
competencies which, in turn, will help standardize program outcomes. This will allow
the development of standards and subsequent criterion reference evaluations to ensure
competence and professional integrity.

Importance

Analysis of the competencies in this study also revealed variability in the
perceived importance of the competencies. The decision of what to include in a
curriculum is of the utmost importance. Importance was defined for this study as a
knowledge or skill that is critical to the health and well being of the patient as well as
competencies that are used on a regular basis.

The NATA educational competencies were developed from role delineation
studies that were performed to determine the knowledge and skills required of athletic
trainers (Grace, 1999; Grace & Ledderman, 1982; NATA, I996; NATA, 1999). The
competencies are used in athletic training programs to provide the template for student

athletic trainer education. These competencies are also recorded so proof of student

119

attainment can be documented for the accreditation process. In addition, the
competencies are the foundation of the National Athletic Trainers’ Association Board of
Certification (NATABOC) exam for students seeking athletic training certification.
Therefore, the competencies must be truly essential for the entry-level athletic trainer.
However, as the results of this study indicate, there is obviously not unanimous support
by athletic training professionals as to the importance of the competencies in the general
medical conditions and disabilities content area.

Characteristics of more important competency statements. Only one competency,
#33, recognizing postconcussional syndrome, received zero ratings of “non-essential”
across the 927 participants who rated this item. Since this competency deals with
cognitive problems for the patient, it is obviously a critical issue and rated as “very
essential.” The variability in perceptions of importance is demonstrated by the ratings.
Every other competency was rated as “non-essential” by at least one person and
conversely, every competency was also rated as “very essential” by at least one person
(Table 10).

As expected, the majority of respondents agreed that assessing vital signs (#52) is
an essential competency (M= 3.88, S_D = .34, Mlog“ = 2.79). When life or death may be
involved, the importance of the competency seems evident. However, the competency in
using a peak-flow meter (#8) that helps asthmatics was rated as one of the least important
(M = 2.27, S_D = .89, M108“ = —1.82), even though an asthma attack can cause death. On
the other hand, the participants rated the psychomotor competency of managing an
asthma attack (#39) as important M: 3.63, S_D = .60, Mlogi. = 1.3 8), along with the

cognitive aspects of competency #9, describing strategies to reduce the problems with

120

asthma (M = 3.17, M)_ = .76, MW = .08). Thus, with similar competencies, there was
discrimination by ATCS and physicians among these various statements as to which
knowledge or skill is essential.

In general, the psychomotor competencies were thought to be more important
than the cognitive competencies. Therefore, the ability to actually perform a skill was
valued as more important than listing and describing conditions or disabilities. However,
cognitive knowledge is often necessary in order to perform a skill. The importance of
skills as compared to the cognitive knowledge may help explain the longevity of the
internship route to certification. The internships ofien focused more on the development
of skills by performing them in the training room setting. The athletic training room
setting may provide an environment that is more conducive to teaching and evaluating
the psychomotor competencies than the classroom.

The affective domain competencies were also perceived to be essential
competencies. As discussed earlier, they were perceived to be only “somewhat
measurable,” but perceived to be important. These are interesting ratings because it is
questionable whether they are perceived as critical or frequently utilized.

Characteristics of less important competency statements. The competencies
perceived to be the least important were some cognitive and psychomotor assessment
competencies. Examination of some of those competencies suggested that they would
not be used frequently. For example, the need to be able to describe common conditions
of the breast, competency #23, does not occur frequently. In addition, although some of
these competencies may be critical to the health of the individual, they will be addressed

through the referral to a physician, as required in other competencies. In examining some

121

of the least important competencies, the investigator noticed that the competencies
dealing with genitourinary or reproductive areas were rated low. There are five
competencies in this area that were rated among the lowest eight for importance. The
competencies include #20, the ability to list common conditions of the urinary system (M
= 2.47, _S_I_)_ = 0.76, Mlogi, = -l .42), #21, the knowledge to list the common infections of
the male reproductive organs (M = 2.35, S_D = 0.80, Mlogi, = -l .69), #22, the knowledge to
list the common infections of the female reproductive organs (M = 2.34, _S_I_) = 0.79, Mm"
= -l .69), #23, the ability to describe common conditions of the breast (M = 2.12, S_D =
0.79, Mrogit = -2. 18), and #25, the knowledge to identify the physiological effects and
changes to a women’s body caused by pregnancy and its effects on exercise (M = 2.27,
812 = 0.83, Mlogi, =-l.83). These results demonstrate that the majority of the participants
did not consider the ability to list the infections and conditions of the reproductive
organs, or have the knowledge to describe common conditions of the breast, as important
for the entry-level ATC. However, competency #53, states the need to refer a person
who presents with complaints in the genitourinary or reproductive areas, is rated twenty-
first with a M = 3.29, SQ of 0.81 and Mlogi, of .34. Recognizing the need to refer people
with genitourinary or reproductive issues was perceived as more important than requiring
the entry-level athletic trainer to have the knowledge to list the common problems in
these areas. Thus, these competencies may not be used frequently, but they may also be
perceived as beyond the scope of practice for the entry-level ATC.

When discussing the importance of the competencies in terms of frequency of
use, one respondent rated a number of the competencies as “somewhat essential” because

she felt that athletic trainers might never encounter these competencies in their lifetime.

122

Included among these “somewhat essential” skills were describing congenital or acquired
abnormalities and identifying the physiological effects of pregnancy. She did not think it
would be a critical issue if the ATC did encounter these conditions or disabilities because
they could refer the person to a physician or hospital. Therefore, some of the infrequently
required knowledge or skills will actually be addressed when performing other
competencies that require physician referral.

Comparing the current study to the only other study found on the importance of
the athletic training competencies (Zylks, 1988), it was determined that variability in
importance ratings existed in both studies. The participants in Zylks study found the
general NATA membership (n = 179) did not rate any of the 175 competencies in 7
content areas with only “S’s-very important” and “4’s-important.” The current study,
using a 4-point scale, did not find any competencies that received only ratings of “very
essential” and “essential.” Therefore, both studies had a wide range of perceptions on the
importance of each competency.

In addition to examining competencies that received only the top two ratings,
Zylks also noted competencies that 50% or more of the respondents rated as less than
“important,” a “3” or below rating. Five competencies had 50% or more of the ratings
below “important.” The content areas were two in education, one in counseling and
guidance, and two in prevention of athletic injuries and illnesses. The current study
found nine competencies, seven cognitive and two psychomotor assessments, were rated
below “essential,” (a rating of “2” or “1”) by over 50% of the respondents. Although the
competencies have changed dramatically since 1988, the fact that Zylks’ study reported

only 5 of 175 competencies as rated below “important” by over 50% of the participants,

123

whereas the current study found 9 out of 57 competencies as rated below “essential” by
over 50% of the participants demands attention. In other words, 16% of the
competencies were rated below “essential” by 50% of the respondents in the current
study as compared to only 3% of the competencies rated below “important” by 50% of
the respondents in Zylks’ study. This demonstrates that some of the current
competencies may not be necessary for the entry-level ATC.

In the current study, one of the competencies rated only “somewhat essential” or
“nonessential” by over 50% of the respondents was, #46, “uses the otoscope correctly to
examine ear and nasal passages” (M = 2.33, _S_D = 0.92, Mlogi. = -1.71). In addition, this
competency received an unfavorable comment by a respondent claiming that this
competency was unnecessary because an otoscope is an expensive tool and he felt the
patient should be referred to a physician regardless of the ATC’s assessment. This
respondent went on to further discuss affective competency #57, stating that this
important competency refers to an athletic trainer’s role in the referral process. The
respondent thought that if this competency is met, there is no need for the ATC to have
some of the skills, such as using an otoscope, listed in the general medical conditions and
disabilities content area.

With regard to this referral issue, another respondent commented about making an
assessment that could lead to a liability issue. For example the respondent thought that
listening to a patient’s heart and then not referring to a physician would create a liability
issue. Further, the respondent mentioned that if every patient was going to be referred to
the physician regardless of the athletic trainer’s assessment, then why waste the athletic

trainer’s time when he or she could be performing another duty. Again, this demonstrates

124

that some of these competencies may require knowledge and skill beyond the scope of
duty of the ATC. Recognition and referral to a physician was deemed more important
than having the skills to assess and treat the conditions listed. Therefore, it might be
better to refer a patient to a physician for a diagnosis, which would also reduce the
liability issues for the ATC. Although beyond the scope of this study, an examination of
all state laws needs to be undertaken because current state licensure or registration bills
for athletic trainers may restrict the scope of practice for the ATC and prevent them from
performing some of the competencies.

The developers of the NATA competencies believed that all the competencies
were important, and many of the competencies in the general medical conditions and
disabilities content area were thought to be important by the current study participants.
However, there is always a limited amount of time to teach, develop, and evaluate
competencies; therefore, a rank order of competencies should be developed and re-
analyzed by athletic training professionals to determine if each competency is critical or
essential to know or just “nice to know.” This is especially true for the competencies
that were rated low on both importance and measurability.

For example, two of the cognitive competencies that were rated low on both the
measurability and importance scales were “describing common conditions of the breast,”
(#23- M = 2.1 1, §I_)_ = 0.79, Mrogi. = -2.18) and “identifying the physiological effects and
changes due to pregnancy with the implications forlphysical activity,” (#25- M = 2.27,
_S_I_)= 0.83, Mlog“ = -l .83). Competency #23 has a mean of 2.82 (ML: 0. 89, Mlog“ = -.
66) while #25 has a mean of 2.86 (SD = 0.82, Mlogn = -.57) for the measurability scale.

Therefore, these competencies are between “somewhat measurable” and “measurable,”

125

and they are also regarded as only “somewhat essential.” These are the type of
competencies that need to be reassessed and possibly eliminated.

After reviewing the results of the research questions, scatterplots (Figures 4, 5, 6,
7, and 8) were created to provide a “big” picture of the competencies when plotted by
both measurability and importance. The patterns shown in the scatterplots support the
earlier comments that many of the cognitive competencies are not considered essential.
Also, the affective domain competencies are considered important, but are difficult to
measure. Furthermore, these figures show that there are a number of competencies that
are both low in importance and measurability.

For example, Figure 4 reveals that 21 (37%) of the 57 competencies were rated as
low in importance as well as low in measurability, while 17 (30%) were rated as high in
both importance and measurability. This finding demonstrates the need to examine some
of these competencies and reassess their necessity. Some of the competencies may need
to be rewritten to increase their measurability in order to obtain an accurate evaluation of
importance. Once the competency is measurable, it should be re-rated to determine
importance. In addition, if a competency is deemed essential, but only-“somewhat

measurable” it should be rewritten.

126

Figure 4

Scatterplots of Measurability and Importance

Scatterplot of Measurability and Importance--All Items

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Measurability Logit r = -37

Figure 5 shows that the cognitive competencies cluster toward the midline of
measurability. It also demonstrates that 23 (62%) of the 37 cognitive competencies are in
the lower aspect in regard to importance. Additionally, 18 of these competencies are also
in the lower quadrant for measurability; therefore, 49% of the cognitive competencies are
in the low-low quadrant. These data indicate that almost half of the cognitive

competencies should either be deleted or revised.

127

Figure 5

Scatterplot for Measurability and Importance of Cognitive Items

Scatterplot of Measurability and lmportance--Cognitive
Items

I
b.)
I
N
I
O
a"
O
O
N
b)

Importance Logit

Measurability Logit

Figure 6 displays the psychomotor assessment items, which are mostly found in
the upper quadrants for importance and close to the midline for measurability. Only two
of the 8 competencies are found in the lower quadrant for both measurability and
importance. These competencies involve the recognition and management of common
disorders of the gastrointestinal tract and the assessment of patients for congenital or
acquired abnormalities, physical disabilities, and diseases that would predispose him or
her to other injury or illness, or would exacerbate the existing condition(s). The low
importance may be due to the perception that these competencies are beyond the scope of

the entry-level ATC.

128

Figure 6

Scatterplot for Measurability and Importance of Psychomotor Assessment Items

Scatterplot of Measurability and Importance
Psychomotor Assessment Items

Importance Logi

t'»
I

N
I

O
N
b.)

-3
Measurability Lo git

The scatterplot in Figure 7 exhibits that five of the nine psychomotor treatment
competencies were found to be important, while the other four are in the lower quadrants
for importance. Four of the five competencies in the upper quadrants for importance are
also in the upper quadrant for measurability. Therefore, these four competencies are

essential and do not require revision.

129

Figure 7

Scatterplot for Measurability and Importance of Psychomotor Treatment Items

Scatterplot of Measurability and Importance
Psychomotor Treatment Items
3

Importance Logit
0;
60
O
N
La)

Measurability Logit r = '79

Figure 8 reveals that all of the affective domain competencies are perceived to be
important, but are considered only somewhat measurable. As discussed earlier,
measurement of affective skills is difficult. This is a challenge that must be addressed by

the NATA given the importance of these competencies.

130

Figure 8

Scatterplot for Measurability and Importance of Affective Items

Scatterplot of Measurability and Importance

Affective Items
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o 1
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Q)
8 -3 -2 -l 0 I 2 3
(3
r:
o -I
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E.
-2
-3

Measurability Logit r = .79

The results of this study demonstrate the need to examine the competencies in
terms of measurability and importance. This sort of analysis is critical to determine what
is truly essential within athletic training educational programs. Other professions, such as
dental hygienists, have developed a comprehensive curriculum, reconsidered what was
perceived to be very essential or critical, and determined the academic time time
required (DeWaId & McCann, 1999). The profession of athletic training needs to take a
similar step.

One way to determine the rank order and develop consensus of the essential

competencies is through a Delphi study. A Delphi study of the competencies within each

131

domain and then throughout the entire list of competencies would create discussions
among a variety of experts in the profession who could discuss the importance and
rationale of each competency. These discussions could help ferret out the competencies
that are critical or essential as compared to those considered somewhat essential or not
necessary for the entry-level athletic trainer. The other competencies may be listed as
“nice to know” for those students who are capable of demonstrating competence in the
mandatory competencies and still have time Iefi in their academic program. If a true rank
order were developed, then the number of competencies that can be accomplished in an
undergraduate program with the time available could be determined. If some of the
competencies that are not included were still considered necessary, an adjustment in the
educational time frame would need to be undertaken.

Athletic trainers are concerned about the understanding of competency statements
and the number of competencies required within the academic programs. This study
supports these concerns. The measurability and importance of the competencies needs to
be re-addressed to help standardize athletic training education, maintain profession
integrity, and protect the patients of athletic trainers.

Limitations

There are a few limitations of the study that should be considered. One limitation
of this study was that the participants were not forced to make a choice among the
competencies; they were able to rank each one as important if they perceived it to be
important. If the inclusion of competencies is based on these ratings, it may create an
unrealistic amount of material to cover, the original concern of many athletic training

educators. A second limitation was that the sample in this study was randomly selected,

132

so the respondents may include athletic trainers or physicians who do not possess the
expertise to evaluate measurability. Finally, the statistical analyses resulted in no
differences in stakeholder group ratings of measurability and importance. This result
may differ if each individual competency statement was analyzed separately in the
statistical analysis.

Recommendations

 

The following recommendations are based upon the findings of this study.

I. A study on importance and measurability for the remaining eleven content
areas of the NATA Educational Competencies (1999) should be undertaken. The use of
an instrument similar to the Competency Evaluation Survey is recommended.

2. Examine the competencies that are perceived to be important and viewed as
less than “measurable” and rewrite them into more specific statements so they will be
better understood.

3. Develop performance indicators for each of the competency statements.
Follow up with evaluation rubrics for each competency statement to help validate the
competency statement and standardize student evaluations.

4. Perform a Delphi study to determine the ranking of importance of each
competency in each content area, and then overall for all the competency statements. This
type of study will help develop consensus of the truly essential competencies. The time
to develop true competence and the time frame of the academic programs should be taken
into consideration.

5. Establish a CEU or Certificates of Added Qualifications (CAQ’s) program that

must be obtained during the first few years following certification, and which covers the

133

competencies that are “nice to know,” but not truly essential. This would help guide
ATCs in their professional education.

6. Place the genitourinary and reproductive competencies into CEU or CAQ
programs. These competencies could be required in a CEU or CAQ program within the
first few years after certification. This would be considered an advanced area of study.

7. Continue to update the role delineation studies and observe for specialized
athletic training skills necessary for specific employment sites. As the profession
continues to advance, specific employment competencies may need to be developed or
offered as CEU or CAQ programs.

Conclusions

 

The results of this study demonstrate a need to further evaluate the NATA
educational competencies (NATA, 1999). These competencies are the heart of the
accreditation of athletic training programs and the certification of athletic trainers.
Therefore, the competencies that are necessary for an entry-level certified athletic trainer
need to be refined to reflect what is truly essential. In addition, they need to be
completely and clearly understood in order for valid, reliable measurements of
competence to occur. This is of extreme importance to the athletic training profession
since the current competencies are deemed necessary by the profession and they define a
certified athletic trainer’s knowledge and skills to society; yet, there are some genuine
concerns regarding their measurability and importance. As athletic training education
programs are converting from internship routes to accredited curriculum programs, it is

critical that they are founded on measurable and essential athletic training competencies.

134

APPENDICES

135

APPENDIX A

Follow up Letter to Non—responsers

136

January 26, 2001

Dear Certified Athletic Trainer,

You received a survey from me approximately three weeks ago. The
questionnaire was about rating the General Medical Conditions and
Disabilities section of the NATA Educational Competencies.

This letter is a reminder that I have not yet received your survey. If you
have already sent it, please disregard this letter and I thank you. If you
have not returned the survey, I understand this is a busy time of year, but I
would really appreciate it if you would take a small time out of your day
today to fill it out and return it in the envelope that was enclosed. If you
have misplaced the envelope the survey can be returned to: Sally Nogle,
Michigan State University, Football Building, East Lansing, MI 48824. If
you no longer have the survey, but are still willing to fill it out, please
email (nogle@msu.edu) or call me (517-353-4412) and I will send or fax
you a new one.

I appreciate your time and effort.

Sincerely,

Sally Nogle, ATC

I37

APPENDIX B

Survey Instrument

138

Importance of NATA Educational Competencies

The National Athletic Trainers Association (NATA) recommends that entry-level athletic
trainers achieve 542 educational competencies across 12 content areas (NATA, 1999).
Athletic training educational programs must prepare student athletic trainers who are
competent in all these areas. There is a limited amount of instructional time in every
curriculum; therefore, critical decisions about curriculum content must be made. Hence,
the most important competencies must be identified. The important or essential
competencies are the ones that are critical in nature or frequently performed by an entry-
Ievel athletic trainer. In addition, the competencies must be measurable so the instructor
can judge when a student is competent.

I want your assistance to help rate these competencies. My dissertation research focuses
on one section of the NATA educational competencies. Specifically, I want you to rate
the competencies in the General Medical Conditions and Disabilities content area on
measurability and importance. The results of my study will help you and other athletic
trainers to determine curriculum content. My study will also serve as a model for
refining the remaining sections of the NATA competencies.

Participation in this study will require about 15-20 minutes of your time. Participation is
voluntary. You may choose not to participate at all, not to answer certain questions, or
discontinue participation at any time without penalty. You indicate your consent to
participate by completing and returning this questionnaire.

Confidentiality will be protected in several ways: (a) your name will not appear on the
questionnaire; (b) results will be presented in aggregate form in any presentations and
publications; and (c) completed questionnaires will be stored in a locked file cabinet.
Confidentiality will be protected to the maximum extent allowable by law.

Thank you for participating in this research. Please contact Sally Nogle (517/353-4412)
if you have any questions or concems about completing the questionnaire. If you have
any questions about your rights as a participant in research, please contact Dr. David
Wright, Chairperson, University Committee on Research Involving Human Subjects
(517/355-2180).

139

PART 1: Demographic Information

Primary Employment (check one):

 

 

[ ]1 Athletic trainer at Division I university
[ ]2 Athletic trainer at Division 11 university
[ ]3 Athletic trainer at Division III university
[ )4 Athletic trainer at a Junior College
[ ]5 Athletic trainer at a High School
[ ]6 Athletic trainer at a clinical or industrial setting
[ ]7 Athletic trainer- other
[ ]3 Team physician — medical specialty
Do you teach athletic training courses in any setting?
I Io Yes
I It N0
Are you an athletic training curriculum director at your college/university?
[ ]0 Yes
I II N0

Gender[ 10 Male
[ ]1 Female

Highest degree earned
[ Io Doctoral degree (including medical degrees)
I It Master’s degree
[ ]2 Bachelor’s degree

Year in which you were certified as an athletic trainer
Year

 

[ ]9 Does not apply

Year in which you earned your medical degree
Year
[ ]9 Does not apply

 

Have you read the NA TA Athletic Training Educational Competencies (1999)?
I Io Yes
I 11 N0

Have you used the NA TA Athletic Training Educational Competencies in curriculum
development in your athletic training program?

[ Io Yes
I 11 N0

140

PART 2: Competency Ratings

Please read each competency carefully and rate each competency on two
characteristics: 1) measurability- the scale on the left hand side of the page and 2)
importanc - the scale on the right hand side of the page.

 

Measurability Rating Scale
Measurability means that the competency statement clearly indicates what entry-
level athletic trainers should know or be able to do, or what instructors in athletic training
programs should teach. The term "measurable" is used because the outcome should be
easily observable. Thus, the question is to what degree does this competency describe
measurable behaviors:

1= unmeasurable

2= somewhat measurable
3= measurable

4= easily measurable

Importance Rating Scale
Importance is the degree to which this competency represents a critical
knowledge or skill, or one that is frequently used by entry-level athletic trainers. Critical
means the health and well being of the athletes depends upon the competence of the
athletic trainer, or conversely, that athletes might suffer serious consequences if the
athletic trainer is not competent. Frequency means that the skill or knowledge is used on
a regular basis.

1= unessential for the entry-level ATC

2= somewhat essential for the entry-level ATC
3= essential for the entry-level ATC

4= very essential for the entry-level ATC

* Note: An entry-level ATC is one who has graduated from an undergraduate
athletic training program and has recently passed the NATA Certification exam.

141

 

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144

 

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145

 

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V M N 5 0505050 50550050508005 000550035 .2 V M N 5
V M N 5 05050500550 0>5055>500 .50 55050m0505 5050 .050555$0 .05m50 $350550 0055.5000n5 .Nm V M N 5
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146

 

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_055000m .......... 5055000m 0305500052.. . 030550002
$505505xm 552 $5500m :3
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5.50505 050550 50>05 0550550025
$550 05 55.5 55055555 050 $058388 05.5.. 55
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148

 

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V M N 5 055 55 555550 5055505550 w55505 .55 $55350555005 500550 550 505555 0555 000553035 dm V M N 5
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$505505xm 552 $5500m . 53

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5.505505 050550 50>05 05505500055
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50555550 .005555005 550 055555550 5005—50: 52050.0

149

APPENDIX C

IRB Approval for Pilot Study

150

MICHIGAN STATE

UNIVERSITY

 

May :30. 2000

TO: Gail DUMMER
132 IM Sports Circle

RE: IRBII 00-306 CATEGORY:1-C
APPROVAL DATE: May 23, 2000

TITLE: PILOT STUDY OF PERCEPTIONS OF THE IMPORTANCE AND CLARITY OF
THE GENERAL MEDICAL CONDITIONS AND DISABILITIES
COMPETENCIES OF THE NATA EDUCATIONAL COMPETENCIES

The University Committee on Research Involving Human Subjects’ (UCRIHS) review ol this
project is complete and I am pleased to advise that the rights and welfare of the human
subjects appear to be adequately protected and methods to obtain informed consent are
appropriate. Therefore, the UCRIHS approved this project.

RENEWALS: UCRIHS approval is valid for one calendar year, beginning with the approval date
shown above. Projects continuing beyond one year must be renewed with the green renewal
form. A maximum of four such expedited renewals possible. Investigators wishing to continue a
project beyond that time need to submit it again for a complete review.

REVISIONS: UCRIHS must review any changes in procedures involving human subjects. prior
to initiation of the change. If this is done at the time of renewal, please use the green renewal
form. To revise an approved protocol at any other time during the year, send your written
request to the UCRIHS Chair, requesting revised approval and referencing the project’s IRBii
and title. Include in your request a description of the change and any revised instruments,
consent forms or advertisements that are applicable.

PROBLEMS/CHANGES: Should either of the following arise during the course of the work,
notify UCRIHS promptly: 1) problems (unexpected side effects. complaints, etc.) involvmg
human subjects or 2) changes in the research environment or new information indicating
greater risk to the human subjects than existed when the protocol was previously reviewed and

 

OFF ICE 0F approved.
RESEARCH If we can be of further assistance. please contact us at 517 355-2180 or via email:
AND UCFIIHS@piIot.msu.edu. Please note that all UCRIHS forms are located on the web:
GRADUATE http://wwwmsu.edu/unit/vprgs/UCRIHS/
STUDIES

niversity Committee on Sincerely,

Research Involving

lluman Sublects <1— 5, -

\I‘

  
 

Michigan State University
:6 Administration Budding
tast Lansmg. Michigan ((QId E. Wright. Ph.D.
488724-1046 UCRIHS Chair
5I7l355-2180

FAX: 517/353-2976
mw msu.edu/user/ucrihs
[Mail ucrihs@msu.edu

DEW:

cc: Sally Nogle
131 Football Bldg. 151

Tilt? Mulligan Sfa/c University
.1": It IS .nSIiluIionai [Jiversd‘y
[me/lance In Action

.. .5qo..,n. Jrhnn

APPENDIX D

IRB Approval for Study

152

MICHIGAN STATE

UNIVERSITY

 

June 21, 2000

TO: Gail DUMMER
132 IM Sports Circle

RE: IRB# 00-306 CATEGORY: 1-C

TITLE: THE IMPORTANCE AND CLARITY OF SELECTED NATA EDUCATIONAL
COMPETENCIES AS PERCEIVED BY ATHLETIC TRAINERS AND TEAM PHYSICIANS:
A PILOT STUDY

ANNUAL. APPROVAL DATE: May 23. 2000
REVISION REQUESTED: June 21, 2000
REVISION APPROVAL DATE: June 21, 2000

The University Committee on Research Involving Human Subjects' (UCRIHS) review of this project is
complete and I am pleased to advise that the rights and welfare of the human subjects appear to be
adequately protected and methods to obtain informed consent are appropriate. Therefore, the
UCRIHS; APPROVED THIS PROJECT‘S REVISION.

This letter also notes approval for changed title, revised questionnalre, additional
pilot study, and consent form.

RENEWALS: UCRIHS approval is valid for one calendar year, beginning with the approval date
shown above. Projects continuing beyond one year must be renewed with the green renewal form.
A maximum of four such expedited renewal are possible. Investigators wishing to continue a project
beyond that time need to submit it again for a complete review.
REVISIONS: UCRIHS must review any changes in procedures involving human subjects, prior to
initiation of the change. If this is done at the time of renewal, please use the green renewal form.
To revise an approved protocol at any other time during the year, send your written request to the
UCRIHS Chair, requesting revised approval and referencing the project's IRB# and title. include in
your request a description of the change and any revised instruments, consent forms or
OFFICE or advertisements that are applicable.
RESEARCH PROBLEMS/CHANGES: Should either of the following arise during the course of the work, notify
AND UCRIHS promptly: 1) problems (unexpected side effects, complaints, etc.) Involvmg human
GRADUATE subjects or 2) changes In the research environment or new information Indicating greater risk to the
human subjects than existed when the protocol was previously reviewed and approved.
STUDIES If we can be of further assistance, please contact us at 517 355-2180 or via email:

University Committee on UCRIHS@piIot.msu.edu.
Research Involving

Human Subj

 

 
  

Michigan State University
246 Administration Building
East Lansing, Michigan

“88244045 David E. Wright, Ph.D.

517/355-2130 UCRIHS Chair
FAX, 517/353-2976

rat www msuedu/user/ucrihs
E-Mail ucrilis@msu.edu

 

DEW: tir

cc: Sally Nogle
131 Football Bldg.
the Michigan State University

if)! A lb institutional Diversity 1 5 3
Excellence in Action.

MSU IS an aI/imiaiive-acli’on,
nililai - WOO/(unify ihslilulian

 

OFFICE OF
RESEARCH
AND
GRADUATE
STUDIES

University Committee on
Research Involving
Human Subjects

MICHIGAN STATE

UNIVERSITY

 

September 28, 2000

TO; Gail DUMMER
132 IM Sports Circle

RE: IRB# 00-306 CATEGORY: 1-C

TITLE: THE IMPORTANCE AND CLARITY OF SELECTED NATA EDUCATIONAL
COMPETENCIES AS PERCEIVED BY ATHLETIC TRAINERS AND TEAM PHYSICIANS
A PILOT STUDY

ANNUAL APPROVAL DATE: May 23. 2000
REVISION REQUESTED: September 15, 2000

REVISION APPROVAL DATE: September 27, 2000

The University Committee on Research Involving Human Subjects' (UCRIHS) review of this pr0ject is
complete and i am pleased to advise that the rights and welfare of the human subjects appear to be
adequately protected and methods to obtain informed consent are appropriate. Therefore, the
UCRIHS APPROVED THIS PROJECT'S REVISION.

This letter approves the title change and slight modification in survey directions
and acknowleges that participants will be contacted by the investigator via mail.

RENEWALS: UCRIHS approval is valid for one calendar year, beginning with the approval date
shown above. Projects continuing beyond one year must be renewed with the green renewal form.
A maximum of four such expedited renewal are possible. investigators wishing to continue a prOjecl
beyoncl that time need to submit it again for a complete review.

REVISIONS: UCRIHS must review any changes in procedures involving human subjects, prior to
initiation of the change. if this is done at the time Of renewal, please use the green renewal form.
To revise an approved protocol at any other time during the year, send your written request to the
UCRIHS Chair, requesting revised approval and referencing the project's lRB# and title. Include in
your request a description of the change and any revised instruments, consent forms or
advertisements that are applicable.

PROBLEMS/CHANGES: Should either of the following arise during the course of the work, notify
UCRIHS promptly: 1) problems (unexpected side effects, complaints, etc.) involving human
subjects or 2) changes in the research environment or new information indicating greater risk to the
human subjects than existed when the protocol was previously reviewed and approved.

if we can be of further assistance, please contact us at 517 355-2180 or via email
UCRIHS@piiot.msu.edu.

Sincerely,

Michigan State University ’ """ 7 /\/. . /“
246 Administration Buildin V'Uxflc ,Q/V //
' ‘ ' ‘ U" V ./ ,

East Lansmg, Michi n / .» .../

48824-1

517/355-2180
FAX: 517/353-2976
mo www msu.edu/user/ucrths
f-Maii- ucrihs@msu.edu

7 he Michigan Stale Un/verslfy
IDEA is Insurer/anal Diversify.

- II in Adelina

Ashir Kumar, MD.
Interim Chair, UCRIHS

AK: bd

cc: Sally Nogle
131 Football Bldg. 154

APPENDIX E

Pilot Study Data

155

 

 

 

 

 

 

 

156

 

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158

 

 

 

 

 

 

 

 

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159

 

 

 

 

 

 

 

 

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160

 

 

 

 

 

 

 

 

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161

 

 

 

 

 

 

 

 

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162

 

 

 

 

 

 

 

 

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3258:0202 3:22.803: @5820: 8:23:80

 

 

 

 

 

3:50:00 .3 033.

164

 

 

 

 

 

 

 

 

:0222 0:.0 2: 5 82.: :2.0 0 2 2 2.0

22.0 5 :: 0:.0 0 0 2: 2: 20
:5222 00.0 0: 5 :5022 02.0 0: 2 : 2.0

20.0 2: 2: 00.0 2 :: 0 2: 22
:0222 05.0 5: 0 :2022 50.0 2: 0 2 2.0

20.0 0: 2 22.0 0: 2 : 2: 02
05.22 50.0 2: 2 :0022 22.0 2 2 2 2.0

:20 :: 2 02.0 0 0 2: 2: 52
82.22 20.0 :: 5 :2022 :2.0 0 2 0 2.0

02.0 5 0 :2.0 : 0 0: 2: 22

802 2 2 0 802 2,: 2 0 0
89:82
8:32.808: 8:22.895 898% 20:83:80

 

 

 

 

 

2222228 .2: 2:222

165

 

 

 

 

 

 

 

 

:02: 20.0 2 2 62.22 20.0 :: 2 2.0

00.0 2 0 22.0 0: 2 2: 00
:5522 50.0 2 :: :2022 02.0 2 0 2.0

22.0 5 : : 22.0 2 0 2: 20
:2222 50.0 0 0 :0222 00.0 2: 2: 2.0

52.0 0 5 50.0 :: 2 2: 00
:0222 05.0 5: 0 :2022 :20 20 0 2.0

05.0 2: 2 20.0 2: 0 2: 00
00.2: 05.0 0: 0 :202 50.0 2: 0 2.0

00.0 0: 2 02.0 2: 0 2: :0

802 2,: 2 0 802 2,: 2 0
898:2
359280202 8:88:05 958% 8:83:80

 

 

 

 

 

2222228 .2: 2:222

166

 

 

 

 

 

:2222 00.0 2 5 5 222.22 02.0 2: 0 2.0
20.0 0 0 2 02.0 2: 0 2: 50
:2022 20.0 0 2 2: 05.22 20.0 2: 0 2.0
00.0 2 0 5 :2.0 0: 5 2: 20
:00: 22 2 0 0 502 :2 2 0
89:82
359080082 35:80:: 058% 8:809:00

 

 

 

 

 

08:50:00 .3 290%.

167

APPENDIX F

Measurability and Importance Data

168

MEASURABILITY SCALE

—-------—--------——-—-—---——--—-——--—---——_——-—---————-—__-----—————

Model Infit Outfit
ITEM Measure SE MnSq ZStd MnSq ZStd PtBis
1 - 18 .05 1.0 0 1.3 4 48
2 - 18 .05 1.0 0 1.1 2 47
3 49 .05 1.0 0 1.0 0 45
4 22 05 .9 -2 9 -1 53
5 - 34 05 .9 -2 l 0 0 55
6 - 48 .05 .8 -4 8 -3 56
7 21 .05 1.0 O 1.0 0 56
8 27 .05 1.4 8 1.4 6 4S
9 .32 05 .9 -2 .9 —1 57
10 -.29 05 .9 -3 1.0 0 59
11 07 05 1.1 2 1.2 2 53
12 57 05 1.0 0 1.1 1 .48
13 .41 05 1.0 0 1.0 0 .51
14 .28 05 .7 -5 8 -4 .63
15 -.14 05 .8 -3 8 —3 .64
16 -.20 05 .8 -3 8 -3 .62
17 -.41 05 .7 -6 7 —6 .68
18 .13 OS .7 -8 7 -7 .68
19 -.28 05 .7 -7 7 -6 .70
20 -.19 05 .8 -4 8 -S .69
21 —.35 05 .9 -3 8 -3 .68
22 -.36 05 .9 -3 8 -3 .68
23 -.66 05 .8 -3 8 -3 .70
24 —.O6 05 .7 -6 7 -S .68
25 -.57 05 .7 -6 7 -S .69
26 .12 05 .8 ~S 7 —5 .66
27 -.01 05 .8 -4 8 —3 .61
28 .23 05 .8 -5 7 -S .62
29 -.31 05 .7 —6 7 -5 .64
30 .01 05 .7 -6 7 -6 .64
31 -.10 OS 1.0 0 1 0 O .55
32 -.O4 05 .7 -8 6 -7 .69
33 .45 05 1.0 0 l 0 0 .48
34 -.27 05 .7 -8 7 -7 .68
35 .22 05 1.0 O 9 0 .59
36 -.29 .05 .7 -8 .7 —7 .69
37 .22 .05 1.0 0 1.0 0 .57
38 -.66 .05 1.0 0 1.0 0 .52
39 -.14 .05 1.1 1 1.1 2 50
40 -.04 .05 1.0 O 1.0 0 51
41 -.78 OS .7 -9 .7 -8 66
42 07 05 1.0 O 1.0 0 SS
43 - 21 05 1.2 5 1.3 4 46
44 .23 OS 1.2 4 1.2 3 48
45 -.38 05 .8 -4 .8 -4 63
46 -.O6 05 1.4 7 1.4 7 48
47 .36 05 1.4 7 1.4 5 48
48 1.57 07 1.0 0 1.0 0 44
49 .70 06 1.2 4 1.3 3 44
50 .05 OS 1.4 8 1.4 6 .42
51 2.16 08 1.1 1 9 0 .34
52 2.34 08 1.0 0 .9 O 33
53 —.53 05 1.4 7 1.4 8 44
S4 .33 05 1.1 2 1.1 1 52
55 ~l.32 OS 2.1 9 2.2 9 28
56 -1.14 05 1.8 9 1.8 9 37
57 -1.05 05 2.1 9 2.2 9 28
Mean 00 .05 1 O -1 0 1 O -.8 .55
S D 63 01 3 5 1 3 4.7 .11
RMSE (Model) .05 Adj S.D. .63 Separation 11.98 Reliability .99

Fixed (all same) chi-square: 6063.9 d.f.: 56 significance: .00
Random (normal) chi-square: 55.8 d.f.: SS significance: .45

169

IMPORTANCE SCALE

Model Infit Outfit
ITEM Measure SE MnSq ZStd MnSq ZStd PtBis
1 - 94 05 1.1 1 1.2 4 .37
2 - 04 OS 1.0 0 1.1 1 42
3 66 05 1.1 l 1.1 1 .39
4 28 05 1.0 -l 1.0 0 .46
5 - 64 05 .9 -1 9 -1 .52
6 - 85 05 .8 -5 8 -5 .54
7 - 41 .05 .9 -3 .9 -2 .53
8 - 82 .05 1.3 6 1.3 6 .45
9 .08 05 .9 —1 9 -1 .53
10 -.98 05 .9 -2 .9 -1 .52
ll 58 05 1.2 4 1.2 3 .45
12 23 05 1.0 0 1.0 0 .48
13 .01 05 1.0 O 1.0 0 .50
14 .05 05 .9 -2 9 -2 .57
15 -.82 .05 1.0 0 1.0 0 .57
16 -.27 .05 1.2 4 1.2 3 .48
17 -1.38 .05 .7 -7 7 -7 .63
18 -.3O .05 1.0 0 1 0 0 .54
19 —1.24 05 .7 -8 7 -8 .65
20 -1.42 05 .6 -9 6 -9 .68
21 -l.69 05 .7 -6 7 -6 .65
22 -l.69 05 .7 -8 7 -7 .66
23 -2.18 05 .7 —6 7 —6 .65
24 -.23 05 .8 -4 8 -4 .59
25 -1.83 05 1.0 0 1.0 O .51
26 -.87 05 1.0 0 1.0 0 .54
27 .47 05 .9 -3 9 -2 .51
28 1.38 06 .8 —3 8 —3 .51
29 04 05 1.1 1 1 l l .51
30 .23 05 1.0 0 1.0 0 .51
31 1.28 06 1.3 5 1.3 3 .39
32 -.14 05 .9 -2 9 -2 .57
33 2.87 11 .9 0 8 -1 .33
34 -.3O 05 .8 -6 .8 -S .57
35 -.27 OS 1.1 2 1.1 2 .50
36 -l.04 05 .7 -7 .7 ~7 .65
37 37 05 1.4 8 1.4 6 39
38 -.13 05 1.2 4 1.2 4 46
39 1.38 06 1.1 l 1.0 0 43
40 1.63 07 1.1 1 1.0 0 .38
41 -.87 05 .8 -4 .8 -4 .59
42 1.36 06 1.2 4 1.5 5 .42
43 1.32 .06 .9 ’1 .9 -l .44
44 1.65 .07 1.2 2 1.0 0 .37
45 .45 05 .9 —3 .8 -3 .54
46 -1.71 05 1.3 5 1.3 5 .51
47 ~1.79 05 1.4 7 1.4 7 .47
48 1.90 07 1.1 1 1.0 0 .37
49 .91 06 1.2 4 1.2 3 .40
50 -.82 05 1.5 9 1.5 9 .46
51 1.47 07 1.1 l 1.0 O .38
52 2.79 10 1.1 0 .9 0 .27
53 .34 05 1.4 7 1.4 6 .37
54 —1.07 05 1.1 2 1.1 2 .49
55 1.21 06 1.3 4 1.2 2 .37
56 .97 06 1.1 1 1.0 0 .44
57 1.83 07 1.2 2 1.2 1 .29
Mean .00 05 l 0 -.1 1.0 —.3 49
S D 1 20 01 2 4.5 2 4.2 10

—-—-----—---------—---------—-------—--—-—---—--—----_-——----—------

RMSE (Model) .06 Adj S.D. 1.20 Separation 21.40 Reliability 1.00
Fixed (all same) chi-square: 22783.7 d.f.: 56 significance: .00
Random (normal) chi-square: 55.9 d.f.: 55 significance: .44

170

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