Un'tpack'ing Athletic Therapy Education in Canada: An

UN'TPACK'ING ATHLETIC THERAPY EDUCATION IN CANADA: AN

EXPLORATION OF AN INNOVATIVE CASE-BASED LEARNING APPROACH

COLIN D. KING

Thesis

submitted to the Nova Scotia Inter-University Doctoral Administrative Committee

in partial fulfillment of the requirements for the degree of

Doctor of Philosophy in Educational Studies

Acadia University

Fall, 2017

This thesis by COLIN D. KING was defended successfully in an oral examination on AUGUST 16, 2017.

The examining committee for the thesis was:

______Dr. Brian Wilson, Chair

______Dr. Anna MacLeod, External Examiner

______Dr. Betul Czerkawski, Internal Examiner

______Dr. Jim MacLeod, Internal Examiner

______Dr. Daniel Robinson, Internal Examiner

______Dr. Gregory MacKinnon, Supervisor

This thesis is accepted in its present form by the Division of Research and Graduate Studies as satisfying the thesis requirements for the degree Doctor of Philosophy in Educational Studies

………………………………………….

I, COLIN D. KING, grant permission to the University Librarian at Acadia University to reproduce, loan or distribute copies of my thesis in microform, paper or electronic formats on a non-profit basis. I, however, retain the copyright in my thesis.

______Author

______Supervisor

______Date

iii

Table of Contents

List of Tables ...... ix

List of Figures ...... xi

Abstract ...... xiii

List of Abbreviations ...... xv

Acknowledgements ...... xvii

CHAPTER 1: INTRODUCTION ...... 1

Chapter 1 Outline ...... 1

1.1 My Doctoral Research: A Narrative Leading to Investigation ...... 2

1.2 Research Question ...... 5

1.3 The Profession of AT: Setting the Context for the Research ...... 6

1.4 Theoretical Framework: TPACK ...... 15

1.5 The M-CBL SIAET ...... 20

1.6 How My Doctoral Research Pursued Broader Understandings of AT Classroom

Interventions? ...... 36

CHAPTER 2: LITERATURE REVIEW ...... 39

Chapter 2 Outline ...... 39

2.1 Introduction to the Research Area ...... 40

2.2 Signature Pedagogies in AT Education ...... 41

2.3 What is CBL? ...... 45

2.4 CBL in AT Education Programs ...... 46

2.5 The Influence of Multimedia Technology on CBL ...... 53

2.6 Using TPACK as a Theoretical Framework for Technology Integration ...... 56

2.7 Literature Review Summary ...... 63

CHAPTER 3: METHODOLOGY ...... 65

Chapter 3 Outline ...... 65

3.1 Interpretivist Methodological Tradition ...... 65

3.2 Research Design ...... 69

3.3 Phases of My Doctoral Research ...... 69

CHAPTER 4: RESULTS ...... 91

Chapter 4 Outline ...... 91

4.1 Phase 1 – Describing the Context of AT Educators ...... 92

4.2 Phase 2 – Improving the M-CBL SIAET ...... 124

4.3 Phase 3 – Case Study – Sheridan College ...... 137

CHAPTER 5: DISCUSSION ...... 161

Chapter 5 Outline ...... 161

5.1 Significant Contributions of the Current Research Project ...... 161

5.2 Why Should AT Educators Consider TPACK When Integrating Technology? ... 178

5.3 How Can AT Educators Apply TPACK Principles in Practice? ...... 181

5.4 Conclusions ...... 191

5.5 Limitations of the Study and Implications for Further Research ...... 193

5.6 My Doctoral Research: A Narrative Leading to Recommendations for AT

Educators ...... 194

REFERENCES ...... 201

APPENDIX A. Competencies in Athletic Therapy ...... 227

APPENDIX B. CATA Accredited Institutions Ethics Approval Letters ...... 245

APPENDIX C. Phase 1 – AT Educators’ Questionnaire ...... 253

APPENDIX D. Phase 1 – AT Educators’ Interview Schedule ...... 261

APPENDIX E. Phase 3 – AT Students’ Questionnaire ...... 263

APPENDIX F. Phase 3 – AT Students’ Interview Schedule ...... 271

APPENDIX G. Phase 3 – AT Students’ Focus Group Interview Schedule ...... 273

APPENDIX H. Phase 3 – AT Educators’ Interview Schedule ...... 275

APPENDIX I. CATA Accredited Institution Curriculum Summary Table ...... 277

APPENDIX J. Instructor’s Guide for M-CBL SIAET ...... 285

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List of Tables

Table 1.1. Definitions and Examples of TPACK Dimensions…………………………..19 Table 2.1. Significant Gaps from Literature Review Chapter…………………………...64

Table 3.1. Demographic Information for Phase 1 Participants…………………………..72

Table 3.2. Sheridan College Athletic Therapy Program Courses………………………..82

Table 4.1. Summary of Phase 1 Questionnaire Responses………………………………93

Table 4.2. Summary of Phase 3 Questionnaire Responses – Initial Predispositions

Towards Using Technology…………………….………………………………138

Table 4.3. Summary of Phase 3 Questionnaire Responses – Feedback Concerning the

M-CBL SIAET……………………………………...…………………………..139

Table 4.4. Summary of Phase 3 Questionnaire Responses – Feedback Concerning the

Pedagogical Model Accompanying the M-CBL SIAET……………………….140

Table 5.1. TPACK Leadership Theory of Action.……………………………………...183

List of Figures

Figure 1.1. The TPACK conceptual framework…………………………………………17

Figure 1.2. The evolution of the M-CBL SIAET...... 21

Figure 1.3. The original case study template…………………………………………….29

Figure 1.4. Examples of Object2VR® interactive models………………………………29

Figure 1.5 Example of Object2VR® interactive models………………………………...30

Figure 1.6. The instructional model accompanying the Multimedia Sports Injury

Assessment Tool…………………………………………………………………32

Figure 1.7. A sample orthopedic assessment concept map………………………………33

Figure 1.8. Relationship between my initial pilot projects and the current

research project…………………………………………………………………..38

Figure 2.1. How the TPACK model was used during each phase of my doctoral

research…………………………………………………………………………..63

Figure 3.1. A description of the three phases of the current research project……………70

Figure 4.1. Modified TPACK framework for AT educators…………………………...123

Figure 4.2. Screenshot showing the hyperlinked answer keys in the student’s version

of the M-CBL SIAET….....……………………………………………….……126

Figure 4.3. 3dRx® anatomy animations for the elbow case scenario in the M-CBL

SIAET…………………………………………………………………………..129

Figure 4.4. Sample mechanism of injury video section for the shoulder injury scenario in

the M-CBL SIAET…………..………………………….………………………133

Figure 4.5. Sample special test videos for the shoulder injury scenario in the M-CBL

SIAET……………………………..……………………………………………134

Figure 4.6 Navigation options (bookmark and buttons) within the M-CBL SIAET.…..136

Figure 5.1 How to use TPACK to design pedagogically meaningful technology

tools……………………………………………………………………………..188

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Abstract

The purpose of this study was to identify the factors that impacted the use of technology- assisted educational tools in athletic therapy education. Data collection was divided into three mixed-methods phases, each contributing to the overall research question. Phase 1 used surveys and interviews to reveal AT educators’ initial pre-dispositions regarding preferred pedagogies and technology integration. Following an iterative constructivist instructional design, Phase 2 used feedback from Phase 1 to design the Multimedia CBL

Sports Injury Assessment Educational Tool to ensure its appropriateness for AT education. The final phase used a case-study to elicit feedback from AT students and educators about the impact of the M-CBLSIAET on the nature of learning and teaching.

Students’ suggested that the tool contributed to the learning experience by: creating contextually-enriched scenarios; engaging students in critical thinking/reflection; stimulating higher levels of clinical decision-making; organizing peer interactions; and extending learning outside of the classroom. Furthermore, AT educators also considered the tool to positively impact teaching by: highlighting the potential roles for technology in AT education; using technology to empower course content/pedagogy; and promoting critical thinking about different pedagogies in AT education.

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List of Abbreviations

AT Athletic Therapy

CATA Canadian Athletic Therapists Association

CBL Case-Based Learning

CEU Continuing Education Unit

CK Content Knowledge

CPR Cardiopulmonary Resuscitation

ID Instructional Design

M-CBLSIAET Multimedia CBL Sports Injury Assessment Educational Tool

NATA National Athletic Trainers’ Association

PAC Program Accreditation Committee

PBL Problem-Based Learning

PCK Pedagogical Content Knowledge

.pdf Portable Document Format

PK Pedagogical Knowledge

R2D2 Recursive, Reflective, Design, and Development Model

TCK Technological Content Knowledge

TK Technological Knowledge

TPACK Technological, Pedagogical, Content Knowledge

TPK Technological Pedagogical Knowledge

xvi

Acknowledgements

I would like to acknowledge a few of the many people who have supported me through my doctoral journey and contributed to this research project. First and foremost, the most important people in my life, my wife Joy and my two daughters Charlotte and

Brianna. Without your endearing love, support, understanding (as well as endless cuddles, laughs and smiles) this project would never have been completed. To my parents, who instilled in me the importance of hard work, never giving up, discipline, and being passionate about what you do, I appreciate all you have every done for me. I leaned on these attributes heavily throughout the completion of this research project.

I would like to especially thank my supervisor, Dr. Gregory MacKinnon. Words cannot express how much gratitude I have for the amount of time and commitment that you dedicated to not only this project, but to my personal growth as an academic. I have learned so much from you over the last five years (in academia and beyond) and would not be in the position I am in now without your hard work, knowledge sharing, support, organization, and direction.

To my doctoral committee, I am very grateful for your ongoing support and feedback throughout this process and am truly amazed at your ability to provide detailed feedback when I sent you draft after draft. Dr. Jim MacLeod, who has been my colleague, mentor, and friend for a number of years, I greatly appreciate your attention to detail, especially with grammar, organization, and structure, and sharing your experiences of the athletic therapy profession. You are one of the most respected ATs in the country and I consider myself lucky to work alongside you on a daily basis. Dr. Betul

Czerkawski, whose knowledge about constructivist learning and instructional design was

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paramount in helping me to develop an effective multimedia educational tool. I learned so much through this process that has helped me to improve as an educator and researcher. Dr. Dan Robinson, who constantly provided very thorough and detailed feedback, which helped me to solidify my research design. He also asked many excellent questions along the way which helped me to rationalize my methodological decisions. I thank you as this high-quality feedback was so important in strengthening my methodology before starting my data collection.

To my fellow PhD Cohort 2 students and teachers, I appreciated our classes together and enjoyed the many discussions and differences of opinion. Many of these experiences were completely new to me at the time and helped to reshape my thinking as an individual. These classes and discussions played a major role in my growth as a doctoral student through this entire process.

To my co-workers and students in the School of Kinesiology at Acadia

University, I am where I am because of you all. I get the opportunity to work with so many academics who are well-respected in their own fields, and see the level of passion that you have for student engagement and life-long learning. For such a small institution, our program is doing many great things and I am excited to be a part of its future.

Finally, to the participants of this study who were willing to endure lengthy questionnaires and elaborate interview discussions. Without your eagerness to participate and passion for the AT profession, this study would not have been possible. Your efforts allowed for a greater understanding of effective technology integration in athletic therapy education and I am grateful for your participation. I hope the findings from this study help to continuously improve AT education throughout the country.

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CHAPTER 1: INTRODUCTION

Chapter 1 Outline

This chapter provides the foundation for my doctoral research by presenting the overall research question and justifying why it was important to complete this type of research. The chapter begins with a personal narrative to set the context of my study by describing how I became interested in the notion of teaching that may be empowered through instructional technologies. The narrative also describes my personal growth in considering different research paradigms, and offers my shift in thinking as it progressed from using a predominately positivist view to adapting a more naturalistic framework when considering classroom interactions. This growth helped to identify and justify an interpretivist paradigm in which I situate the current study. While my research philosophy is a critical preamble to this work, it is also important when generalizing the findings of such studies to have a clear picture of the context in which it transpired.

The chapter continues with a detailed examination of the current state of the athletic therapy (AT) profession including: a brief history of the profession, the scope of practice of an AT, a description of what is included in the education of an AT student, information about accredited post-secondary programs, and further, why these programs might be considered complex learning environments. My study involved participation from AT educators and students so it is fundamentally important to describe this context in detail before introducing my dissertation work.

Following these sections, the writing becomes more focused on the use of pedagogically sound technologies in AT education. The ‘Technological, Pedagogical, and Content Knowledge’ (TPACK) framework is introduced as the guiding theoretical

model with regard to the design of the technology-assisted educational tool employed in the current study (the Multimedia Case-Based Learning Sports Injury Assessment

Educational Tool [M-CBL SIAET]). The TPACK framework further informed the analysis of empirical materials that were gathered during each phase of research in this study. Next, the specific design and development of the M-CBL SIAET is introduced, including its evolution as a direct result of two preliminary action research studies. The utility of these pilot projects was demonstrated through in-depth examinations that informed such questions as why should educators consider pedagogically sound technologies, and how can these practices actually be implemented?

The last section of this introductory chapter finishes with how my current study pursued broader understandings of technology-assisted pedagogies in AT classrooms and describes how the TPACK model was used to contribute to the overall theoretical understanding of this research area.

1.1 My Doctoral Research: A Narrative Leading to Investigation

When I began teaching at Acadia University after several years in both field and clinical AT practices, I was not familiar with the concepts of instructional design (ID), educational theories, or pedagogical strategies. I designed my own curriculum and taught my classes based on my previous experiences as a student. I would reflect upon my former teachers and fashion my approach, grounded in my preferred modes of learning.

As I moved through my graduate education, I discovered when reviewing the literature that ‘defaulting to the ways we were taught’ was a common practice in health professional programs, especially in AT contexts (Maggio, Tannery, Chen, Cate, &

O’Brien, 2013; Thistlethwaite et al., 2012). Generally, health educators are held to a high

standard in their respective professions (high levels of content knowledge) but have very little, if any, formalized educational training (also known as pedagogical knowledge)

(Searle, Thibault, & Greenberg, 2011). One might suggest that to be considered an effective pedagogue, a health educator should be equipped with the necessary medical knowledge, educational theory, practical teaching skills, and concomitant evaluation skills (Searle et al., 2011). It was upon the recognition of my own lack of pedagogical knowledge, and the shortage of research in this area, that began my educational journey towards becoming a more effective pedagogue.

This educational journey allowed me to become familiar with different research paradigms and methodologies. Like many other health professionals, my earlier years of education were dominated by a positivist way of thinking. Terms such as evidence-based medicine and randomized control trial experiments dominated the literature I was reading. I assumed that reputable research was only measured in quantifiable terms and excluded any qualitative methods and/or interpretations of data. In my pursuit of becoming a more effective pedagogue, I was introduced to naturalistic research paradigms and immediately was able to appreciate the use of these other research methodologies. I realized that there was more than one way to investigate a research question and the selection of a particular paradigm should coincide with the researchers’ own objectives, assumptions, values, and beliefs. When thinking about the intricacies of teaching and learning, I began to view these constructs from a distinctly different philosophical position. In the work I will hereafter describe, I discovered through observation and data collection, the complexities associated with using pedagogically sound technologies and questioned the sole use of objective statistical measures to

determine a technology-assisted teaching tool’s effectiveness. My ongoing development had me becoming interested in completing a more comprehensive analysis of my research question by incorporating a blend of both quantitative and qualitative measures.

Coupled with my interest in more effective teaching and naturalistic research inquiries, was my curiosity regarding the role of technology as a teaching tool in AT education. In this 21st century, there are copious amounts of innovative digital technologies at our disposal that can be integrated into educational environments, especially in medical professions such as AT. Multimedia technologies including computer animations, smart phone applications, interactive software programs, videos, pictures, and high-fidelity training tools (e.g., simulation manikins) are all frequently used in AT programs to simulate realistic scenarios, injuries, and conditions. Within these simulated environments, students are able to learn foundational knowledge and practise the necessary skills required to demonstrate competence as medical professionals.

As an AT student, I used some of the aforementioned multimedia technologies to practise my own assessment and rehabilitation skills. For example, in our assessment courses we would watch a video of a specific athletic injury and were then tasked with pretending to be the therapist on site and as such, go through all the steps we would follow as the attending therapist. Even though this could be classified as a type of case- based learning (CBL), it was not a structured learning activity. In this instructional context, we were given little guidance from the instructor much less making use of established pedagogical strategies such as instructional scaffolding, peer-assisted learning, or Socratic interactions. Obviously, I did not realize this at that time because I

was not familiar with these types of strategies, nor, presumably, was my instructor. After

I learned more about pedagogy and began to explore effective pedagogical strategies, I reflected upon my experiences as an AT student and realized that far more could have been done to enhance student learning in CBL environments. These reflections helped to form my critical analysis of AT education. I asked myself important questions such as:

1) Why are certain pedagogical strategies used for particular courses in AT programs? 2)

What strategies are the most effective in teaching an AT student assessment/rehabilitation skills and techniques? 3) How familiar are AT educators with different pedagogical strategies? 4) How would technology change the nature of these pedagogies? and 5) Are

AT educators prepared to teach effectively in this digital age?

Throughout my educational journey, I diligently searched the AT research literature and realized that the aforementioned questions had not been adequately explored in an AT specific context. These specific gaps in the literature are presented in more detail in the next chapter, the Literature Review. My lack of understanding of the current context of teaching and learning in AT education, combined with the pursuit of using pedagogically sound technologies, compelled me to look closer at the potential for technology to improve teaching in the AT profession. These insights led to the design of my current research study, beginning with defining the research question.

1.2 Research Question

With these personal learning events in mind, I designed a specific technology- assisted educational tool (described in detail in Section 1.5) grounded in foundational educational theory. The purpose of my current research study was to explore the impact of using this educational tool in an AT specific context. More specifically my main

research question was, “What is the impact of using a technology-assisted pedagogy on the nature of teaching and learning in AT-accredited institutions?” My primary interest was to establish the factors that influenced the use of a technology-assisted teaching tools in AT education rather than suggest that this tool categorically or statistically improved the attainment of objective learning outcomes.

At the very onset of this investigation, I became abundantly aware of the inherent complexities of this research topic. To this end, in the ensuing paragraphs, I will set the context of the study by providing a more in-depth examination of the AT profession, the education of an AT student, and the complexities associated with AT teaching and learning environments.

1.3 The Profession of AT: Setting the Context for the Research

Athletic therapy is a healthcare profession that is dedicated to the health, well- being, and rehabilitation of physically active individuals (Canadian Athletic Therapists’

Association, 2008a). As a point of clarification, in Canada the profession is referred to as athletic therapy whereas in the United States it is known as athletic training, a difference that is mostly in name only. Therefore, throughout the rest of this dissertation, these two terms will be used interchangeably and be represented by the acronym AT.

Certified Athletic Therapists can be found working in many diverse employment settings including professional sports, private rehabilitation clinics, hospitals, colleges/universities, research institutions, national or international sporting organizations, and even within the performing arts (e.g., Cirque de Soleil or dance companies) (CATA, 2013a). The AT profession first emerged in the United States in the early 1900s, with the majority of individuals being employed by either professional sport

teams or as a part of the military ranks (Delforge & Behnke, 1999). Early accounts of the first ATs portrayed these individuals as those on the team who carried water bottles and passed out towels, not recognizing them as qualified health professionals who specialized in orthopedic assessment and rehabilitation (De Conde, 1990).

Since that time, the AT profession has grown exponentially (currently there are approximately 2,300 members in the Canadian Athletic Therapists’ Association [CATA] and 40,000 members in the United States’ National Athletic Trainers’ Association

[NATA]) and has evolved to become a respectable and recognized paramedical healthcare profession throughout North America (CATA, 2013a). Correspondingly, AT is also gaining more international exposure and recognition with the expansion of professional associations into the United Kingdom, Ireland, South Africa, Japan, Taiwan,

Italy, Korea, Spain, and Georgia (World Federation of Athletic Training & Therapy,

2013).

The development of a Certified Athletic Therapist begins with the in-depth knowledge, education, and training in the areas of the human musculoskeletal system, exercise physiology, injury assessment, rehabilitation, pathophysiology, biomechanics, and basic emergency care (CATA, 2016a). More specifically, the scope of practice of the profession is divided into five main domains: 1) prevention (e.g., instructing individuals to use or apply custom-made protective equipment to minimize the risk of injury); 2) assessment (e.g., formulating an index of suspicion by interpreting specific physical, orthopedic, or fitness tests); 3) intervention (e.g., administering therapeutic or conditioning exercises); 4) practice management (e.g., maintaining appropriate medical records to comply with accepted best practice guidelines); and 5) professional

responsibility (e.g., adhering to statutory and regulatory provisions for the practice of AT by contributing to the safety and welfare of the public) (CATA, 2016a).

Each of these five domain areas of the scope of practice is representative of a core competency area that CATA-accredited institutions are expected to deliver when educating certification candidates, helping with their transition towards becoming entry level Certified Athletic Therapists. This process of ‘How to become certified?’ is defined by the CATA and is considered to be one of the most stringent certification processes in the Canadian healthcare system (CATA, 2016a).

1.3.1 What is included in the AT certification process? To achieve the status of

Certified Athletic Therapist from the CATA, a candidate must meet all academic requirements as set by a CATA-approved AT curriculum, leading to a Bachelor’s degree from an accredited post-secondary institution. In Canada, there are currently seven

CATA-accredited AT institutions: Sheridan College (Brampton, Ontario), York

University (North York, Ontario), Concordia University (Montreal, Quebec), University of Winnipeg (Winnipeg, Manitoba), University of Manitoba (Winnipeg, Manitoba),

Mount Royal University (Calgary, Alberta), and Camosun College (Camosun, British

Columbia).

Furthermore, each certification candidate is also required to hold a valid First

Responder qualification (an advanced first aid designation) and complete an internship of at least 1,200 hours of practical training (600 in field settings and 600 in clinical setting) under the supervision of Certified Athletic Therapists. Once these criteria have been met, a candidate is eligible to attempt the comprehensive written certification exam and then a practical exam that covers all required components of the AT scope of practice,

including: on-field management procedures; taping/bracing procedures; clinical evaluation and management; and modality applications (CATA, 2013b). After successfully completing these exam components, candidates earn the title Certified

Athletic Therapist and are recognized as Canadian Athletic Therapists (Certified), designated by the letters CAT(C).

Once certified, CATA members must maintain their certification by staying up- to-date with current trends in orthopedic assessment, rehabilitation, and emergency care.

Members are required to submit proof of adequate professional liability insurance, hold current CPR-Health Care Provider certification, and attain 21 continuing education units every three years via completing courses, attending conferences, or through other professional development opportunities (e.g., committee work) (CATA, 2016b). To ensure that all certification candidates are prepared for the route towards certification, the

CATA has developed strict policies and procedures for each of its accredited institutions, including annual curriculum reports, reviews of all formative and summative evaluations, and on-site visitations.

1.3.2 How are CATA-accredited programs designed and evaluated?

Accredited education programs of the CATA prepare students with the essential content knowledge and practical skills from a variety of domain areas that demonstrate an understanding of the human body, how it works, and how injury affects it (Mazerolle &

Yeargin, 2010). The CATA promotes a competency-based educational model and principles of Bloom’s hierarchal cognitive taxonomy (Bloom, Engelhart, Furst, Hill, &

Krathwohl, 1956) to ensure that all accredited institutions have similar, although not exact, entry-level curriculum design, course content, and clinical/field experiences.

The core competencies of the AT profession are divided into six broad domains:

1) prevention; 2) recognition and evaluation; 3) management, treatment, and disposition;

4) rehabilitation; 5) organization and administration; and 6) education and counseling

(CATA, 2008). Based on Bloom’s taxonomy framework, each of these domains is further subdivided into three categories: cognitive domain (knowledge and intellectual skills); psychomotor domain (manipulative and motor skills); and affective domain

(attitudes and values) (CATA, 2007a). A complete list of the specific competencies and domains of the AT profession are included in Appendix A. When designing academic programs, AT educators need to ensure that they are delivering each of these competencies to their students through a variety of educational experiences.

To become accredited, an academic institution must formally apply to the CATA, through the Program Accreditation Committee (PAC). In the application package, the institution must provide the following documents: 1) a self-study report identifying the educational experiences (courses, clinical experiences, field practicums, etc.) that provide students with the opportunities to develop competencies in each domain (as listed in

Appendix A); 2) descriptions of all core courses required for the AT program; 3) copies of all evaluation forms used to assess students; 4) the schedule of practical hour accumulation over the course of the students’ education; 5) copies of practical experience logbooks to be used by the students; 6) inventories of all AT equipment; 7) list of pertinent texts and journals from the institutional library; 8) list of potential clinical and field placements (with proposed contractual agreements); and 9) other general information about the academic institution (CATA, 2007b). The PAC reviews all documents to decide whether the next stage of the process, a site visitation, is warranted.

The on-site evaluation includes a review of all didactic and practicum aspects of the academic program, including visits to both on-campus and off-campus practicum sites.

The purpose of this site visit is to validate the self-study report and to evaluate the program’s compliance with the CATA’s standards and guidelines. Before the PAC formulates its accreditation recommendation to the CATA, the post-secondary institution is given the option to respond to the site visit report by correcting any factual errors or commenting on any identified deficiencies. Once these steps have been completed, the

PAC determines a recommendation for accreditation (a two-year or four-year accreditation), or no accreditation, and sends the decision to the CATA’s Board of

Directors for ratification (CATA, 2007b).

When an academic institution is granted accreditation, it is still required to maintain accreditation on an annual basis by submitting curriculum forms and updated self-study reports. There are also scheduled site visits every four-years with the PAC

(except in unique circumstances [e.g., if the institution was on probation] that may warrant an earlier site visit). Failure to meet maintenance requirements may lead to changes in accreditation status or ultimately, having accreditation withdrawn.

Although the PAC ensures that all accredited institutions meet the required competencies of the CATA, there are still many differences in program design, curriculum delivery, practical experiences, and evaluation between each program. For example, Sheridan College offers a degree in AT (Bachelor of Applied Health Sciences:

Athletic Therapy) which delivers the CATA competencies through 52 courses over a four-year period (mixing theoretical knowledge with practical clinical and field placements). However, Mount Royal University delivers their competencies through a

two-year program. Students at Mount Royal University receive a post-graduate diploma in AT and require an undergraduate degree in a related field to gain entry into the program. Based on this fact alone, there are bound to be many differences in how the required competencies are presented to students. However, by stating that one program is longer in duration than another is not inferring that it is a better program. Rather it signifies how complex the AT educational landscape is in Canada, particularly since all students are attempting the same high-stakes certification exam.

1.3.3 Why might AT education be considered a complex phenomenon? The processes of teaching and learning are very complex by nature and are influenced by many different variables. The nature of these processes is affected by variables such as the learning environment, types of preferred pedagogies, students’ prior knowledge, differing learning styles, student attitudes towards learning, and educators’ attitudes towards teaching. These factors cannot be easily explored through simple cause and effect research methodologies because of their inherent complexities (Loughran, 2006).

Therefore, I believe that an exploration of any teaching and learning environment requires a more comprehensive analysis using a blend of quantitative and qualitative research tools.

Moreover, teaching and learning within health professional programs such as AT are especially complicated because of the expectation for students to acquire a mixture of theoretical knowledge and practical skills, demonstrating competence in both classroom and clinical environments (Carr & Drummond, 2002). For example, each student within a CATA-accredited program simultaneously completes courses in classroom and laboratory settings while also acquiring experience in diverse practical environments

(e.g., acting as a student therapist in a private sports therapy clinic, or as a first responder covering a live athletic event). Carr and Drummond (2002) have suggested that because of these numerous settings, domains, competencies, and expectations of AT students, educators should attempt to use a variety of pedagogical strategies to complement student learning in its multiple forms.

Further adding to the complexity of contemporary AT education, is the emergence of digital technologies in CATA-accredited programs. Many educational researchers posit that appropriate use of technology can potentially transform and enhance higher education teaching and learning (Berrett, Murphy, & Sullivan, 2012; Davies & West,

2013; Jackson, Helms, & Jackson, 2008). Others have expressed caution for technology integration by indicating that student distractions, faculty costs, and excessive time associated with learning how to use new tools may actually outweigh the benefits of technology integration (Smith, 2001; Tsai & Chai, 2012). However, with the innovative advancements of digital technologies and the increasing exposure of these technologies in educational contexts, educators have come to recognize the potential for integrating technologies in classroom settings (Issa et al., 2013).

Multimedia technologies are commonplace in today’s health professional programs (including AT), as they are frequently used in courses to simulate various scenarios, injuries, or illnesses (Issa et al., 2013). By creating realistic simulations/scenarios through innovative technologies, students are able to practise their skills in a ‘safe’ environment at any time, and in any place, eliminating the risks associated with practicing on actual patients (Issa et al., 2013). For example, if an AT student was working with a real patient (e.g., in an actual clinical setting) then there is a

risk that the patient could be harmed by the student if an incorrect procedure or technique was performed. Furthermore, the actual progress of the patient’s injury may be delayed while the student confirms a diagnosis or attempts various rehabilitative approaches in an inexperienced ‘trial-and-error’ approach. Thus, simulated environments reduce these risks by allowing the student to use authentic technology-assisted scenarios to practise the necessary theory, concepts, and skills before working with actual patients. However, scenario-based learning should not be considered as simple as designing a case, integrating various technologies, and giving it to the student. Educators need to consider and promote vital practices (e.g., promoting student reflection) by carefully designing these educational tools (Jonassen, 2000).

According to Moreno & Ortegano-Layne (2008), effective teaching in the 21st century requires an understanding of teaching and learning (pedagogical knowledge), subject matter (content knowledge), and knowledge of various technologies

(technological knowledge). More importantly, an educator should be able to combine these three types of ‘knowledges’ into an integrated form of teaching that applies pedagogically sound technologies to the curriculum. Since many medical educators have very little formalized teacher training, it is unlikely they will formally consider the pedagogical impact while attempting to integrate technology into their courses (Searle et al., 2011). Educators often focus on the logistics of learning how to use a specific type of technology, without considering how that technology actually affects their pedagogical choices, how it empowers their teaching, or how it enhances the course content (Mishra

& Koehler, 2006).

The purpose of my current research project was to design a pedagogically sound technology tool and to explore the impact of using this specific technology-assisted educational tool on the nature of teaching and learning in AT education. A theoretical framework known as TPACK was employed throughout my study to: 1) design this technology intervention; 2) guide the analysis of the empirical materials; 3) and to deconstruct the main research question.

1.4 Theoretical Framework: TPACK

In the early 2000s, the educational community acknowledged the lack of theoretical or conceptual frameworks that informed researchers or prepared educators for effective technology integration (Angeli & Valanides, 2005; Koehler & Mishra, 2008;

Margerum-Lays & Marx, 2003; Niess, 2005; Pierson, 2001). Combined with the continual presence of digital technologies in educational settings, created the need for original frameworks to guide educators’ thinking about technology integration.

Researchers posited “to promote teaching with technology, educators needed to develop a specialized body of knowledge for dealing with the complex teaching and learning situations that occur during the integration of technology in their actual teaching practices” (Bransford et al., 1986, p. 7). A theoretical framework that evolved from this need is known as the TPACK theoretical framework.

The TPACK framework provides researchers and educators alike with the theoretical means to recognize the types of knowledges that should be considered to effectively implement various technologies in the classroom. The TPACK framework was originally articulated by Punya Mishra and Matthew Koehler in 2006, as an extension of Lee Shulman’s pedagogical content knowledge (PCK) model. The early

work associated with this PCK model speculated that individual disciplines had unique pedagogies (also known as signature pedagogies) that fostered the ways of thinking within that specific discipline (Gurung, Chick, & Haynie, 2009). For example, psychologist educators taught in ways that made their students more likely to think like psychologists and medical educators taught in ways that made their students more likely to think like medical professionals. Shulman’s PCK model was an extension of the signature pedagogy concept by encouraging educators to move beyond being known as just content experts in their respective disciplines, and to contemplate the intersection between pedagogical knowledge and content knowledge (Shulman, 1986a). Shulman encouraged educators to explore different teaching strategies/approaches and to know when to use a particular strategy (e.g., knowing what makes a concept difficult to learn, assessing students’ prior knowledge, knowing what strategies fit specific course content).

The PCK framework also raised important questions such as, “what are the domains and categories of content knowledge in the minds of teachers” and “how are content knowledge and general pedagogical knowledge related?” (Shulman, 1986a, p. 9). Mishra and Koehler (2006) added a third dimension to this PCK framework, technological knowledge (and all of its overlaps with the other two knowledge domains), because of the absence of a comprehensive conceptual framework that considered the complex relationships among students, educators, content, technologies, teaching practices, and tools. Koehler and Mishra (2005), “view technology as a knowledge system that comes with its own biases, and affordances that make some technologies more applicable in some situations than others” (p. 132). According to these researchers, an understanding

of the TPACK framework is essential to effectively use technology to teach course content in pedagogically meaningful ways (Mishra & Koehler, 2006).

TPACK can be described as a model that conveys an understanding of the complex interplay between three main domains of knowledge – content, pedagogy, and technology. These knowledge domains should not be thought of in isolation, but rather as an integrated whole (Thompson & Mishra, 2007). Figure 1.1 illustrates the multifaceted relationships between the three domains of the TPACK model.

Koehler & Punya Mishra. Reprinted with permission.

By itself, content knowledge (CK) can be defined as the type of knowledge that covers course concepts, theories, ideas, organizational frameworks, knowledge of evidence and proof, as well as established practices and approaches toward developing such knowledge (Koehler & Mishra, 2009). Pedagogical knowledge (PK) is composed of the processes and methods of teaching and learning including understanding how

students learn, general classroom management skills, lesson planning, and modes of student assessment (Koehler & Mishra, 2009). Technological knowledge (TK) consists of specific ways of thinking about, and working with, technology, tools, and resources

(Koehler & Mishra, 2009). Table 1.1 provides a summary of each domain construct within the TPACK framework, complete with succinct definitions, and examples from

AT education.

The introduction of the TPACK model established a credible framework that contemporary theorists deemed necessary to effectively integrate technology into pedagogically sound teaching practices (Mishra & Koehler, 2006; Moreno & Ortegano-

Layne, 2008; Schmidt et al., 2009). According to these researchers, educators should have a certain amount of knowledge in each primary domain, while also being able to relate to, and integrate, each overlap with the rest of the other domains. For example, when educators decide to use a new piece of technology in the classroom, they should also consider the potential pedagogical implications of using that particular technology and think about how it actually enhances the course content or empowers their teaching.

As described earlier, the TPACK framework was used in my current research project to guide the analysis of empirical materials, and to deconstruct the research question. My project was divided into three distinct phases, each of which will be described in more detail in the Methodology chapter. The TPACK framework was also used to guide the development of the M-CBL SIAET, which was the specific technology- assisted pedagogy that was designed for this study. In the next section, the history of the design and development of this AT educational tool is presented.

Table 1.1 Definitions and Examples of TPACK Dimensions

TPACK Constructs Definition Example from AT Education

TK Knowledge about how to use General knowledge of using technological hardware and software computers, PowerPoint, Adobe Acrobat, etc.

CK Knowledge about the subject matter Knowledge about human without consideration about teaching the anatomy (or other related subject subjects)

PK Knowledge about the students’ learning, Knowledge about how to use instructional methods, educational PBL or CBL in the classroom theories, learning assessment (and how to evaluate performance)

PCK Knowledge of representing content Knowledge of using analogies knowledge and adopting specific or scaffolding to teach pedagogical strategies to make the topic orthopedic injury assessment more understandable for learners skills

TCK Knowledge about how to use technology Knowledge about Primal to create course content in different ways Anatomy Software and how without considering common teaching to use it to teach Anatomy methods content

TPK Knowledge of the existence and Knowledge of computer- specifications of various technologies to supported collaborative enable teaching approaches without learning opportunities reference towards course content

TPACK Knowledge of using various technologies Knowledge about how to use to teach and to facilitate knowledge a multimedia assessment CD- creation of specific course content ROM to enhance collaborative learning/peer- assisted learning opportunities when teaching orthopedic injury assessment content Note: Table adapted from Mishra & Koehler (2006).

1.5 The M-CBL SIAET

It was through my experiences as an AT student and educator that led me to improve my own teaching practice by developing a specific type of technology-assisted pedagogy. This tool, known as the M-CBL SIAET, was prototyped prior to the onset of my doctoral research (MacKinnon & King, 2012) but was significantly modified and improved during the current research project. Figure 1.2 provides a snapshot of the evolution of the M-CBL SIAET, complete with a summary of the additions and modifications that were addressed during each stage of development.

Originally, the tool was designed to integrate various multimedia technologies with sport injury case scenarios and was intended to be used as a supplementary resource to the traditional didactic lecturing in orthopedic assessment courses. Instead of just freelancing the design of the educational tool, development was grounded in ID theory.

Doctoral Research: Canadian Athletic Therapy Students •significant additions and improvements were made during this stage. These will be presented in the Results chapter, Pilot Project #2: including: UTECH Jamaican Pilot Project #1: Athletic Training •development of Acadia Kinesiology Students (2014) instructors guide Students (2012) •participants thought it •integration of Kinduct •initial tool design and would be advantageous animations development to embed videos that •addition of special test demonstrated the videos mechanisms of injury •participants requested more instructor involvement and •participants requested scaffolding of the more structured peer interaction activities diagnosis and treatment processes

•study findings led to the development of a specific pedagogical model to guide educational tool use

Figure 1.2. The evolution of the M-CBL SIAET. This figure shows the evolution of the tool by summarizing the significant modifications and additions that were made during each stage of development.

1.5.1 Original tool design: Underlying ID framework. When designing and developing educational tools or pedagogical resources, it is advantageous to use a specific model of ID to guide the process (Shibley, Amaral, Shank, & Shibley, 2011). ID can be defined as “the systematic and reflective process of translating principles of learning and instruction into plans for instructional materials, activities, information

resources, and evaluation” (Smith & Ragan, 2005, p. 4). Taking an ID approach can assist in: 1) improving the delivery of instruction; 2) helping to create effective and meaningful tools/lessons/resources; 3) ensuring that students have a more valuable learning experience; and 4) ensuring that educators consider different pedagogical strategies for diverse content areas (Smith & Ragan, 2005). By using ID models, it can also give structure and direction to exploring a pedagogical problem (Richey, Klein, &

Tracey, 2011).

According to Colon, Taylor, and Willis (2000), over 200 ID models have been published in the educational technology literature alone. Many of the traditional ID models follow a systems approach by using a reductionist lens to break instruction down into smaller, researchable components (Willis, 2009). Then the process of ID is often guided by a linear progression of analyzing, designing, developing, and evaluating educational materials. Examples of these instructional systems design models (such as the ADDIE Model and the Dick & Carey Model) are commonly found throughout the educational design literature (Gagne, Wager, Golas, Keller, & Russell, 2004; Gustafson

& Branch, 2002; Peterson, 2003; Shibley et al., 2011).

Even though reductionist models are prevalent in the educational ID literature, there are many limitations and weaknesses to these traditional models. Willis (1995) criticized these linear models because of the behaviourist foundations of promoting a sequential type of learning where students learn each step in a systematic order, until the entire sequence is learned. He further proposed eight characteristics that he considered to be the most undesirable with these traditional approaches: 1) the process is considered sequential and linear; 2) planning is top down and systematic; 3) objectives guide

development; 4) experts, who have special knowledge, are considered as being critical and central to the ID work; 5) careful sequencing and the teaching of subskills are important; 6) goal is delivery of preselected knowledge; 7) summative evaluation is critical; and 8) objective data are critical (Willis, 1995). When reviewing the strengths and weaknesses of common ID models, I realized that I supported the limitations as postulated by Willis (1995) and shared similar assumptions, values, and beliefs.

Therefore, I decided to use a non-reductionist ID model to design my educational tool.

The M-CBL SIAET was originally designed using a rapid prototyping framework which according to Jones and Richey (2000), “Involves the development of a working model of an instructional product that is used early in a project to assist in the analysis, design, development, and evaluation of an instructional innovation” (p. 63). Proponents of rapid prototyping consider it to be a sophisticated way of understanding a pedagogical problem because it encourages a non-linear way of thinking about ID. This method of inquiry is opposed to many traditional models of ID which endorse a more systematic and linear form of thinking (Piskurich, 2006). According to Selwyn (2011), designers and educators alike should not only focus on measurable/observable behaviours when developing pedagogical strategies and/or educational tools. Rather, they should also consider non-behaviourist theories and frameworks in an attempt to find out how learning actually takes place, what factors affect it, and how knowledge is constructed within the student mind. Furthermore, advocates of rapid prototyping view the traditional methods of ID to be incomplete, naïve, or even counterproductive because the up-front analysis that is used in these models is rarely sufficient enough to allow someone to select an instructional model with confidence (Hokanson & Miller, 2009).

Several ID researchers recommend integrating rapid prototyping within another non-bevaiourist ID framework to develop even more effective pedagogical tools (e.g., combining rapid prototyping with a constructivist ID model) (Jones & Richey, 2000;

Richey et al., 2011). According to Bednar, Cunningham, Duffy, and Perry (1992),

“instructional design and development must be based upon some theory of learning and/or cognition; effective design is possible only if the developer has developed reflexive awareness of the theoretical basis underlying the design” (p. 17). Integrating theories could potentially improve the effectiveness and appeal of a particular instructional strategy, while also reducing the amount of time needed to develop the prototype itself (Hokanson & Miller, 2009). Based on these assumptions and limitations of the traditional models of ID, I decided to select an ID model that coincided with my personal assumptions, beliefs, and values. This led me to explore the area of constructivist ID as the paradigm to situate the M-CBL SIAET.

1.5.2 Constructivist ID. Constructivist theories describe learning as being a process of knowledge construction that is based upon the learner’s previous experiences and prior knowledge (Gordon, 2009). Constructivist theories portray learning as a much more active process when compared to passive behaviourist interpretations.

Correspondingly, constructivists believe that the most effective learning occurs when individuals actively derive meaning from their experiences and the context in which the learning takes place (Richey et al., 2011). As Selwyn (2011) stated, “The constructivist learner is not solely receiving and acting upon information that is transmitted to them from others. Instead learners are seen as constructing their own perspective of the world through individual experiences” (p. 73). Aligning with this theory of learning, new

knowledge construction can be considered to be based upon previous learning experiences and further built through the process of individual exploration (Selwyn,

2011).

Constructivist ID theory has evolved from the criticisms of traditional behaviourist models, combined with the growing interest in constructivism in education and its view of the learning process (Smith & Ragan, 2005). The fundamental philosophical assumptions encompassing constructivist ID are rooted in three basic principles: 1) learning results from a personal interpretation of experience; 2) learning is an active process occurring in realistic and relevant situations; and 3) learning results from an exploration of multiple perspectives (Richey et al., 2011). These three basic tenets of constructivist ID can be applied with a non-linear, cyclical, and iterative design approach when attempting to address a pedagogical problem (Willis, 2009).

There are many different ID models that are based on constructivist principles, but a popular model to consider when designing technological educational tools is known as the Recursive, Reflective, Design, and Development (R2D2) model (Bonk & Zhang,

2006; Soto, 2013; Willis, 2009). The R2D2 model was first introduced by Jerry Willis in

1995 and provides a set of design guidelines rather than required steps. This model was built upon the following key principles for instructional design: 1) the design model follows an iterative process (recursive), allowing the developer to make refinements and revisions at any time (depending on what makes sense to the particular design); 2) reflection is based on feedback and ideas from many different sources, not just the developer; 3) the design is non-linear, meaning the tool was not created using a linear sequence of steps (such as the traditional general systems theory models); and 4) the

model is developed by a group of individuals (participatory design) and not just the developer because users are considered participants, not just observers (Richey et al.,

2011).

I decided to use this type of ID to develop my technology prototype because I wanted to use a model that was non-linear, followed an iterative approach, and allowed for more designer creativity and user input throughout the entire developmental process.

In addition, many of the traditional linear ID models ignore the interactions between instructors and students and do not involve multiple stakeholders in the design process.

For my educational tool, I wanted to explore the significance of these interactions because I considered them to be a very important component of designing effective educational resources for AT education.

After selecting the ID theory that guided the process of the educational tool development, the next steps were to: 1) decide upon the pedagogical model that would structure the tool design; 2) choose the technologies that would be integrated within the tool; and 3) design the actual template of each case scenario.

1.5.3 Original design: Educational tool. The M-CBL SIAET was designed for

AT students by using multimedia-enhanced case studies to provide a forum for practicing the necessary theory and skills of a detailed orthopedic injury assessment. A CBL pedagogical framework was implemented in the design of this tool because of its familiarity with AT educators/students and popularity in AT programs. One of the objectives of the current project was to have AT students and educators compare my innovative technology-assisted CBL approach to more traditional text-based cases that were historically used in AT classes. Many educators and clinical supervisors in the AT

profession implement various forms of case scenarios as a part of their teaching to provide students with simulated learning experiences (Thistlethwaite et al., 2012).

However, there is a wide range of comprehensiveness to the cases themselves and to the underlying teaching strategies considered in the activities. For example, some AT educators provide context to a particular topic by simply attaching an anecdote or story and consider it to be a CBL activity, while other AT educators use much more structured case assignments as authentic learning activities. By definition, both of these examples are representative of CBL. Due to these complexities of labelling and describing what actually constitutes a CBL activity, it becomes difficult to compare and contrast CBL to other teaching methods such as problem-based learning. Since there is no universal model to define a CBL activity, it is impossible to cluster all case scenario activities into a single framework and assess its impact on deep learning, critical thinking, or assessing the transfer of knowledge from simulated environments to real-life situations. Although there are many complexities associated with categorizing CBL, it has been shown to be a useful teaching tool in AT programs. According to Mensch and Ennis (2002), most AT students and instructors consider the use of scenarios and case studies to be an essential component of the educational experience because: 1) they make learning more meaningful by allowing students to integrate content knowledge with practical skills; 2) they offer real-life context to normally hypothetical injury situations; 3) they allow for critical thinking opportunities by encouraging students to make decisions of how to handle each situation; and 4) they increase student motivation/engagement by using discussions and peer interactions to work through each case.

The M-CBL SIAET was designed with the Adobe Acrobat® Reader software because of the program’s ability to be edited and interact with all types of portable document format (.pdf) content, including various forms and multimedia. In addition, since Adobe Reader is a free program that can be downloaded to any computer, tablet, or smartphone, it is easily accessible for any student that has an electronic device and access to the internet. The organizational system within Acrobat also streamlines the process of indexing different pages, sections, and multimedia links to allow for easy navigation through different case studies.

The original educational tool was housed on an Acadia University webpage and included a single case study of an ankle injury. Interactive technologies were incorporated into this supplemental resource to make the scenario more engaging when compared to traditional text-based cases. It was also thought that these interactive case studies would help to extend learning beyond the classroom doors by allowing students to have access to detailed scenarios at any time. Through the course of development, it was assumed that students would have constant access to adequate internet bandwidth to access all interactive technologies included in the tool.

The template for the case (as seen in Figure 1.3) included: a scenario (e.g., a 21- year-old high jumper injures her ankle); timeframe photos breaking down the mechanism of injury; interactive 3-d models (created using Object2VR® software); an information section (patient history with probing questions, orthopedic assessment, observations); the problem to be solved; and proposed treatment plans. Figures 1.4 and 1.5 show the interactive anatomy models that were developed using the Object2VR® software.

Figure 1.3. The original case study template. This image shows the contents of the very first case scenario for the M-CBL SIAET.

Figure 1.4. Example of Object2VR® interactive models. This picture depicts a lower leg/ankle skeleton anatomical model.

Figure 1.5. Example of Object2VR® interactive models. This picture depicts a lower leg/ankle muscular anatomical model.

These models could be opened as Quicktime® movies and manipulated by the student so they could navigate around the model and rotate it in the x, y, and z planes. Students could also zoom in on the model to magnify any salient features of the model such as sites of muscle attachment.

After developing the original educational tool, I completed two pilot projects prior to designing this current research project. The purpose of these pilot projects was: 1) to solicit participant feedback regarding improvements, additions, and modifications for the educational tool; 2) to create a more streamlined educational tool that could then be presented in my current project; 3) to complete initial explorations concerning the impact of integrative technologies on the nature of learning in health professional students. The significant findings from these pilot studies are presented in the ensuing sections.

1.5.4. Pilot study #1: Acadia University; kinesiology students. After designing the M-CBL SIAET it was originally piloted with a group of 14 undergraduate

kinesiology students (and course instructor) who were enrolled in a sports therapy course at Acadia University (MacKinnon & King, 2012). The main objective of this project was to elicit feedback on the best way to incorporate interactive technologies into a meaningful case study learning activity.

The educational tool was implemented in the sports therapy course and the students/instructor were approached for feedback through a survey, individual interviews, and focus groups. In a general sense, the results suggested that the participants viewed the educational tool as being a productive resource. However, the overwhelming response from participants was that the multimedia tool needed to be embedded in a teaching and learning model that invoked more instructor involvement and scaffolding of the diagnosis and treatment processes. At the time of original design, I was unaware of the TPACK framework and did not consider how to integrate technology in pedagogically meaningful ways. Truthfully, I did not acknowledge the importance of considering the pedagogical impact of technology integration. The findings from this pilot project prompted me to consider a more comprehensive investigation of the TPACK framework and led to the development of a detailed instructional model to accompany the educational tool (Figure 1.6). This proposed model of instruction was built upon established principles of quality teaching in higher education as identified by Chickering

& Gamson (1986).

First Case study Instructor Led Addressed in Analysis – step-wise Lecture approach, techniques demo

Student/Instructor Interaction – Socratic; Q/A 2 Practice Case Online Feedback – Studies Online encourage student teams to practice techniques

Case Study Assignment (Independent)

Figure 1.6. The instructional model that was designed for use with the Multimedia

Sports Injury Assessment Tool. The model demonstrates a sample step-by-step approach of how to implement the educational tool in an AT classroom setting.

In an effort to respond to participant feedback, it was recommended that future use of the educational tool should begin with an example case study led by the course instructor. This would give students the opportunity to see how the educator worked through the problem (by having the instructor think out loud) and how the instructor might follow a systematic approach to assessing an injury. Another recommendation to assist in the instructor-led case was to include a concept map activity. An instructor could use this type of activity to scaffold instruction by building a concept map with students, involving the various components and processes required to assess/diagnose an injury. An example of a completed concept map is included in Figure 1.7.

Figure 1.7. A sample orthopedic assessment concept map. This is an example of an activity that could be completed with AT students to get them to think about the steps required to complete an effective orthopedic assessment.

After reviewing the findings from this project, improvements were made to the

M-CBL SIAET and another action research study was carried out with a sample of athletic training students from the University of Technology in Kingston, Jamaica. 33

1.5.5 Pilot study #2: University of Technology, Jamaica; athletic training students. With the introduction of a new instructional model, more case scenarios were needed for future implications. Therefore, four more scenarios were added to the tool before the onset of the second pilot project, including two shoulder injuries and two elbow injuries (to go along with the original ankle injury scenario). Modifications were also made to the template of each case scenario with the addition of further brainstorming questions and more detailed probing questions in each section. Finally, participants from the initial pilot study experienced problems when attempting to access the interactive technologies unless they were connected to a high-speed internet network. To resolve this issue, the educational tool was moved to a DVD format (with all technologies being embedded on the disc) so that students were not dependent on being connected to the internet (or having a high quality connection) to access the multimedia. This modification was considered very important for AT educational settings because oftentimes students are studying in environments where they cannot access high quality internet. For example, AT students often study while on field/clinical placement that may involve studying on a bus, plane, football field, or hockey rink. Even in the current climate of technological advancement, internet access is not always guaranteed in these field/clinical settings.

After invoking the aforementioned changes, a second pilot study was carried out with 15 students from the Bachelor of Science in Sports Sciences (Sport Athletic

Training Stream) program at the University of Technology in Kingston, Jamaica (King,

MacKinnon, & Lawrence, 2014). The main objectives of this study were: 1) to elicit student feedback on the effectiveness of multimedia CBL in a more specific context

(Jamaican athletic training education); 2) to evaluate the effectiveness of the proposed teaching model; 3) to explore the best ways to integrate technology into injury case studies; 4) to investigate cultural differences in the way the curriculum and the learning process was perceived; and 5) to investigate cultural differences in the way students perceived or engaged with the educational tool.

The results from this study suggested that the educational tool was effective in helping the participants to think critically about how to assess/react to injury simulations.

The participants also provided suggestions of how to streamline the technologies and offered ways to improve the instructional model. These participants thought that it would be advantageous to embed videos to demonstrate the mechanisms of injury so they could observe exactly what happened to the injured athlete. In addition, participants requested a more structured peer interaction section so that there was a list of activities for them to work on together as they moved through each scenario. These suggestions were noted and modifications were made within one of the stages of my doctoral research (Phase 2).

A further discussion of these modifications is presented in the Results chapter.

These two pilot projects allowed me to improve an educational tool prototype by gathering valuable participant feedback. Following the guidelines of the R2D2 ID model,

I used these suggestions to make the necessary additions and improvements so that a more streamlined technology-assisted pedagogy was presented to participants in my current research project. It is also important to note that both pilot projects involved students from either outside the AT profession, or from an international context.

Although many similarities exist between these settings, the goal of the current study was to explore the impact of this technology-assisted pedagogy with CATA-accredited

institutions in Canada. A general summary depicting the relationship between my pilot projects and doctoral research is included in Figure 1.8.

1.6 How My Doctoral Research Pursued Broader Understandings of AT Classroom

Interventions?

While one of the objectives of the current study was to develop a multimedia tool that could be used within CATA-accredited institutions across Canada, I was more interested in how the technological educational tool impacted the nature of teaching and learning in this specific context. When compared to my two pilot projects, a much more detailed investigation was employed in this study to explore participants’ considerations

(both student and instructor) of effective technology integration and the resulting impact on pedagogy. As previously discussed, exploring such a research question is very complex because of the many factors and variables that influence the nature of teaching and learning in AT education. Therefore, it was important to use a theoretical framework to help deconstruct the complexities associated with this phenomenon. In the current study, the TPACK framework was used during all phases of research (each phase is described in detail in the Methodology chapter) to: 1) design/modify the M-CBL SIAET;

2) describe AT educators’ initial attitudes towards using technology in AT education; 3) guide the analysis of the empirical materials; 4) promote critical thinking about pedagogically meaningful technology integration in AT education; 5) deconstruct the main research question; and 6) provide practical/applied implications for AT educators.

In the next chapter, the Literature Review, I present the significant findings from the research areas that were introduced in this chapter and identify any gaps in theory or practice. It was evident that very little prior research investigated the use of

pedagogically sound technologies in AT, especially in a Canadian context, thus creating a need for my study.

Doctoral Research Doctoral Research Question Objective Previous Pilot Studies What impact does using a Designed and explored the effectiveness of To develop a multimedia multimedia CBL pedagogy have a multimedia CBL educational tool CBL educational tool for on the nature of teaching and prototype in similar disciplines to athletic use in CATA-accredited learning in CATA-accredited therapy programs in Canada education programs?

Kinesiology Athletic Athletic Therapy Students Training Students Acadia Students CATA-Accredited University UTECH, Institutions Jamaica

Figure 1.8. This graphic shows the relationship between my initial pilot projects and the current research project. It briefly describes the research objectives of each project as well as defines the participants from each study.

CHAPTER 2: LITERATURE REVIEW

Chapter 2 Outline

This chapter provides an overview of the literature associated with using technology-assisted pedagogies in AT education, beginning with identifying the signature pedagogies used within AT classrooms, including an introduction to CBL. Shulman

(2005) defines signature pedagogies as “the types of teaching that organize the fundamental ways in which future practitioners are educated for their new professions”

(p. 52). A signature pedagogy has three main dimensions: 1) the surface structure, which consists of the concrete and operational acts of teaching and learning; 2) the deep structures, which reflect a set of assumptions about how to best impart a certain body of knowledge; and 3) the implicit structure that comprises a set of beliefs about professional attitudes, values, and dispositions (Shulman, 2005). Educators use defined teaching approaches that are inextricably linked to the course content and are dependent upon many different factors such as the needs and interests of a particular profession.

Since the technological educational tool for the current study (the M-CBL

SIAET) was situated within a CBL model, a detailed literature review is presented on: the history of CBL as a pedagogical strategy; using CBL in AT education programs; the transfer of knowledge during CBL activities; and the influence of integrating multimedia technologies within CBL frameworks. The remainder of the chapter presents literature related to using pedagogically sound technologies to empower AT education, with a specific focus on research situated within the TPACK framework. As a component of this chapter, significant research gaps are identified, thus demonstrating the need for my research project.

2.1 Introduction to the Research Area

Digital technologies and technology-enhanced learning strategies continue to influence the ways that course content is delivered in health professional education programs, including AT (McCoy et al., 2015). There is some research evidence that suggests current health professional students expect their educators to use a variety of digital technologies as a part of their teaching because of the capacity to: provide more detailed context to a particular topic; simulate accurate/realistic experiences; and provide rapid and interactive feedback to both the student and educator (McCoy et al., 2015).

While new digital technologies tend to attract AT educators to explore their functionality, the potential for empowering pedagogy is often a secondary consideration

(Mishra & Koehler, 2006). Given that the present-day student lives in a culture of innovative emerging technologies, it is imperative that educators critically assess the potential roles for technology integration in enhancing classroom learning (Liang, Walls,

Hicks, Clayton, & Yang, 2006). However, this is not a simple task, especially when one considers the complexities of classroom interactions within CATA-accredited institutions. In these settings, students are exposed to a variety of learning environments

(e.g., classroom, field, and clinic), content, pedagogical strategies, activities, and innovative technologies, with the ultimate goal of demonstrating competence in a defined list of skills and abilities as set by the CATA.

Before discussing the use of technology-assisted pedagogies in AT education, it is important to first identify the most common AT teaching approaches (often referred to as the signature pedagogies) employed in CATA-accredited institutions. Once identified, I will discuss how digital technologies impact these pedagogies.

2.2 Signature Pedagogies in AT Education

As previously described in the Introduction chapter, the CATA defines the detailed learning objectives for accredited institutions by dictating a list of specific core competencies. These competencies help with curriculum development as each CATA- accredited institution must provide evidence that their courses, labs, and practica deliver all the required competencies. Core competencies are organized into six main professional AT domain areas, including: 1) prevention; 2) recognition and evaluation; 3) management, treatment and disposition; 4) rehabilitation; 5) organization and administration; and 6) education and counseling (Appendix A). However, although there is a detailed list of competencies developed by the national organization, it is still up to individual educators at each institution to design courses that respond to the professional outcomes set by the CATA.

Some AT educators have a formalized background in pedagogy but many others do not (Searle et al., 2011). It is therefore important to define the range of pedagogical approaches in AT education by exploring the signature pedagogies used by educators to deliver the core competencies/curriculum. After reviewing the literature, there were no apparent studies that identified what proportion of educators at CATA-accredited institutions actually have a certified background in pedagogy. Similarly, little is known about the number of American educators with formal pedagogical knowledge. In one study however, Hertel, West, Buckley and Denegar (2001) interviewed 116 AT educators throughout the USA and asked what competencies were viewed as being the most important of an effective educator. These participants rated the skills and strategies required to teach AT courses (pedagogical knowledge) as being the most important competency for an effective educator. The results from this study also indicated that the majority of AT educators were interested in improving their own personal pedagogical 41

knowledge by taking additional courses in pedagogy and/or attending professional workshops related to this area.

Traditionally, health professional educators develop their signature pedagogies and teaching philosophies by using a combination of their own experiences as a learner and through general conceptions about teaching acquired from personal experiences and observations (McLeod et al., 2009). In many of these health professional programs, there is a tacit assumption that expertise in clinical practice automatically translates into competence in clinical teaching. However, studies suggest that mere content expertise does not necessarily correspond to teaching excellence (Darling-Hammond & Youngs,

2002; Misch, 2002).

As previously discussed, there are many different domains, knowledges, skills, and competencies expected of an AT student as a part of their educational program (Carr

& Drummond, 2002). The main goal of any CATA-accredited institution is to educate each student while assisting in their development towards becoming competent health professionals. Therefore, it seems reasonable that AT educators should be familiar with diverse pedagogical strategies to ensure student learning in its multiple forms and styles

(Pashler, McDaniel, Rohrer, & Bjork, 2008). However, within these CATA-accredited institutions many educators use teaching strategies that encourage a singular, passive mode of learning by offering a body of knowledge in a sequence of lectures and then asking their students to internalize that knowledge outside of class on their own time

(Paul & Elder, 2001). Conversely, current learning theory (Bryan, Kreuter, & Brownson,

2009; McLean & Gibbs, 2009) suggests that the education of an AT student should involve complementary active modes of learning that promote a balance between foundational knowledge acquisition, practical skill application, and clinical reasoning skill development. 42

Few educational researchers have attempted to investigate the range of signature pedagogies employed by CATA-accredited programs. Mensch and Ennis (2002) examined the types of pedagogical strategies used in five NATA-accredited AT education programs from Pennsylvania, Virginia, and Maryland. More specifically, these researchers were focused on identifying the pedagogical strategies that were recognized by students as being essential components to their success in an accredited curriculum.

The results of this study showed that the most beneficial strategies were identified as: using CBL; creating authentic athletic training experiences through observational or hands-on activities; and using collaborative/peer activities. Although these strategies were considered to be the most valuable by the sample of students, AT educators at these institutions still predominately used the passive, didactic lecture method as their preferred pedagogy.

Mazerolle and Yeargin (2010) investigated how various pedagogical tools were used by NATA-accredited programs to promote a deeper understanding of anatomy and its relationship to athletic injuries. These researchers found that the most effective pedagogical strategies for teaching anatomy to AT students were: CBL, concept mapping, collaborative assignments, injury simulations, and univocal/dialogic discourse.

These authors also suggested that effective educators should introduce learners to a variety of instructional methods, to allow for differences in learning styles. Although, it is important to note that the claim that students have different learning styles is controversial (Feely & Biggerstaff, 2015).

Other educational researchers have investigated the use of active-learning strategies in AT education. Walker (2003) outlined the importance of developing a disposition to think critically in AT students and encouraged educators to explore active- learning strategies to endorse this practice. Activities such as developing Socratic 43

questioning skills, using case scenarios, allowing time for peer discussions, organizing topic debates, and allocating reflective written assignments can all be used to promote critical thinking, if used properly. Walker (2003), has posited that to implement these strategies effectively, an educator should expose students to a variety of activities/teaching methods that are designed with the specific goal of stimulating critical thought. These recommendations for implementing multiple pedagogical strategies are also supported in the literature by other researchers. According to Kloss (1994),

“students must be exposed to ambiguity and multiple interpretations and perspectives of a situation or problem in order to stimulate growth” (p. 154).

The majority of the AT signature pedagogy research originated in NATA- accredited programs of the USA (Mazerolle & Yeargin, 2010; Mensch & Ennis, 2002).

As previously stated, no known educational researchers have investigated the types of pedagogies that are most prevalent in Canadian AT education programs. It was therefore important to address this gap within the design of my study. Phase 1 of my data collection (introduced in Section 3.3.1 of the Methodology chapter) involved asking AT educators, through questionnaires and interviews, to identify the types of pedagogies that they used most frequently as a part of their teaching. Furthermore, these educators were asked how they perceived their personal level of pedagogical knowledge and how this level of knowledge was developed. These findings from Phase 1 are presented later in the Results chapter.

While there is a dearth of research capturing the Canadian AT context, through my own anecdotal observations, informal conversations with AT educators, and in conjunction with previous research (Mazerolle & Yeargin, 2010; Mensch & Ennis, 2002;

Speicher, Bell, Kehrhahn, & Casa, 2012), CBL appears to be one of the most commonly used pedagogical strategies in Canadian AT education. AT educators often use case 44

scenarios (either formally or informally) in a number of different courses to challenge students to apply their knowledge and skills to real-life situations. Educators are also able to examine the level of student competence while they are working on such cases.

Based on these trends, CBL was the model chosen to structure the M-CBL SIAET.

Furthermore, CBL is an example of a constructivist learning environment, recognized in the literature as being an established form of active-learning that is very effective and popular with contemporary learning preferences, especially in health professional education programs (Ahmad, Ching, Yahaya, & Abdullah, 2015; Brooks & Brooks,

1993).

2.3 What is CBL?

Case-based learning is a particular method of teaching that poses an active problem for students to solve, based on a real-life situation or hypothetical simulation

(Berry, Miller, & Berry, 2011). To successfully complete any CBL activity, a student needs to participate in a situated learning environment that emphasizes the need to find associations between content, context, understanding, meaning, and the construction of various types of knowledge (Kim & Hannafin, 2009). For example, in AT education, a

CBL activity could provide a student with a simulation of an athletic injury (e.g., ankle sprain scenario) and have the student work through the case to ultimately find a solution, or more specifically, use the information within the scenario to figure out the type and degree of simulated injury (also known as developing an index of suspicion).

The formal adoption of CBL as a pedagogical strategy first emerged in 1870 under the guidance of Christopher Columbus Langdell, a Dean at Harvard Law School

(Merseth, 1991). The main objective of this innovative type of instruction was to use real-life examples to practise the intricacies of analyzing and discussing individual law cases. Although this method was initially met with skepticism from other law schools in 45

the United States, by 1915 CBL was implemented in most of the well-known law schools throughout that country (Culbertson, Jacobson, & Reller, 1959). With supportive anecdotal and empirical evidence being presented in the literature (Culbertson et al.,

1959; Merseth, 1991), CBL soon became a commonly used instructional strategy (Dunn

& Brooks, 2007) and was adopted by other professional programs in business, medical, and teacher education. This type of instruction remains in frequent use in many professional programs throughout the world, especially within health professional education programs such as AT (Levett-Jones, Gilligan, Lapkin, & Hoffman, 2012).

2.4 CBL in AT Education Programs

The CBL pedagogical strategy is regularly used in medical professions, such as

AT, because it provides a safe, dynamic, and simulated learning environment for students to acquire, analyze, learn, and judge the clinical decision-making skills necessary to appropriately handle injury situations (Berry et al., 2011). Most of the cases used in CBL activities are based on actual patient scenarios and are presented in one of the following formats: 1) simulated (people act as a patient with specific problems; often referred to as standardized patient models); 2) real (the student is working in an actual healthcare setting under the direct supervision of a certified professional); 3) text-based (text is used to describe the patient’s problems); or 4) virtual (using multimedia technology to simulate a patient with specific problems) (Thistlethwaite et al., 2012).

Despite the fact that CBL appears to be frequently used in AT education programs, there have been few educational researchers explore the potential benefits and limitations of this strategy within this specific context. Furthermore, most of the research that has been completed in this area is theoretical by nature and provides a weak rationale as to why CBL should be considered by AT educators. For example, Speicher et al.

(2012) provide only a discussion of CBL and how it could be implemented to improve 46

AT students’ clinical reasoning skills, student motivation, and critical thinking ability.

Even though there are limited findings to inform the AT profession, the use of CBL is well researched in other health professions (e.g., medicine and nursing) so these findings can help to provide potential benefits for this particular teaching strategy within AT classrooms.

Van Dijken et al. (2008) evaluated a CBL approach to teaching pathophysiology topics to 244 medical students. These researchers developed interactive discussion-based clinical cases and added them to the pathophysiology curriculum at the University

Hospital in Lausanne, Switzerland. Students were exposed to traditional didactic lectures for the majority of their classes but were then asked to work with the CBL approach towards the end of their semester. They were then asked to evaluate the CBL pedagogical approach by comparing it to the traditional didactic delivery method. The results showed that the majority of students had a positive experience with CBL teaching and learning. More specifically, this sample of students found CBL to be more a stimulating, interactive, and motivating pedagogical strategy and was considered to be an effective way to bridge the gap between theory and practice in pathophysiology courses.

Hofsten, Gustafsson, and Haggstrom (2010) explored the use of CBL in a sample of 72 nursing students from the University of Gavle in Sweden. The sample of students included in this study suggested that CBL helped them to develop a deeper understanding of the course material because of the opportunity for collaborative discussion with other students. They also suggested that CBL helped to improve their critical thinking abilities by integrating course theory with practical skills and forcing them to apply it to real-life situations. In addition, they suggested that CBL allowed for increased participation when compared to the traditional didactic lecture method, where many students chose not to

participate in class discussions because of a variety of reasons, including: a sense of lack of engagement; introverted personalities; and a fear of failure.

Williams (2006) completed a qualitative analysis of undergraduate paramedic students’ perceptions towards using CBL in an online learning environment. This sample of students viewed CBL as being an enjoyable learning experience by giving the opportunity to integrate content theory with real-world examples. Several students commented that the ability to associate a specific clinical situation with ‘real’ stories would make it more likely that they would remember the pertinent points when faced with a similar situation out on the job. Williams (2006) concluded that CBL was a useful and enjoyable teaching and learning tool with advantages of increased student motivation and a student forum to integrate theory with clinical skills. The author also posited that similar research should be carried out in other health professions to see how CBL is viewed in different educational contexts.

The findings from these studies reveal potential benefits for using CBL as a pedagogical strategy in AT education. However, there are many other pedagogical strategies that are also available to AT educators, all with their own potential benefits.

For example, problem-based learning (PBL) and the clinical presentation model of curriculum delivery are other examples of popular pedagogical strategies that are frequently used in health professional programs (Savery, 2015). The literature suggests that AT educators should consider a range of factors when deciding upon what strategy to use to deliver the curriculum, including: available resources; knowledge with the pedagogical strategy; students’ prior knowledge; students’ prior experiences; and transferability of knowledge within the selected pedagogical framework (Savery, 2015;

Speicher et al., 2012).

To summarize, the main goal of CBL as a pedagogical strategy is for the student to learn from a particular scenario in a simulated environment and to be able to transfer the knowledge and skills acquired from that context when faced with similar real-life situations. For example, if an AT student learned how to perform an ankle sprain assessment in a CBL activity (e.g., an ankle injury in a football athlete), would the knowledge and skills learned from that scenario transfer to another related context (e.g., an ankle injury in a real-life soccer player)? This should be a primary consideration for

AT educators because a main goal of instruction should be to ensure that students are retaining knowledge while acquiring the problem-solving skills and decision-making abilities to transfer over when working with actual real-life individuals (Speicher et al.,

2012). Thus, when choosing a pedagogical strategy for the delivery of a particular topic, an educator should be familiar with how that strategy assists in the transfer of knowledge for students, while also realizing the important factors that actually impact knowledge transfer (Merriam & Leahy, 2005).

2.4.1 Transfer of knowledge and skills in CBL. In educational settings, knowledge transfer (also known as learning transfer) refers to the capacity to apply acquired knowledge and skills to new situations (e.g., learning in one context and applying it to another) (Kolodner, Gray, & Fasse, 2003). For the transfer of knowledge to occur, three main processes are required: 1) recalling something relevant from memory; 2) deciding on its applicability and relating prior knowledge to a new context; and 3) applying what has been recalled to a new situation (Kolodner et al., 2003).

According to Bransford, Brown, and Cocking (1999), knowledge transfer can only be expected if a student actually understands a concept or strategy well, therefore rote memorization of facts cannot be expected to promote the transfer of knowledge to actual real-life contexts. Based on these assumptions, an AT educator should focus on using 49

active-learning strategies where deeper understanding is facilitated, instead of the surface type of learning associated with rote memorization.

Other important factors that impact the transfer of knowledge include the concepts of deep understanding and deliberate practice (Ericsson, Krampe, & Tesch-

Romer, 1993). Deep understanding refers to a student’s ability to move past the surface approach to learning and to actively seek an enriched understanding of the material

(Fullan & Langworthy, 2014). This type of learning allows the student to: relate concepts to everyday experiences; relate ideas to one another; relate ideas to previous knowledge; make informed decisions; and justify why a particular decision was made (Fullan &

Langworthy, 2014). Considerable time, support, and deliberate practise is needed to be able to develop a deeper understanding of a particular concept/topic. According to

Ericsson et al. (1993) students require deliberate practice with frequent feedback from the instructor to allow them to assess their own depth of understanding and to evaluate transfer implications of what they are learning. Although complicated concepts, these factors should be considered by AT educators when comparing the effectiveness of different pedagogical strategies to transfer skills to real-life situations.

The transfer of learning is also influenced by prior experiences and the context of the initial learning experience. When a student is presented with a contextually-enriched example, and is able to fully understand a problem and its underlying structure, then transfer to similar situations can occur (Dixon & Brown, 2012). Therefore, exposing students to multiple contexts, including examples from a wide application base, help to develop a flexible representation of the knowledge and skills required to complete a specific task (Dixon & Brown, 2012). This process should help to facilitate the transferability of important skills from simulated environments to real-life contexts.

One of the most difficult aspects of comparing learning transfer in different pedagogical strategies is that there are no universal guidelines for employing such teaching methods. This creates difficulties when trying to objectively measure factors such as knowledge/learning transfer to determine the ‘most effective’ model for transferring knowledge or skills from simulated experiences to real-life situations. For example, individual educators may use slightly different curriculum models (e.g., one educator may perform a base set of lectures first and then incorporate a CBL activity; whereas another educator may structure the entire lesson within a CBL activity), ask a different series of questions (e.g., the level of pedagogical knowledge dictates the types and depth of questions asked), or use different activities/resources to structure the session. Therefore, it is almost impossible to objectively compare the transfer of knowledge within CBL activities to other pedagogical strategies (e.g., PBL or clinical presentations models) because of too many confounding variables to determine causal effects. Even though comparisons are difficult to make, there are some promising findings within the CBL literature that endorse it as an effective method in allowing students to acquire knowledge and skills and transfer these abilities to real-life situations.

Kantar and Massouh (2015) completed a qualitative study with a cohort of nursing students, exploring the specific professional skills that were gained through implementing a CBL instructional approach. The findings from this study suggested that the CBL approach was more effective than the traditional didactic lecture in developing professional skills that transferred over to actual clinical practice, including: recognizing the particulars of a clinical situation; making sense of patient information; making informed decisions (based on patient information); considering multiple forms of inquiry; enhancing professional self-concept (through self-awareness from the process of

reflection); and improving professional caring (based on more in-depth interactions with the patients).

Furthermore, Morrow, Sepdham, Snell, Lindeman, and Dobbie (2010) evaluated the effectiveness of using web-based case studies with 210 medical students. These researchers found that their cases helped to expand student knowledge on specific conditions, especially ones that they were not exposed to in clinical settings. The students indicated that their clinical environment was completely randomized where they may experience the same condition five times in one day and never get the opportunity to deal with another condition that they were expected to know. Therefore, cases were able to supplement learning in topics that were absent from clinical experiences. The participants from this study also considered CBL to be a useful vehicle to help transfer learning from foundational knowledge/theory into clinical application.

Although there is potential for CBL to be considered an effective pedagogical strategy in AT education, it is difficult to make comparisons with other models of curriculum delivery and to ultimately determine the ‘most effective’ strategy. There are many inherent complexities that make it near impossible to design a controlled study that objectively measures the differences in student performance/competence and thus makes comparisons between strategies difficult. It seems clear that AT educators need to make careful decisions regarding the types of pedagogies that fit into their personal curriculum delivery model, teaching philosophy, and objectives for the course. These educators should also have an in-depth understanding of how to implement each particular strategy and know what factors need to be considered to make it an effective strategy that promotes deeper understanding.

One of the most promising characteristics of using CBL as a pedagogical strategy in AT education is that multimedia technologies can be implemented into simulated 52

scenarios to create a more contextually-authentic experience for the student. Even though it is important to note that there are many aspects of authenticity that need to be taken into consideration by the case designer. For example, a discourse analysis study by

MacLeod (2011) exposed how the writing of cases in medical education actually impacted the authenticity of the scenarios and how they were viewed in comparison to real-life encounters. This study uncovered how cases are often trivialized by medical students into thinking that they are just a type of ‘detective game’ instead of considering it a realistic experience. By trivializing these case experiences, it takes away from the ultimate goal of the simulation activity which is to mimic an actual real-life clinical encounter with a patient. Similarly, writing cases in a passive tone, using joke names for patients, and failing to include important social information all potentially impacts the authenticity of a case and how it is perceived by the learner (MacLeod, 2011).

Innovative case studies have the potential to benefit AT classrooms because they can provide a simulation of actual injury situations, therefore creating an enhanced contextual environment, increasing student engagement/motivation, promoting deeper understanding, and developing critical thinking ability. However, careful consideration is required into the writing, implementing, and use of case scenarios to ensure that they are contextually-authentic and place the student in a realistic experience.

2.5 The Influence of Multimedia Technology on CBL

As discussed in the preceding section, technology-enhanced CBL activities have the potential to impact learning transfer by creating an authentic contextual environment that encourages deeper levels of critical analysis. Several researchers have proposed that multimedia technology can in fact be combined with a CBL framework to present students with a more complete and accurate depiction of the necessary complexities required to work through a case scenario process (Han, Eom, & Shin, 2013; Kurz & 53

Batarelo, 2010; Moreno & Ortegano-Layne, 2008). Boltz (2002) suggested that multimedia case studies could be advantageous for student learning by combining the strengths of a CBL method with important tenets of constructivist learning. More specifically, Boltz (2002) posited that multimedia technology could be used to create more authentic, realistic, and complex case scenarios that can positively affect factors such as learning retention, cognitive learning objectives, student motivation, and attitudes towards learning. Even though these ideas sound promising, few researchers have actually explored the integration of technology-assisted pedagogies in an AT specific context.

Wikstein, Spanier, and LaMaster (2002) examined the effectiveness of using a multimedia platform with NATA AT students as a supplemental tool to the traditional didactic lecture instruction. These researchers randomly assigned AT students to either the traditional lecture group or the traditional lecture combined with the multimedia platform group. Combined scores from two written examinations and one practical examination were then compared between these two groups. In addition, all students wrote weekly journals and participated in a focus-group interview to express their feelings toward the various educational resources. The results of this small sample study

(26 AT students in total) suggested that there was no significant quantitative difference in test performance between the lecture group and the group who used a combination of lectures with multimedia technology supplements. However, qualitative data in the form of interviews and focus groups suggested that the use of multimedia technology significantly increased student motivation, engagement, and access to important course material. These authors concluded that AT educators should explore effective ways to integrate multimedia technology into their classrooms.

Rehberg, Gazzillo-Diaz, and Middlemas (2009) compared the effectiveness of two instructional methods in teaching AT students how to perform cardiopulmonary resuscitation (CPR). Subjects in Group 1 took part in the CPR training program through traditional classroom instruction (including lectures, watching videos, and opportunities for skill practice). Subjects in Group 2 participated in the online version of the CPR training program. This program presented subjects with the same content as the traditional classroom instruction but also included a series of simulations where subjects were required to indicate the correct procedures/processes. After completing the program, the performance of both groups was evaluated through a standardized written examination and skill performance (e.g., performance in compression depth, compression rate, and correct hand position). The results showed no statistically significant differences between groups on the standardized written exam but there were significant differences in the quality of CPR compressions, ventilation rates, and volume (Group 1 performed better than Group 2). Based on these findings, the authors suggested that multimedia technology can be beneficial for AT classrooms but students also need to be given the opportunity to practise the hands-on skills with one another to develop competence.

Other educational researchers have supported the use of multimedia CBL in AT classrooms, but these sentiments are opinion-based rather than being grounded in research findings. For example, Payne, Berry and Lowry (2012) suggested that AT educators should be encouraged to research and use innovative teaching strategies, including implementing advanced digital technologies, because of the resulting impact on student learning. These authors endorsed innovative active-learning strategies to further develop critical thinking abilities that will ultimately make the student a more competent health professional. 55

Because there are a limited number of research-based articles that have explored the use of technology-assisted pedagogies in an AT specific context, there is a need for further research and/or conceptualization in this area. It was recognition of these significant gaps within the AT literature that led to the development of the M-CBL

SIAET (as introduced in Section 1.5 of the Introduction chapter).

While new digital technologies, such as technology-assisted case studies, tend to be attractive options, it is important for AT educators to consider the impact that these technologies have on their specific pedagogical choices. Oftentimes, educators will use technology just for the sake of using technology and cannot articulate how it has empowered teaching or impacted learning. To integrate technology effectively, AT educators should critically assess the role of technology-assisted pedagogies within their curriculum and explore how these technologies assist in developing student competence, critical thinking, deeper understanding, or transferability of knowledge (Mishra &

Koehler, 2006). A useful framework that can help to guide this critical analysis of technology integration is the TPACK model (as introduced in Section 1.4 of the

Introduction chapter). In the ensuing paragraphs, a summary of the TPACK literature is presented to demonstrate how technology can be integrated in pedagogically meaningful ways.

2.6 Using TPACK as a Theoretical Framework for Technology Integration

Up until 2005, research on educational technology integration was atheoretical by nature thus creating a need for the development of theoretical models to help guide educators’ understanding of this topic (Angeli, Valanides, & Christodoulou, 2016).

According to Bransford et al. (1986), “teachers need to develop a specialized body of knowledge for dealing with the complex teaching and learning situations that occur during the integration of technology in their actual teaching practices” (p. 5). The 56

introduction of the TPACK model in 2005 helped to identify such a specialized body of knowledge and changed how educators considered effective technology integration.

Previously, educators often used a trial-and-error type of design when integrating technology, whereas the TPACK framework helped to make more theory-informed decisions.

Since its inception, many research studies have focused on the TPACK theoretical framework as a lens to explore the use of technology in ways that are contextually authentic and pedagogically appropriate (Abbitt, 2011; Chai, Koh, & Tsai, 2013). For example, a recent systematic review by Rosenberg and Koehler (2015) found 193 empirical journal articles related to the TPACK model. As the popularity of this framework has grown, so has the use of TPACK in a wide range of subject areas, levels of education, and in various contexts. However, prior research has not considered

TPACK as a model to investigate technology integration in health professional education programs, such as AT. A review by Chai et al. (2013) identified this gap in the literature and suggested that TPACK would be a valuable framework to explore how medical educators integrated technology for the teaching and learning of various injuries and pathologies. Therefore, the TPACK framework was employed in my study to guide the critical analysis of technology integration in AT education.

Although the current TPACK literature encompasses a wide range of subject areas, levels of education, and various contexts, two common themes emerged from this model that were directly related to my study: 1) theoretical aspects of TPACK; and 2) practical applications of TPACK.

2.6.1 Theoretical TPACK Studies. During the last 10 years, TPACK researchers have been engaged in developing a theory-based perspective of technology- enhanced teaching (Angeli et al., 2016). This theory-based approach has provided the 57

research community with a common language for discussing effective technology integration and has set a focus for productive discussions and knowledge construction

(Angeli et al., 2016). Although TPACK is recognized as being a significant contributor to the educational literature, it is also considered to be a young research field that is still searching for a generally accepted theoretical conceptualization. Therefore, many researchers continue to investigate the theoretical aspects of TPACK, including: 1) discussing the need for developing new TPACK frameworks; 2) investigating the integrative versus transformative nature of TPACK as a body of knowledge; 3) describing the differences between domain-general versus domain-specific TPACK; and

4) validating the components of the TPACK framework (Angeli et al., 2016).

Future studies should continue to expand on these theoretical considerations as it will assist in making the model more unified and recognized by researchers from multiple paradigms. Although there are some theoretical aspects of TPACK that remain unresolved, it is still widely considered to be a useful framework to guide the critical analysis of effective technology integration (Abbitt, 2011; Chai et al., 2013). Researchers just need to understand that the TPACK model acts in contextualized ways because of the specificity of educational environments. According to Angeli et al. (2016), “from a methodological point of view, the authors encourage TPACK researchers to engage in rich empirical and qualitative investigations of how TPACK manifests itself in real practice within the context of different content domains” (p. 25). Therefore, high quality studies that explore the practical implications of TPACK are also necessary for unifying the TPACK model.

2.6.2 Practical Applications of TPACK. Because my study engaged in an exploration of how TPACK manifested itself in real practice within an AT specific context, this area of research is expanded in more detail than the theoretical 58

considerations. Due to the popularity of TPACK, there are many examples throughout the educational literature that explore TPACK in practice. In the ensuing sections, these practical application examples are divided into quantitative and qualitative TPACK studies.

Quantitative TPACK research. One area of great interest in the practical implications of the TPACK literature encompasses the attempt to design a valid and reliable tool to measure the levels of TPACK knowledge (and its individual constructs) in educators (Archambault & Crippen, 2006; Kadijevich, 2012; Lux, Bangert, & Whittier,

2011; Schmidt et al., 2009). In theory, this sounds promising because identifying areas that are in need of improvement (e.g., constructs that were measured to be low in the

TPACK tool) could then be targeted through specific professional development sessions.

However, since there are so many complexities associated with each construct within the

TPACK model, it has proven difficult to separate them while providing a valid and reliable measurement for each domain (Archambault & Barnetta, 2012). Moreover, many of these validity/reliability studies involved self-reported findings from the educators so many questions arose concerning whether or not the educator actually reflected an understanding of TPACK while teaching (Archambault & Crippen, 2006;

Voogt, Fisser, Roblin, Tondeur, & van Braak, 2012).

Other studies have yielded positive findings that support the use of a TPACK framework for exploring how educators consider technology integration that is contextually authentic and pedagogically appropriate. More specifically, TPACK has been shown to: 1) guide educators to deal with the challenges of teaching and learning that are brought on by rapidly changing technologies (Cox & Graham, 2009); 2) enhance instruction from both student and educator perspectives (Harris, Mishra, & Koehler,

2009); 3) be a useful framework for software development (Wu, Chen, Wang, & Su, 59

2008); and 4) enhance student learning using technology (Khan, 2011). Therefore, it can be suggested that there is a level of practicality about the TPACK model that assists in creating valuable educational tools and effective instructional methods.

Similarly, another category that has emerged from the practical applications of

TPACK is concerned with exploring strategies for developing educators’ TPACK knowledge. Niess, van Zee, and Gillow-Wiles (2011) identified four central components that are required for TPACK development, including: 1) an overarching concept about the purposes of incorporating technology in teaching a particular subject; 2) knowledge of students’ understanding, thinking, and learning with technology in that particular subject; 3) knowledge of the curriculum and curriculum materials in a particular subject that integrates technology in learning and teaching; and 4) knowledge of instructional strategies and representations for teaching and learning that particular topic with technology. Additional research by Koehler and Mishra (2009) suggested that effective technology integration requires starting with authentic curriculum problems for which technology-based solutions can be collaboratively designed. Although these two studies were conceptual by nature, they establish how important context is in truly understanding and developing TPACK knowledge.

Despite recognizing the importance of considering context within the TPACK model, this area remains an underdeveloped and under-researched component of the framework (Rosenberg & Koehler, 2015). According to Kelly (2010), “context is one of the most complex, important, and least understood components of the TPACK framework” (p. 52). However, the impact of technology integration depends on how successfully educators adapt and understand their unique contexts (Kelly, 2010). Based on these shortcomings, future TPACK studies should consider the contextual environment to better understand the specific conditions where teaching with technology 60

is most effective (Rosenberg & Koehler, 2015). By recognizing this gap in the TPACK literature, one of the aims of my current research project was to develop an enhanced understanding of the context in question, technology integration in AT education, before exploring the impact of using a TPACK-designed educational tool with a group of participants (AT students from Sheridan College). This step is described in detail in

Phase 1 of my Methodology chapter.

Furthermore, another limitation to the current TPACK literature is that this area is dominated by those individuals who follow a positivist approach to conducting research.

Many of the TPACK researchers believe that the constructs included in the framework are something that can be objectively measured through valid and reliable quantitative measures. Conversely, researching a complex framework such as TPACK might consider alternative methods and methodologies to develop a more enriched understanding of pedagogically sound technology integration as a phenomenon.

Therefore, mixed methods or qualitative research methodologies have the potential to enhance the exploration of TPACK in a variety of different contexts.

Qualitative TPACK Research. Although not as prevalent, several researchers have successfully employed qualitative research methods to explore the TPACK phenomenon. Harris et al. (2010) developed a TPACK-based technology integration assessment rubric to qualitatively assess the level of technology integration of specific lesson plans. Even though this study gathered qualitative data (e.g., lesson plan snapshots, teacher reflections, interviews), the article was still written from a positivist point-of-view. These researchers constantly referred to developing a tool that ‘measured the amount of knowledge in each TPACK construct’; they just used different methods than traditional positivist researchers. The same positivist spin on qualitative research was also employed in other studies by Hofer and Grandgenett (2012) and Harris and 61

Hofer (2009). Therefore, to develop an enriched understanding of using pedagogically sound technologies, researchers and educators alike should consider other paradigms to situate their research.

Another useful research paradigm to explore TPACK as a phenomenon is known as interpretivism (Corbin & Strauss, 2008). A study by Harris and Hofer (2011) used an interpretivist qualitative methodology to explore how/why educators combined elements of content, pedagogy, and technology to design the curriculum. This underlying methodology allowed the researchers to gain an enriched description of the specific factors that educators considered when integrating technology into their courses. The findings from this study showed that participating educators felt that the course content was the driving force behind selecting digital technologies. In other words, these educators first considered the specific content that needed to be conveyed to the student, then how to best relate the content to students in an engaging manner. Finally, the educators reflected on how various technological tools could be used to support the course content. These enriched results would be difficult to replicate in quantitative studies, demonstrating the effectiveness of using multiple forms of research methodologies to explore this specific phenomenon. All types of research have unique advantages and disadvantages, and by employing a variety of methods, assists in developing a greater understanding of the phenomenon in question.

Based on these findings in the literature, my study was designed to deconstruct the complexities associated with integrating pedagogically sound technologies in AT education. An interpretivist paradigm situated my research and empirical materials were gathered through a mixed methods approach to explore the research question. More specifically, the TPACK model was used during all phases of research to design my

educational tool, guide the data analysis, and to deconstruct the research question, as outlined in Figure 2.1.

grounded the design and modifications of the M-CBL SIAET

guided the deconstructed analysis of the research TPACK empirical question materials

promoted critical thinking amongst participants

Figure 2.1. A graphic that demonstrates how the TPACK model was used during each phase of my doctoral research.

2.7 Literature Review Summary

As demonstrated in the literature review, it is clear that there are some significant gaps in the field of integrating and interpreting pedagogically sound technologies in AT education. A depth and breadth of research has been completed in other areas of education, but not in the profession of AT. Therefore, it can be easily demonstrated that an exploration of the AT field is both necessary and timely. Before transitioning into the detailed methodology of my current research study, Table 2.1 summarizes the most 63

significant gaps that were presented in this Literature Review chapter. Furthermore, the table also includes how my study was designed to address these specific gaps.

Table 2.1

Significant Gaps from Literature Review Chapter

Significant Gap in the How the Current Reference Section in Literature Research Study Methodology Chapter Addressed the Significant Gap What are the signature Surveyed and interviewed Phase 1 pedagogies used in AT educators from each Canadian AT accredited accredited institution to institutions? explore their signature pedagogies What are the potential Surveyed and interviewed Phase 1 benefits and limitations of AT educators from each using CBL in Canadian AT accredited institution to accredited institutions? explore CBL as a pedagogical strategy How do AT educators Surveyed and interviewed Phase 1 critically assess the role of AT educators from each technology-assisted accredited institution to pedagogies within their deconstruct this question curriculum? What is the contextual Used the TPACK model to Phase 1 landscape for AT educators analyze the surveys and in Canadian AT accredited interviews of educators institutions? from each accredited institution. Each overlap of the TPACK model was described based on AT educators’ experiences. What is the impact of using Modified the M-CBL Phase 2 technology-assisted SIAET and explored the Phase 3 pedagogies in Canadian impact of using this tool AT accredited institutions? with a CATA-accredited institution How can the TPACK More detailed exploration Phase 3 model promote critical into how the M-CBL thinking amongst SIAET impacted educators around educators’ thinking in this technology integration and area the resulting impact on pedagogy?

CHAPTER 3: METHODOLOGY

Chapter 3 Outline

This chapter provides a detailed description of all methods, instruments, and procedures that were employed during each phase of my research study. The beginning of the chapter first introduces interpretivism, the overarching methodological tradition that grounds my views as a researcher. Next, each of the three phases of research of this study are described in detail, including: descriptions of the participants, the types of empirical materials collected during each phase, and an explanation of the data analysis procedures employed. Furthermore, this chapter provides a thorough explanation of how each phase contributed to exploring my main research question of, “What is the impact of using a technology-assisted pedagogy on the nature of teaching and learning in CATA- accredited institutions?”

3.1 Interpretivist Methodological Tradition

Traditionally, researchers from medical education consider a positivist approach as the most acceptable research method to investigate medical inquiries (McMillan, 2015;

Stenfors-Haynes, Hult, & Dahlgren, 2013; Zeinaloo, 2004). A fundamental assumption of the positivist research paradigm promotes an objective reality that can be known, measured, and predicted by the researcher (Willis, 2007). In such an approach, any concerns linked to the rigour of an inquiry are resolved by determining the validity and reliability of the measurement tools (Zeinaloo, 2004). Once validity and reliability have been established, then data can be collected and analyzed to identify existing relationships between identifiable variables (Zeinaloo, 2004).

With the emergence of reputable and credible naturalistic research techniques, medical education professionals and researchers have begun to appreciate a wider range of methodological approaches for interpreting phenomena and exploring knowledge 65

(Bleakley, Bligh, & Browne, 2011; Stenfors-Haynes et al., 2013). The dominant positivist paradigm in medical education fields is now being replaced in the literature with more naturalistic approaches to research, including methods rooted in interpretivism, post-positivism, constructivism, and critical theory. This methodological shift has many medical education researchers realizing that not all phenomena (and especially classroom discourse) can be validated through objective measurements, given the vast array of inherent variables which are difficult to control in a research study. These complex contexts in fact require a lens that accommodates a broader social constructivist view of the classroom (Bailey, 1997).

Complex social phenomena, such as AT education, cannot be explored exclusively through a positivist research lens because it is not ‘out there’ in an objective world, just waiting to be discovered, measured, or predicted. Rather, this phenomenon is socially and historically mediated by the different educators, students, curricula, and academic institutions (Ashley & Orenstein, 2005). Athletic therapy educators have specific teaching styles, teaching philosophies, differing levels of teaching experience, diverse educational backgrounds, all of which cannot be controlled in a single research study. Therefore, I believe the context of AT classrooms is far too complex to measure outcomes of an intervention study purely from a statistical perspective that relies on causal comparison of variables. Based on these assumptions, I decided to use an interpretivist/social constructivist methodological tradition to situate my research question.

Interpretivism focuses on interpreting and understanding the specific meanings, constructions, purposes, and intentions that people give to their own actions and interactions with others (Given, 2008). Therefore, to understand a particular social construction (e.g. pedagogical approach to teaching) then the researcher must explore the 66

meanings and factors that influence that contextually-bounded construction (Schwandt,

2000). According to Orlikowski and Baroudi (1991), “People create and associate their own subjective and intersubjective meanings as they interact with the world around them and thus interpretive research attempt[s] to understand phenomena through accessing the meanings participants assign to them” (p. 5).

Interpretivist research rejects the measurable objectivity of a phenomenon and as an alternative, attempts to gain an enhanced understanding of the particular context in question (Willis, 2007). Thus, my main motive for using an interpretivist tradition was to gain a better understanding of the participants’ construction, understanding, and experiences of integrating technology-assisted pedagogies in their specific contexts

(Denzin & Lincoln, 2011). More specifically, I explored how AT educators constructed, understood, experienced, and used technology-assisted pedagogies in their respective classrooms. This approach favors an investigation of the perspectives of multiple stakeholders in the process of classroom interventions (Beaulieu, 2013).

Social constructivism is a specific theory of knowledge that can be blended with an interpretivist research paradigm by “placing priority on the phenomena of study and seeing both data analysis as created from shared experiences and relationships with participants and other sources” (Charmaz, 2006, p. 331). In this blended approach, interpretivism acts as the epistemological stance of the researcher that underlines the entire research process and governs the theoretical perspectives and methodological assumptions (Crotty, 1998); whereas social constructivism acts as the underlying theory of knowledge construction that the researcher uses to explore participants’ perceptions of a particular phenomenon (Thomas, Menon, Boruff, Rodriguez, & Ahmed, 2014).

Social constructivism emphasizes the significance of culture, societal interactions, and context when attempting to understand various phenomena within a society (Kukla, 67

2000). Social constructivist research assumes that individuals (e.g., AT educators) interpret their own environment, and interactions within that environment, in a way that is shaped by their culture, what they do, and how they do it. Therefore, an interpretivist/social constructivist research approach added value to my research by allowing me to: 1) investigate how AT educators interpreted and made sense of their own teaching practises; and 2) examine their individual beliefs and attitudes towards using technology-assisted pedagogies in their AT classes.

An interpretivist/social constructivist research tradition does not ascribe to a single, universal methodology when investigating human inquiries (Willis, 2007).

Interpretivists and constructivists alike recognize that it is theoretically impossible to achieve a single, ultimate explanation for complex phenomena such as employing effective, pedagogically sound technologies. Instead, this tradition calls for multiple forms of methodologies and research methods to explore how individuals construct and convey knowledge in a particular context (Riegler, 2012). Researchers that embrace an interpretivist tradition also accept that others may have differing assumptions and values and may therefore hold different beliefs from those of the researcher (Appleton & King,

1997). These foundational ideas that coincide with my personal philosophy concerning investigations of educational phenomena form the rationale for why I decided to use a mixed-methods approach to explore my research question through an interpretivist/social constructivist lens.

By embracing an interpretivist/social constructivist research framework, I assumed that knowledge construction is socially constructed within the norms of a specific community of practice (e.g., the AT educational community). I also assumed that there is no ultimate truth that can be used to define a complex phenomenon such as pedagogically sound technologies. Based on these assumptions, it is important to note 68

that my research findings are representative of a very specific context (CATA-accredited institutions in Canada). Generalizability of the results is left to the readers as they compare their own particular contexts to the descriptions detailed in my study.

3.2 Research Design

A sequential mixed-methods approach was used to explore my research question through an interpretivist lens. More specifically, an explanatory sequential research design provided the framework for gathering empirical materials during two phases of research (Phase 1 and 3), described in more detail in the next section of this Methodology chapter.

An explanatory sequential design is a mixed-methods approach in which the research begins with a quantitative phase, followed by a qualitative component aiming to further explain the initial results in more depth (Creswell & Plano-Clark, 2011). In this way, one style of research ‘drives’ the other by providing further explanations and descriptions (Shank & Brown, 2007). Within the different phases of my research, both types of data (quantitative and qualitative) were valuable in providing enriched descriptions of the specific research context.

3.3 Phases of My Doctoral Research

Following the framework of interpretivist research, I gathered a wide range of empirical materials (through both quantitative and qualitative methods) to gain an enhanced understanding of the main research question. Empirical materials were gathered during three distinct phases, as outlined in Figure 3.1.

Phase 3 Phase 1 Phase 2

I used feedback from I explored the main I used the TPACK Phase 1, TPACK theory, research question by framework to explore the and principles of unpacking what impact initial considerations of instructional design to this educational tool had Technological, further refine the on the nature of teaching Pedagogical, and Content Multimedia CBL and learning in a single Knowledge in AT Educational Tool. AT accredited institution educators case study Then sent the Multimedia Empirical Materials CBL Educational Tool to Empirical Materials - Survey educators at accredited - Survey - Interviews institutions - Interviews - Focus Groups

Figure 3.1. A description of the three phases of the current research project. This figure outlines the objectives of each phase as well as the empirical materials that were gathered to explore each objective.

Phase 1 involved surveying and interviewing AT educators across Canada to explore their initial pre-dispositions and views regarding digital technologies and preferred pedagogies. During this phase, the TPACK framework was used to analyze all data by describing, in detail, AT educators’ experiences with each overlap as defined by the TPACK model. Such an analysis helped to describe the context of the study by showing where AT educators viewed themselves in relation to the overlapping constructs of content knowledge, pedagogical knowledge, and technological knowledge. Phase 2 of my research involved using feedback from Phase 1, as well as results from my previous pilot studies (as discussed in the Introduction Chapter), to make significant edits and improvements to the M-CBL SIAET, and accompanying pedagogical model. The main purpose of this phase was to incorporate TPACK and R2D2 ID theory to continuously improve the design and implementation strategies of my educational tool before exploring the impact of this tool in a CATA-accredited institution. Following the main tenets of the R2D2 ID model, it was imperative to: use a non-sequential process that was 70

context-driven; continuously reflect on design problems, improvements, etc.; and involve feedback from multiple stakeholders (participatory design) at different stages within the development and design of my educational tool (Willis, 2009). These recommendations guided the specific modifications and improvements to the educational tool/pedagogical model that were made during this phase. Finally, Phase 3 involved a detailed exploration of the impact of using the M-CBL SIAET in a single CATA-accredited institution

(Sheridan College). During this phase, both AT students and educators were involved in exploring the impact of the technology tool on the nature of teaching and learning.

In the next section of the Methodology chapter, each of these three phases will be described in more detail. For each phase of research, I: 1) describe the empirical materials that were gathered; 2) describe the specific procedures for collecting data; and

3) provide a rationale for what each component contributed in responding to the overall research question.

3.3.1 – Phase 1 – describing the context of AT educators

Participants. All full-time AT educators from the seven CATA-accredited institutions (Concordia University, Camosun College, Mount Royal University, Sheridan

College, University of Winnipeg, University of Manitoba, and York University) were invited to participate in Phase 1 of my research. An introductory email was sent to the

Program Director at each accredited institution, outlining the purpose of the research and expectations for study participants. These Directors were then asked to forward the information to their full-time faculty, which totaled 26 educators from the seven institutions. Twenty-one of these eligible educators voluntarily responded to the survey

(81% response rate) while 15 educators participated in the individual interviews (58% response rate). Table 3.1 provides the demographic information for participants from both the survey and interview components of Phase 1. 71

Table 3.1

Demographic Information for Phase 1 Participants

Gender Age Main Area of Teaching Accredited Range Specialization Institution

Survey Female – 16 51+ - 5 Ortho Assessment – 8 Sheridan – 5 Male – 5 41-50 – Emergency Assessment MRU – 4 11 – 5 Camosun - 3 31-40 – 4 Manual Therapy – 3 Concordia – 3 20-30 – 1 Rehab – 3 Winnipeg – 2 Modalities - 2 Manitoba – 2 York – 2

Interviews Female – 11 51+ - 3 Ortho Assessment – 5 Sheridan – 5 Male – 4 41-50 – 9 Emergency Assessment MRU – 4 31-40 – 2 – 4 Camosun - 2 20-30 – 1 Manual Therapy – 2 Concordia – 0 Rehab – 2 Winnipeg – 2 Modalities – 2 Manitoba – 1 York – 1

Additionally, of the 15 educators interviewed, six held PhD degrees, eight held Master’s degrees, and one participant had a Master’s degree with a doctorate in Osteopathy. The average number of years teaching at a CATA-accredited institution was found to be 13.10 years, with a range from 6-38 years.

Sources of empirical materials. Before starting Phase 1, the study was first approved by the Acadia University Research Ethics Board, as well as the Ethics Boards of all seven CATA-accredited institutions (Appendix B). The main goal of this phase was to describe AT educators’ initial views towards using digital technologies and preferred pedagogical strategies. One of the main advantages of using an interpretivist research paradigm was having the ability to use multiple data sources to enhance data credibility (Patton, 2002; Yin, 2003). Thus, each type of empirical material was considered to be ‘one piece of the puzzle’, with each piece contributing to the

researcher’s overall understanding of the phenomenon in question (Baxter & Jack, 2008).

Therefore, a mixed-methods approach was warranted for this particular stage. More specifically, a sequential explanatory mixed-methods approach was employed to collect empirical materials through both a quantitative questionnaire and qualitative interviews.

Questionnaire. An online questionnaire was designed to explore how familiar AT educators were with using technology for teaching within CATA-accredited institutions

(Appendix C). To summarize, participants were asked a series of questions about: 1) general pedagogical knowledge; 2) most frequently used teaching strategies; 3) use of technology for educational purposes; and 4) most frequently used digital technologies.

Most questions asked participants to read a statement and to then select an appropriate response on a 5-point Likert scale, ranging from 1 = strongly disagree to 5 = strongly agree. The questions from this survey were adapted from existing TPACK questionnaires (Archambault & Crippen, 2006; Schmidt et al., 2009), suitably modified to make them more applicable to an AT-specific context. To field test for question ambiguity, the survey was first screened by two AT educators.

The first page of the questionnaire, the informed consent (Appendix C), outlined the purpose of the research, provided my contact information, and identified the terms of participation (e.g., understanding the nature of participation, reserving the right to withdraw participation). Through responding to the survey cues, the individual consented to participate in this phase of my research project.

Following the main tenets of interpretivist research, the data collected from these questionnaires were analyzed (by way of means and standard deviations) to establish trends in responses. Each question from the survey was matched up with a corresponding overlap from the TPACK model, as recommended in previous studies (Archambault &

Crippen, 2006; Schmidt et al., 2009). For example, the statement “I only use technology 73

in teaching when it clearly advances a curriculum outcome” was an indication of TCK

(technological content knowledge). Of note, the quantitative results were not used to

‘measure’ the amount of TPACK knowledge in AT educators, as is common practice in many other TPACK studies. Rather, the findings were used to identify trends that were further deconstructed during the qualitative interviews.

As presented in my Literature Review chapter, many of the previous TPACK research studies focused on using objective, self-reported measures to describe the amount of knowledge in each overlap of the TPACK framework (Archambault &

Crippen, 2009; Han et al., 2013). However, these studies discussed the potential for combining questionnaire results with additional qualitative data to gain a more profound understanding of TPACK theory. Therefore, I decided to use individual interviews, in combination with the questionnaire responses, to gain an enriched understanding of educators’ initial views towards using digital technologies for teaching in an AT context

(Collins, 1998).

Individual interviews. At the end of the questionnaire schedule, all educators were invited to participate in an individual interview, following a standardized, open- ended format. The interviews themselves were more conversational than standardized (in the traditional sense) to ensure that the respondents fully understood each question

(Turner, 2010). Questions were based on emergent trends found in the questionnaire results as per Patton (2002). For example, if the questionnaire showed a trend that the majority of AT educators considered technology to be an effective teaching tool, then I would design specific interview questions to further deconstruct this trend.

Following the claims of social constructivism, it was assumed that AT educators constructed their personal pedagogical approach by interpreting and interacting with their own environment. It was also assumed that this approach was shaped by various 74

professional, (e.g., expectations from the CATA), institutional, personal, and cultural factors. Therefore, individual interviews were used to listen to participants’ accounts of their pedagogical approach to teaching with technology in AT education and to further deconstruct these factors. A detailed list of the questions from the open-ended interview schedule is included in Appendix D.

According to Guba and Lincoln (1994), qualitative interviews must ensure that all questions are clearly written, substantiated, and appropriate for exploring the research question(s). By accomplishing these goals, a researcher increases the rigour and trustworthiness of the qualitative data (Guba & Lincoln, 1994). Therefore, all questions in my individual interviews were initially field-tested with two AT educators to ensure that all questions were clear and easily understood.

Individual interviews were audio-recorded (with permission from participants), manually transcribed, and coded in an iterative process (Auerbach & Silverstein, 2003) to establish emergent themes within each overlap of the TPACK framework. All interviews were originally transcribed in true verbatim to give an accurate account of how the words were actually spoken. Grammatical errors, repetition, filler phrases, and false starts were all transcribed to explore the thought processes, confidence, and comprehensiveness of interviewee responses (Bucholtz, 2000). When writing selected quotations in the Results chapter, all non-verbal utterances (e.g. stuttering, ‘uhms’, ‘ahs’) were removed from the original transcriptions so that the focus could be placed on the meanings and perceptions created and shared during the interviews (Oliver, Serovich, & Mason, 2005).

Interviews, from a social constructivist perspective, assist in generating contextually bounded understandings about a phenomenon by listening to participants’ perceptions of the social world around them (Mojtahed, Baptista Nunes, Tiaga Martins,

& Peng, 2014). A modern inductive approach known as thematic analysis can be used to 75

gain insight into these social environments (Mojtahed et al., 2014). In an attempt to develop a deeper understanding of each construct in question, a coding approach as proposed by Hahn (2008) was used. The first step was to manually transcribe all available interview data, allowing me to gain an appreciation for what was said and how it was said (Hahn, 2008). The next step involved reviewing the transcriptions and developing general coding categories. Typically, in social constructivist research, the researcher analyzes all data sources and looks for emergent themes that can be used to describe the participants’ construction of a particular phenomenon (Morrow, 2005). I decided to use pre-determined codes (the overlaps from the TPACK framework) to initially organize the interview data so that it could be combined with the questionnaire findings to describe the current context of technology integration in AT education.

Responses were coded as being representative of TK, PK, CK, TPK, TCK, PCK, or

TPACK. For example, if the participant’s response included an example of how technology was used to teach a particular course topic than it was coded as TCK (also known as Technological Content Knowledge). The final step of the coding approach involved studying these general coded categories and developing highly refined themes, also known as thematic coding (Mojtahed et al., 2014). For each of the TPACK overlaps, several themes emerged from the data. These themes are presented later in the Results chapter.

After the interviews were coded and analyzed, I performed member checks to confirm the themes that emerged from the data (Auerbach & Silverstein, 2003). During this member checking process, my interpretations of the themes were shared with three randomly selected participants (these individuals were selected from the sample of AT interviewees) during additional individual interviews, to allow for further discussion or clarification related to my interpretation of any of these themes (Shenton, 2004). 76

After identifying and member checking the final emerging themes, I described each overlap of the TPACK framework for an AT specific context. I was also able to uncover certain areas that AT educators did not consider (e.g., not considering pedagogical implications when integrating digital technologies) when using technology to teach. Some of these areas are addressed in Phase 2 of the research (e.g., modifying the educational tool to include a new instructor’s guide that explained how to use pedagogically sound technologies in AT classrooms) and others are included in the

‘Implications for Further Research’ section of the Discussion chapter.

What does phase 1 contribute to our understanding of the research question?

To explore the impact of using a specific type of technology-assisted pedagogy in a

CATA-accredited program, I first needed to establish the initial perspectives that AT educators had towards using technology for educational purposes. This was important to establish because if the educators had negative attitudes towards using technology, then it would be difficult to explore the perceived impact of using my M-CBL SIAET in their classrooms due to initial negative predispositions towards technology. Furthermore, with the main precept behind interpretivist research being an enhanced understanding of the context under investigation, it is imperative that a researcher provides a detailed and comprehensive description of the research context so that other readers can see what was done and with whom (Willis, 2007). Phase 1 of my research accomplished these goals by defining and describing the context of the study while also showing where AT educators viewed themselves in the different domains associated with content knowledge, pedagogical knowledge, and technological knowledge.

3.3.2 – Phase 2 – improving the M-CBL SIAET – the next stage of my research involved modifying and improving my educational tool and instructional model, by using participant feedback and emerging themes that were identified in Phase 1 of my study. 77

Additionally, essential principles of TPACK theory were also applied to ensure that the tool and accompanying teaching model incorporated pedagogically sound methods to effectively integrate technology into orthopedic assessment courses. Furthermore, important principles of R2D2 ID theory also guided the overall process for improving the multimedia tool and instructional model.

As described in the Introduction chapter, I chose the R2D2 ID approach to guide the evolution of my educational tool because I wanted to use a constructivist ID model that: 1) followed a non-linear approach to design and development; 2) used an iterative process to obtain feedback from multiple stakeholders at multiple points in time; and 3) allowed for more designer creativity throughout the entire design process. Moreover, many of the traditional behaviourist ID models ignore the interactions between instructors and students by failing to consider students’ input/feedback during the design process. In my research, I considered these interactions to be quite significant and wanted to elicit feedback from multiple participants (students and educators) throughout the process to develop an effective educational tool.

In the Results chapter, I present a detailed list of the specific modifications and improvements that were made to the M-CBL SIAET/pedagogical model during this stage of research.

What does phase 2 contribute to our understanding of the research question?

Before sending the M-CBL SIAET to AT educators and exploring the impact of this intervention, I wanted to ensure that it was appropriate for the specific context under investigation. As described in my Introduction chapter, the original pilot projects that led to the initial development of the M-CBL SIAET explored the use of this tool within a sample of Kinesiology students from Canada and a sample of athletic training students from Jamaica. Even though these are similar professional environments, I wanted to 78

elicit feedback from AT educators in CATA-accredited institutions to make sure that the tool was appropriate for an AT specific context.

The original plan of my research was to send the educational tool to each CATA- accredited institution (those that agreed to participate) and to complete multiple case- studies with each school. Using multiple case studies would have allowed me to gather multiple perspectives, use a wide range of data sources, and make contextual recommendations when discussing the differences between CATA-accredited institutions. However, upon analyzing the data from Phase 1, it became apparent that some of the AT institutions were moving towards completely different curriculum development models (e.g., the clinical presentations model of curriculum development) that did not align with the CBL framework that guided the design of the M-CBL SIAET.

Therefore, it would be unconducive to explore the impact of the technology tool in a classroom environment that did not support this type of learning. Based on these obvious differences, I decided to focus on a single case study with an AT program (Sheridan

College) that had a curriculum that closely aligned with the CBL framework. Therefore,

I was able to explore the impact of using this educational tool on the nature of teaching and learning in a CATA-accredited program.

Another important component of Phase 2 involved analyzing the feedback from

Phase 1 to design and develop additional resources to accompany the educational tool.

The purpose of these additional resources were to help AT educators understand the different types of pedagogies included in the educational tool, and to provide suggestions/examples of how these strategies could be implemented in their courses. To investigate the impact of using this technology-assisted pedagogy in AT education, I first established that each AT educator understood the nature of the tool itself and how it was intended to be used in the classroom. Once this was established, then I could complete 79

Phase 3 of my research – a case study with AT students and educators at Sheridan

College.

3.3.3 – Phase 3 – case study – Sheridan College

Setting the context. To interpret the impact of a technology-assisted pedagogy, it is important to first understand the specific educational context in which it is was employed. This includes a description of the institution, program, nature of the curriculum, and study sample that helps lend credibility to the research findings.

Phase 3 of my current case study took place in an undergraduate AT program at

Sheridan College (located in Brampton, Ontario, Canada) with a group of fourth-year students and full-time AT educators. Sheridan College is a diploma and degree-granting polytechnic institution that values itself on providing students with the knowledge and skills to thrive in a rapidly changing world (Sheridan College, 2016a). Programs at

Sheridan College focus on better preparing students for a world in which innovation – the ability to acquire new knowledge and apply it in novel ways – is considered to be the key to future prosperity (Sheridan College, 2016a). Educators at this institution are expected to inspire creative and innovative learning by integrating various technologies with effective teaching strategies in inter-professional environments (Sheridan College, 2013).

The aforementioned goals are embedded within the Sheridan College AT program, recognized as being the first CATA-education program dedicated to AT education. Sheridan College was also the first official accredited institution of the

CATA, in 1998. As the AT profession evolved, so did the requirements for professional certification. In the early 2000s, the CATA set a new prerequisite for certification candidates that stated “to achieve the designation of Certified Athletic Therapist, a certification candidate must successfully complete a CATA-accredited program and have earned a Bachelor’s degree” (CATA, 2016b). Sheridan College responded to this change 80

by introducing a Bachelor of Applied Health Sciences (Athletic Therapy) program in

2003 (Sheridan College, 2016b).

The new four-year program was specifically designed to provide students with the knowledge, skills, and experiences to become competent, certified ATs. The program integrates practical, hands-on field/clinical experience with lecture and lab experiences, to provide students with advanced skills in field assessment, initial injury treatment, clinical assessment, and clinical rehabilitation for all types of injuries (Sheridan College,

2016b).

When planning a program curriculum, all accredited institutions are expected to abide by the AT competencies as set by the CATA (see Appendix A). While applying for accreditation, or re-accreditation, institutions have to complete a self-study report that demonstrates the courses in the curriculum where each competency is given primary consideration. These detailed lists of competencies help guide entry-level curriculum design, sequencing specific courses, evolving curriculum maps, development of course content, and structuring of clinical experiences.

The Bachelor of Applied Health Sciences (Athletic Therapy) program at Sheridan

College currently consists of 135 credit hours completed over eight semesters. Table 3.2 lists the specific courses offered during each semester of the AT program.

Table 3.2

Sheridan College Athletic Therapy Program Courses

Course Code Course Title Credits Term 1 BIOL 10000 Introduction to Cell and System Physiology 3 SCIE 12941 Introduction to Biomechanics 3 SCIE 17893 Nutrition 3 ATHL 10000 Introduction to Athletic Therapy 3 ENGL 17889GD Introduction to Composition and Rhetoric 3 General Elective 3 Term 2 BIOL 14717 Human Physiology for Athletic Therapy 3 ATHL 20082 Protective Equipment and Bracing 2 PHYG 20025 Exercise Physiology for Athletic Therapy 4 FLPL 20111 Seminar in Athletic Therapy 0.5 FLPL 26529 Sports Injury Clinic 0.5 General Elective 3 Term 3 ANAT 23672 Anatomy of the Lower Quadrant 4 ATHL 24998 Emergency Conditions 1 3 ATHL 27900 Conditions of the Lower Quadrant 3 PHYG 23672 Growth, Development and Physical Activity 3 FLPL 20082 Sports Injury Clinic 1 0.5 FLPL 20123 Field Practicum 2 0.5 General Elective 3 Term 4 ANAT 27545 Anatomy of the Upper Quadrant 4 ATHL 20001 Emergency Conditions 2 3 ATHL 20000 Conditions of the Upper Quadrant 3 PHYG 27900 Pathophysiology 3 PSYC 10025 Statistical Methods in Behavioral Science 3 FLPL 23314 Field Practicum 3 0.5 General Elective 3 Term 5 ANAT 38448 Anatomy of the Spine 4 ATHL 37545 Injury Treatment Modalities 3 ATHL 37370 Therapeutic Exercise 1 4 ATHL 30001 Clinical Assessment and Rehabilitation 1 3 FLPL 36529 Field Practicum 4 0.5 General Elective 3 Term 6 ATHL 30199 Clinical Biomechanics of the Lower Quadrant 2.5 ATHL 38263 Therapeutic Exercise 2 3 ATHL 33314 Clinical Assessment and Rehabilitation 2 4.5 ANAT 33672 Anatomy of the Head, Thoracic Cavity and Abdomen 3 FLPL 36367 Field Practicum 5 0.5

ATHL 38100 Psychology of Injury and Performance 3 General Elective 3 Term 7 ATHL 30000 Emergency Conditions 3 2 ATHL 46048 Clinical Biomechanics of the Upper Quadrant 3 ATHL 40102 Clinical Assessment and Rehabilitation 3 4.5 ATHL 49999 Independent Research Proposal 3 FLPL 30009 Sports Injury Clinic 3 0.5 FLPL 40172 Field Practicum 6 0.5 General Elective 3 Term 8 ATHL 45586 Manual Therapy Techniques 4 ATHL 40001 Clinical Assessment and Rehabilitation 4 3 FLPL 40001 Sports Injury Clinic 4 0.5 FLPL 43314 Field Practicum 7 0.5 ATHL 45777 Current Trends in Athletic Therapy 3 General Elective 3 Note: retrieved from https://academics.sheridancollege.ca/programs/bachelor-of-applied- health-sciences-athletic-therapy

In addition to undergraduate courses, the Sheridan College program also embeds

1,200 hours of practical experience within the curriculum by setting a required number of hours that are expected to be accumulated during each semester. To attempt the CATA certification exam, a candidate must submit detailed log books that document the 1,200 hours of practical experience (600 in field settings and 600 in clinical settings). Students at Sheridan College acquire these hours by completing various field and clinical practicums with high schools, colleges/universities, private clinics, independent contractors, and professional teams. During these practicums, students have the opportunity to practise assessment and rehabilitation techniques and skills on real individuals while still being under the supervision/direction of a certified AT. (Sheridan

College, 2016b).

Participants. The goal of Phase 3 was to explore the impact of using the M-CBL

SIAET on the nature of learning and teaching at Sheridan College. Therefore, feedback

from multiple stakeholders (both students and instructors) was necessary to gain an enhanced understanding of this research question.

Fourth-year AT students. Once the M-CBL SIAET was modified with the findings from Phase 2, it was sent to a class of 47 fourth-year students from the Bachelor of Applied Health Sciences (Athletic Therapy) program at Sheridan College. The goal of this phase was to ask students to compare and contrast this innovative technology- assisted CBL teaching tool with more traditional CBL applications. Therefore, I wanted to ensure that the sample of students had experience with previous: CBL applications; injury assessment courses; field placement practicums; and clinical placement practicums.

At the time of this study, the group of fourth-year students were in their last semester of the program and had already completed three clinical assessment and rehabilitation courses, three emergency injury assessment courses, and three clinical practicums. All students were concurrently finishing their fourth clinical assessment and rehabilitation course which focused on injury conditions of the spine, thorax, and pelvis.

During the Clinical Assessment and Rehabilitation 4 course, the educational tool was presented to the students according to the proposed pedagogical model that was previously introduced in Figure 1.6. The course instructor led the students through the first case study as an example, then allowed the students to work through two scenarios in smaller independent groups. Due to time constraints, and not having an evaluation component included in the original course syllabus, the independent assignment part of the pedagogical model was excluded from this sample but explained to the group.

Following the class where the tool was presented, all 47 students were sent a link to an online questionnaire to collect reactions regarding the impact of the educational tool/pedagogical model (Appendix E). Fifteen students (32% response rate; 11 female; 4 84

male) volunteered by completing the questionnaire. Ten of these participants also volunteered to participate in individual interviews (8 female and 2 male). Finally, two focus groups (each group containing three students [2 female; 1 male] from the individual interview sample) were formed and used to corroborate the findings from Phase 3.

AT educators. As stated earlier, the goal of Phase 3 was to explore the impact of the technology-assisted educational tool on learning and teaching. Therefore, it was also important to elicit feedback from AT educators to explore the impact the tool had on teaching. All seven full-time AT educators who were employed at Sheridan College at the time of research were invited to participate in individual interviews. The purpose of these interviews was to investigate the impact of using technology-assisted pedagogies within Sheridan College’s AT curriculum. Four educators (3 female; 1 male), including the instructor of the Clinical Assessment and Rehabilitation 4 course, volunteered to participate in these interviews. Two of the educators held Master’s degrees, one educator held a Master’s degree and had completed their course work towards a PhD, and the other educator had a Master’s degree with a doctorate in Osteopathy. The average number of years teaching at a CATA-accredited institution was 15.00 years, with a range from 8-24 years.

Sources of empirical materials. As described earlier, one of the main advantages of using an interpretivist lens is being able to use multiple data sources to contribute to the overall understanding of the research phenomenon under investigation (Baxter &

Jack, 2008). Additionally, using multiple data sets helps to triangulate the findings by providing stronger evidence to describe the phenomenon under investigation (Shank,

2002). If only a single data set was used (e.g., questionnaire findings) to explore the research question than the supporting evidence would not be as strong. Therefore, a

sequential explanatory mixed-methods approach was also used during this phase of research to collect empirical materials.

The mixed-methods approach that was employed during Phase 3 included: 1) fourth-year students completing a questionnaire that was designed for feedback around using the educational tool, pedagogical model, and overarching questions about using technology for learning (Appendix E); 2) fourth-year students completing individual interviews that identified emerging themes by explaining the questionnaire findings in more depth; 3) fourth-year students participating in focus group interviews to help corroborate the themes/findings from the questionnaire and interviews; and 4) AT educators participating in individual interviews to elicit feedback on the educational tool as well as exploring how the TPACK framework helped to promote critical thinking about using pedagogically sound technologies in the classroom.

Student questionnaire. An online questionnaire was designed to explore students’ experience with the M-CBL SIAET and accompanying pedagogical model (Appendix E).

More specifically, participants were asked a series of questions about: 1) previous experiences with using technology; 2) previous experiences with using technology for learning; 3) the educational tool itself; and 4) suggestions/improvements for the educational tool/teaching model. Most questions asked participants to read a statement and then select an appropriate response on a 5-point Likert scale, ranging from 1 = strongly disagree to 5 = strongly agree. To field test for question ambiguity, the survey was first screened by two AT students before being sent to the rest of the sample.

The first page of the questionnaire (see Appendix E) followed the same informed consent process as Phase 1. By responding to the survey cues, individuals consented to participate in Phase 3 of the research project.

The quantitative data collected from these questionnaires were analyzed through means and standard deviations to establish trends in responses, not to prove the validity or reliability of my educational tool. Instead, the findings were considered to be indicative of how this group of students viewed the impact of the technology-assisted pedagogy on learning.

Student interviews. At the end of the questionnaire, students were invited to participate in a 30-minute individual interview. These conversational interviews were used to further deconstruct the emergent trends from the questionnaire, through a standardized, open-ended question schedule (Patton, 2002). For example, if the questionnaire showed a trend that the majority of AT students considered technology to be an effective teaching tool, then I would design specific interview questions to further deconstruct this trend. A list of the questions from the interview schedule are included in

Appendix F. Again, to avoid ambiguity, all questions were field-tested with two AT students to ensure that they were clear, easily understood, and appropriate for exploring the research question.

A thematic analysis coding approach was also employed during this phase of research to gain a deeper understanding into AT students’ perceptions about my educational tool and effective technology integration in general. After the audio-recorded interviews were manually transcribed (using the same true verbatim technique as described earlier), I organized the data via general coding categories that emerged from the interviews including: advantages of using technology-assisted pedagogies; disadvantages of using technology-assisted pedagogy; contributions of incorporating the educational tool; drawbacks to incorporating the educational tool; and suggested improvements/modifications for the educational tool or pedagogical model. The final step of the coding approach involved studying the previous general categories and then 87

breaking them down into more refined themes. For example, data that were previously identified as being representative of a contribution of incorporating the educational tool were further refined into: creating a contextually-enriched scenario; engaging students in critical reflection/thinking; stimulating high level analysis; increasing peer interaction; and extending the learning outside of the classroom. This same procedure was followed for all other emerging themes. As described in Phase 1, all selected quotations presented in the Results chapter were also removed from the original transcriptions to focus on the meanings, perceptions, and constructions of AT students (Oliver et al., 2005).

Student focus group interviews. After the individual interviews were coded and analyzed, I organized two small focus groups to help corroborate the results (Morgan,

1997). I decided to use small focus groups during this phase of research because I wanted to give the opportunity to each individual student to respond to each question in a group setting (which does not happen in larger focus groups). Participants in smaller focus groups encourage each other and build on previous comments, resulting in more interactive and in-depth discussions when compared to individual interviews or larger focus groups (Krueger & Casey, 2008). In this study, the focus groups were essential in exploring how AT students constructed their perceptions of the impact of technology- assisted pedagogies in AT learning environments. The in-depth discussions offered rich details of students’ complex experiences with technology, and provided further reasoning explaining their beliefs, perceptions, attitudes towards technology-assisted pedagogies

(Morse, 1994). During this phase of research the focus groups also acted as a form of member checking since I was able to present the emerging themes to participants and garner further discussion, clarification, or interpretation. The smaller group dynamics allowed for each participant to comment on the emergent themes which helped to facilitate the discussion by building on each other’s ideas. After analyzing these focus 88

group interview responses, I further refined the emerging themes and presented a more accurate description of the impact of using my technology-assisted pedagogy in this AT specific context. The focus group question schedule is included in Appendix G. These focus group interviews were also audio-recorded (with permission from participants) and manually transcribed (Auerbach & Silverstein, 2003).

AT educator interviews. The final component of Phase 3 involved interviewing

AT educators from Sheridan College. The purpose of these interviews was to: 1) stimulate conversation surrounding the topic of incorporating pedagogically sound technologies in AT classrooms; 2) elicit specific feedback about the educational tool/pedagogical model; and 3) explore how knowledge of the TPACK framework helped to promote critical thinking about using pedagogically sound technology in AT classrooms. Appendix H provides a list of questions from the instructor interview schedule. Before interviewing the sample, all questions were field-tested with two AT educators to avoid question ambiguity and to address the areas of rigour and trustworthiness of qualitative data.

After the interviews were manually transcribed through a true verbatim technique, all data were organized via general coding themes including: advantages of using technology-assisted pedagogies; disadvantages of using technology-assisted pedagogy; contributions of incorporating the educational tool; problems associated with incorporating the educational tool; additional ways to implement the educational tool; and benefits of understanding the TPACK model. The final step of the coding approach involved reviewing the previous coding categories and further refining them. For example, data that were previously identified as being representative of the benefits of understanding the TPACK model were further divided into: using TPACK to promote critical thinking; using TPACK to design future technology interventions; identifying 89

barriers to understanding TPACK; and identifying barriers to implementing TPACK.

This same coding procedure was followed for all other emerging themes. When writing quotations for these emerging themes in the Results chapter, all transcriptions were removed (utterances, grammatical errors, filler words, etc.) so that the focus could be placed on the meanings and perceptions constructed during the interviews

What does phase 3 contribute to our understanding of the research question?

Phase 3 provided a case study example of the impact that the technology-assisted pedagogy had on the nature of teaching and learning in a CATA-accredited institution, while assisting in establishing the factors that influenced the use of technology-assisted teaching tools in AT education. By employing multiple data sources as described above,

I was able to triangulate the interpretation of results. Following the main tenets of R2D2

ID theory, I elicited feedback from multiple stakeholders (both students and instructors) in a recursive and reflexive process to make further improvements/revisions to the educational tool and pedagogical model. Furthermore, both the positive and negative impacts of using this specific technology-assisted pedagogy were explored and these findings were considered to develop future recommendations for AT educators who are interested in integrating innovative technologies that are pedagogically sound.

CHAPTER 4: RESULTS

Chapter 4 Outline

The purpose of my study was to investigate the research question, “What impact does using a technology-assisted pedagogy have on the nature of teaching and learning in a CATA- accredited institution?” The main objective of this research was to uncover emergent trends in how AT students and educators reacted to using a pedagogical intervention of technologically-enhanced case studies. The primary interest was to explore the impact of the M-CBL SIAET on teaching and learning while establishing the specific factors that influenced the integration of technology-assisted teaching tools in

AT education. Whether this approach is more or less productive (from a learning outcomes perspective) than traditional pedagogies, was not the focus of this work.

This study was divided into three phases, each with a unique set of research goals and objectives. Phase 1 defined the context of the study by establishing AT educators’ initial attitudes towards using various pedagogies, technologies, and what factored into the decision-making process of implementing different pedagogies/technologies into the

AT curriculum (e.g., factors that influenced the implementation of a new pedagogical strategy). Phase 2 used the findings from Phase 1 and earlier pilot projects to make modifications and additions to the M-CBL SIAET to ensure its applicability for an AT- specific context. Finally, Phase 3 explored the main research question by investigating the impact that the updated multimedia teaching tool had on teaching and learning in a single CATA-accredited institution. This chapter summarizes the significant quantitative and qualitative findings that emerged from all three phases of research.

4.1 Phase 1 – Describing the Context of AT Educators

As outlined in the Methodology chapter, Phase 1, following an explanatory sequential mixed-methods design, offered a detailed and comprehensive description of the research context by establishing AT educators’ initial attitudes towards using technology-assisted pedagogies. Establishing these initial attitudes was imperative to determine if a collective negativity surrounding technology integration existed, which would have created difficulty in studying the perceived impact of my technology-assisted teaching tool during Phase 3. Furthermore, by analyzing the initial attitudes and views towards technology integration, I was able to make specific modifications and additions to the M-CBL SIAET to ensure that it was suitable for an AT context.

The explanatory sequential mixed-methods approach began by collecting quantitative data through an online questionnaire (see Appendix C) to determine how familiar AT educators were with using different pedagogies and digital technologies within CATA-accredited institutions. Table 4.1 provides a summary of the questionnaire responses from 21 full-time AT educators, beginning with question seven. The first six questions requested demographic information and these results were used to describe the participants as presented in the Methodology chapter. More specifically, Table 4.1 includes: 1) the identifying question number; 2) the TPACK construct represented by each question (as identified by Archambault & Crippen, 2006; Schmidt et al., 2009); 3) mean response out of a score of 5; 4) standard deviations out of a score of 5; and 5) the descriptive word used to classify the mean response (either 5 - strongly agree; 4 – agree;

3 neither agree or disagree; 2 – disagree; or 1 - strongly disagree).

Table 4.1

Summary of Phase 1 Questionnaire Responses

Question TPACK Construct Subscale Mean SD Descriptive Number (/5) 7 Technology (TK) 4.29 0.70 Agree 8 Technology (TK) 2.24 1.19 Disagree 9 Technology (TK) 3.38 1.05 Neither Agree or Disagree 10 Technology (TK) 4.14 0.71 Agree 11 Technology (TK) 3.33 0.94 Neither Agree or Disagree 12 Content (CK) 4.71 0.45 Strongly Agree 13 Content (CK) 2.38 1.17 Disagree 14 Content (CK) 4.19 0.66 Agree 15 Content (CK) 3.81 0.66 Neither Agree or Disagree 16 Content (CK) 3.76 0.92 Neither Agree or Disagree 17 Pedagogy (PK) 3.90 0.81 Neither Agree or Disagree 18 Pedagogy (PK) 3.52 1.10 Neither Agree or Disagree 19 Pedagogy (PK) 3.67 0.99 Neither Agree or Disagree 20 Pedagogy (PK) 4.00 0.76 Agree 21 Pedagogy (PK) 4.57 0.49 Strongly Agree 22 Pedagogy (PK) 4.29 0.93 Agree 23 Pedagogy (PK) 4.29 0.55 Agree 24 Pedagogy (PK) 4.14 0.64 Agree 25 Pedagogy (PK) 4.24 0.53 Agree 26 Pedagogy (PK) 2.24 0.92 Disagree 27 Pedagogy Content (PCK) 4.00 0.76 Agree 28 Pedagogy Content (PCK) 4.33 0.64 Agree 29 Pedagogy Content (PCK) 1.86 0.77 Disagree 30 Pedagogy Content (PCK) 4.24 0.68 Agree 31 Technology Content (TCK) 3.48 0.91 Neither Agree or Disagree 32 Technology Content (TCK) 2.14 0.64 Disagree 33 Technology Content (TCK) 3.90 0.87 Neither Agree or Disagree 34 Technology Content (TCK) 4.57 0.73 Strongly Agree 35 Technology Content (TCK) 4..57 0.49 Strongly Agree 36 Technology Content (TCK) 3.33 1.21 Neither Agree or Disagree 37 Technology Content (TCK) 4.33 0.94 Agree 38 Technology Content (TCK) 3.57 1.22 Neither Agree or Disagree 39 Technology Content (TCK) 3.10 0.97 Neither Agree or Disagree 40 Technology Pedagogy (TPK) 3.86 0.89 Neither Agree or Disagree 41 Technology Pedagogy (TPK) 3.27 0.94 Neither Agree or Disagree 42 Technology Pedagogy (TPK) 3.52 0.85 Neither Agree or Disagree 43 Technology Pedagogy Content (TPCK) 2.57 1.14 Disagree 44 Technology Pedagogy Content (TPCK) 2.52 1.05 Disagree 45 Technology Pedagogy Content (TPCK) 2.10 1.02 Disagree 46 Technology Pedagogy Content (TPCK) 3.76 0.92 Neither Agree or Disagree 47 Technology Pedagogy Content (TPCK) 3.81 0.91 Neither Agree or Disagree 48 Technology Pedagogy Content (TPCK) 2.90 1.31 Disagree 49 Technology Pedagogy Content (TPCK) 3.90 0.61 Neither Agree or Disagree

As an alternative to discussing noteworthy findings from an isolated questionnaire, I blended together the questionnaire results with the findings from the qualitative interviews (the second stage of the sequential explanatory mixed-methods research design [Creswell & Plano-Clark, 2011]) to describe educators’ initial views towards using digital technologies for teaching in an AT context. To guide this analysis, the TPACK framework was applied to organize the empirical findings into the seven unique constructs of the TPACK model: 1) technological knowledge (TK); 2) content knowledge (CK); 3) pedagogical knowledge (PK); 4) pedagogical content knowledge

(PCK); 5) technological content knowledge (TCK); 6) technological pedagogical knowledge (TPK); and 7) overall technological pedagogical content knowledge

(TPACK). In the ensuing sections, each of these TPACK constructs are presented individually, offering an enriched description by blending both quantitative and qualitative findings.

4.1.1 Technological knowledge (TK). TK is defined as an educator’s familiarity with standard technologies (e.g., books, blackboard), more advanced digital technologies

(e.g., Internet, digital videos), and the skills required in the operation and understanding of interacting with different products, operating systems, software programs, and computer hardware (Mishra & Koehler, 2006).

After analyzing the empirical findings, the sample of AT educators displayed a self-perceived high level of TK, especially with common basic digital technologies, identified as PowerPoint, word processors, email, internet browsers, images/graphics, videos, animations, and smart phone/iPad applications. Furthermore, questionnaire respondents agreed with the statements: “I enjoy using technology as a part of my teaching” (4.29) and “I generally have a positive attitude towards learning new technologies” (4.14). If one considered only this evidence, it would appear that AT 94

educators were well versed in using a variety of digital technologies to enhance course content. However, when these themes were further deconstructed in the qualitative interviews, it became clear that there was actually a wide range of TK among the sample of AT educators.

All AT educators (ATEd-1-15) appeared to be comfortable with using basic software tools (such as word processors, spreadsheets, internet browsers, email, and

PowerPoint) and many considered these digital technologies to be enough to match the current demands of today’s students. In the questionnaire, AT educators also indicated that they generally did not feel pressure from students to use more technologies as a part of their teaching. However, seven participants commented in their interviews about increasing expectations from either the student or institutional level to incorporate more advanced technologies in the classroom. Several of these AT educators gave detailed examples of how they responded to these increased expectations by implementing more advanced digital technologies. For example, one educator (ATEd-5) described how private blog sites were used as a forum for students to describe and comment on each person’s practicum experiences. Another educator (ATEd-9), from a different accredited institution, discussed integrating various exercise analysis applications (e.g., Coach My

Video iPad app) into the course so that students could record and critique exercise technique and prescription. Other examples of more advanced technology integration that emerged from the interviews included: integrating scenario-based learning with mid/high fidelity simulation manikins; using 3-dimensional anatomy models of the human body to give students more accurate depictions of anatomical structures; incorporating interactive polling software during lectures to make sessions more interactive; and giving students access to video instructional technologies to help extend

the learning outside of the classroom. Based on these diverse examples, there was clearly a broad range in how technology was currently being integrated by AT educators.

Although there was a wide range of TK in AT educators, the majority of respondents (11/15) expressed a desire to learn more about advanced digital technologies and to explore how technology integration could enhance the AT classroom experience.

According to one educator,

For me personally, I wish I could use more ideas related to technology. Students

today are more visual. When you look at everything that students do now,

Instagram, Facebook, Twitter, they are constantly looking at pictures. Therefore,

there are more visual learners than ever, they are not as auditory as in the past. So

what can I use to help engage these students? (ATEd-1)

Another AT educator (ATEd-4) added, “I wish I knew more about different technologies because I am sure there are lots out there that could benefit my students. I just do not know where to start sometimes when looking for new innovative technologies”. While the desire to increase TK was present in the majority of AT educators, several limiting barriers emerged from the interviews that could explain why TK was not as high in this sample of educators.

The most significant barrier to increasing TK was identified as the time constraints associated with learning new technologies and skills. On the questionnaire, educators were asked to respond to the statement, “I keep up-to-date with new technologies” with the average response being 3.3 (neither agree or disagree). Further discussions during the interviews also suggested that time constraints were the number one reason for not keeping up-to-date with newer technologies. In the AT profession, many educators held non-traditional (non-tenure-track) academic appointments and actively assessed/treated individuals, attended major games (e.g., Olympics, Pan- 96

American Games), or had varsity athletic commitments outside of teaching at a post- secondary institution. Therefore, between course preparation, teaching, marking, and additional AT responsibilities, there was limited time available for learning how to use new technologies. Other educators in more traditional tenure-track academic appointments also had additional research and service responsibilities which again take away from the time available to learn new technological skills.

Another limiting factor for increasing TK was the costs associated with learning and implementing new technologies. Depending on the type of digital technology, there may be costs for both the educator and the student. An educator may need to pay for the technology itself, or pay for professional development sessions to learn how to use that particular piece of technology. As well, some digital technologies may be expensive for the student, requiring them to purchase new equipment and/or software. As one AT educator stated in an interview,

With technology comes cost. Students have to be able to afford it if you are

integrating it into your curriculum. If you are saying that a student needs x, y, and

z to succeed in this class, then what happens when a student cannot afford x, y,

and z? (ATEd-2)

Therefore, educators should be cognizant of the associated costs of implementing new digital technologies and be aware of the impact that these costs potentially have on student accessibility.

Finally, five AT educators (ATEd-4, 8, 9, 13, 14) articulated another barrier concerning how innovative technologies could be viewed by classroom teachers as a threat. These educators were apprehensive about school administrators who could potentially view the inclusion of more advanced digital technologies as a rationale for replacing traditional in-class teaching environments. According to one educator, 97

Some administrators may get the idea that if I can use videos and different

technologies to teach in my classroom, then in-class teachers can be replaced and

the program can move towards an online model. This would be a cheaper option

for the institution and allow them to take in a lot more students. (ATEd-9)

Another educator added,

In today’s university climate, we are all experiencing budget cuts and changes to

student expectations. Pressures are often placed by administration to accept more

students, no matter if they are on campus or not. Therefore, moving towards an

online teaching model would reduce costs and increase the number of students

that could register in an AT course. So I think that could cause some worry in AT

educators about implementing more digital technologies into their classrooms.

(ATEd-4)

Although these concerns were expressed several times, all educators pointed to the practical nature of the AT profession and rationalized the importance of having actual face-to-face educator/student interactions. For example, a student can watch a video of an anterior cruciate ligament (ACL) special test (e.g., Lachman test) online and then attempt to perform the test on a peer but they really need an expert there to show them the proper hand position, amount of force, direction of force, share experiences, etc. These are essential psychomotor skills that are required to demonstrate competence and are difficult to teach in comprehensive online environments.

In summary, the sample of AT educators from my study had a self-perceived high level of TK and appeared to be interested in learning more about how advanced digital technology integration could enhance AT education. However, further analysis indicated a technological distinction between those educators who used basic software tools to deliver course content and those who incorporated more advanced digital technologies to 98

enhance student learning. When interviewing educators from both of these groups, it was clear that there was a wide range of TK amongst this sample of AT educators.

4.1.2 Content knowledge (CK). CK is defined as an understanding of subject matter that is to be taught or learned in a particular course (Mishra & Koehler, 2006).

According to Shulman (1986b), to demonstrate a high level of CK, teachers must know and understand: 1) the subjects that they teach, including knowledge of central facts, concepts, theories, and procedures within a given field; 2) explanatory frameworks that organize and connect ideas; 3) rules of evidence and proof; 4) curriculum knowledge with a particular grasp of the materials and programs that serve as “tools of the trade”; and 5) knowledge of educational contexts. Educators must also appreciate the differences in knowledge of similar subject fields to avoid misrepresentations being shared with students (Ball & McDiarmid, 1990). For example, an educator from a

CATA-accredited program should be able to recognize the differences in the acute injury assessment techniques taught by different health professional groups such as emergency room triage nurses, family physicians, emergency medical technicians, and ATs. Even though there are many similarities in assessment procedures, the unique differences should be critiqued and shared with AT students to avoid a misrepresentation that there is a universal assessment procedure that is recognized by all professions.

Of the 15 educators interviewed in this study, six held PhD degrees (ATEd-3, 5,

7, 10, 11, 15), eight held Master’s degrees (ATEd-2, 4, 6, 8, 9, 12, 13, 14), and one had a

Master’s degree with a doctorate in Osteopathy (ATEd-1). Due to the amount of graduate-level education in this cohort, it was expected that CK would be relatively high in the group. This assumption was confirmed by the questionnaire results, as the sample of AT educators felt confident that they possessed a high level of CK. When asked on the questionnaire to comment on the statement, “I feel confident in my knowledge of key 99

concepts in my area of specialization”, the participants strongly agreed with a mean response of 4.71. Additionally, the educators agreed that they “felt confident that I use the latest resources to support the content of my teaching” (3.81); “I am aware of the significant research contributors in my area of specialization” (3.76); and did not have difficulty sequencing content topics by disagreeing with the statement “I sometimes have difficulty sequencing the topics in my teaching” (2.38).

When the AT educators were further questioned about how they acquired or maintained their high levels of CK, three main themes emerged. First, these 15 educators considered experience to be the most important attribute for developing a high level of

CK. The sample of educators suggested that graduate school experience, previous AT experiences, and previous teaching experiences were all essential in building a foundational CK base. On further examination, the sample of AT educators were found to be an experienced group (the average number of years teaching at a CATA-accredited institution was 13.1 years; with a range of 6-38 years), and many of them taught the same courses year after year. Hence, as one educator stated,

When you teach the same course in multiple years it allows you to review the

curriculum, update with new topics, and read literature in that particular area.

Therefore, you get to increase your own knowledge in that particular subject area

by preparing for each year. (ATEd-15)

The second CK theme that emerged was linked to continuing education. To maintain certification as certified athletic therapists, CATA members must accumulate 21 continuing education units (CEUs) every three years (CATA, 2016c). These units ensure that members remain up-to-date with current trends and new research, and can come in the form of courses, conference attendance, or other recognized forms of professional development (CATA, 2016c). A committee from the CATA decides upon the number of 100

CEUs to assign to a professional development opportunity, based on criteria such as the length of the course, how applicable the topic is to the scope of practice of an AT, and if an additional certification is attached to completion of the course. Eleven of the AT educators (ATEd-1-4, 6, 9, 10-15) mentioned this CEU requirement and commented on how this obligation for maintaining certification assisted in keeping up-to-date with current topics, concepts, theories, procedures, etc. in the AT profession

The third theme that emerged from this sample was related to maintaining CK by concurrently practicing as a therapist. Some of the AT educators held the dual positions at their accredited institutions of teaching courses in the program as well as working as an

AT with the varsity teams (providing assessments and treatments for these athletes).

Other educators assessed and treated individuals in clinical environments outside of their postsecondary environment. Finally, many of the educators also travelled to major provincial, national, and international competitions (e.g., Canada Games, Olympics, or

Pan-American Games) to work as ATs with core healthcare service teams. All these experiences working as ATs outside of the classroom environment allow the educators to constantly practise and apply the theory and techniques that are being taught inside the

AT classrooms. As an illustrative example, one educator commented,

By continuing to practice as an athletic therapist, I am able to keep up with the

newest treatment techniques and therapeutic modalities because I want to use

what is best for my client. Then I get to turn around and teach these same

techniques to my students. (ATEd-12)

In any academic program it is difficult to quantify the amount of CK that an educator possesses because of the many inherent complexities associated with measuring this construct (Ball, Thames, & Phelps, 2008). This held especially true in the current

AT context for two main reasons: 1) the vast differences in program design among 101

accredited institutions; and 2) the number of courses taught by each educator at each institution (depending on the quantity of AT educators employed at each institution).

Currently, the CATA does not have a universal curriculum sequencing map that is required of each accredited program to achieve the professional competencies, so there are many unique differences from program to program. For example, the Sheridan

College program offers a degree in AT that delivers the CATA competencies through 52 courses over a four-year period. Comparatively, the York University program delivers the CATA competencies through six AT specific courses over a two-year period with a pre-requisite requirement of completing an undergraduate degree before entry into the

AT program. To highlight these differences across Canada, the curriculum sequencing maps for each CATA-accredited institution are included in Appendix I.

Since there are so many different curriculum models across CATA-accredited institutions, there are also inconsistencies in the number of AT educators that are employed at each institution, a discrepancy that directly impacts the number of courses that each AT educator teaches, and whether or not these courses are included in the same discipline area. For example, one AT educator (ATEd-4) taught five courses a year from four completely different AT disciplines, including: injury conditions, motor development, research methods, and fitness training/leadership. Another educator

(ATEd-10) taught only courses related to orthopedic assessment as a part of their teaching load. However, though an educator may teach courses in a wide range of disciplines, does not automatically suggest that it would negatively impact CK. Still, one might wonder if CK would be higher in an individual who just taught courses in a single discipline. Since there are AT educators who are more generalist by nature and teach in multiple areas of specialization, future studies may want to explore the differences in CK

102

between those who teach in a single area versus those who teach across multiple disciplines.

In summary, this sample of AT educators perceived their level of CK to be high.

Further analysis through individual interviews supported this finding by classifying these educators as content experts. A high level of graduate education, the nature of the AT profession, combined with the fact that most of the AT educators still practiced as ATs, contributed to this high level of CK.

4.1.3 Pedagogical knowledge (PK). PK is defined as a deep understanding about the processes and practices of teaching and learning and how it encompasses overall educational purposes, aims, and values (Mishra & Koehler, 2006). PK includes knowing about: cognitive, social, and developmental theories of learning and how these apply to students in the classroom; effective techniques or methods to be used in the classroom; the nature of the target audience; strategies for evaluating student understanding; and how students construct knowledge, acquire skills, and develop habits of mind (Mishra &

Koehler, 2006).

After analyzing the questionnaire, the majority of AT educators perceived their level of PK to be high. This opinion was formed based on the respondents agreeing with the following statements: 1) “I feel confident in my ability to assess student performance in the classroom” (4.57); 2) “I feel confident in my ability to adapt my teaching methodology based on student performance” (4.29); 3) “I feel confident in my ability to adapt my teaching to different learning styles” (4.29); and 4) “I am confident in my ability to assess student learning using multiple measures” (4.14).

When the AT educators were further questioned about how they acquired or maintained their PK, three central themes emerged. First, 10 AT educators (ATEd-2, 3,

5, 9-15) commented about their personal experiences as a student and how these 103

reflections led them to develop similar strategies and philosophies as their favourite teachers. As an illustrative example, one educator commented,

I learned how to teach through the school of hard knocks. I tried to emulate my

favorite teachers and then experienced, reflected, and altered my teaching

practices for the next time. Good teachers constantly think about how they can

improve as an educator. (ATEd-5)

Although this comment resonated with the central theme, it could be considered as a flawed idea because current students may learn differently than the preferred strategies/learning modes of a particular educator, especially if they are from a different generation.

The second theme that emerged related to improving PK was associated with formalized professional development courses. Nine of the AT educators interviewed

(ATEd-1-7, 11, 12), participated in regular formalized pedagogy sessions. These developmental sessions covered an assortment of topics including: teaching in a college setting; introduction to innovative teaching methods; connecting effective teaching methods to match differing learning styles; summative and formative assessment; and cooperative learning. When comparing the different CATA-accredited institutions, there was a wide range of formalized pedagogy opportunities readily available for AT educators. The greatest difference was observed between CATA programs that were housed in college settings compared to those from universities. The college environments with CATA programs (Sheridan College, Camosun College) provided many opportunities for AT educators to develop their PK. For example, at Sheridan

College all new faculty members were initially hired on two-year probationary contracts that required them to participate in the ‘Teaching and Learning Academy’ on campus.

This academy assisted with the transition into a full-time teaching role by enhancing PK 104

and teaching skills. Similar programs were also established at Camosun College and

Mount Royal University. In 2009, Mount Royal College became officially recognized as

Mount Royal University to allow for an increase in the number of applied degrees being offered at that institution (Baker, 2011). Although it is now labelled as a university, many of the past practices of the college environment (including the pedagogical support for new faculty) are still engrained in the institution. Comparatively, AT educators from the other university programs (excluding Mount Royal University) did not have the same level of access to PK courses and if they did, the educators had to actively pursue these courses on their own time. For example, an educator from the University of Winnipeg

(ATEd-9) stated, “There are no professional development sessions that I am aware of about effective teaching strategies or other topics related to pedagogy. Or at least I haven’t heard of any.” Another educator from Mount Royal University had experiences in teaching in both college and university settings and summed up this theme by articulating,

Mount Royal is more community based so you have more resources and support

with regards to pedagogy and improving as an educator. The teaching part of the

job is really emphasized. At the University of Calgary, you are more out on an

island and are just thrown in there. And the focus is not really on being the most

effective educator. (ATEd-11)

The final theme of how AT educators acquired or maintained PK was through informal professional development. Some of the AT educators interviewed were very passionate about improving as teachers and considered themselves to be life-long learners of pedagogy. According to one educator (ATEd-5), “I read a lot about pedagogy and experiment in the classroom. I like to learn about a new strategy or way to approach a

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topic, think about how it would fit with my course, and then implement it.” Another participant added,

For me personally, I enjoy reading and discussing these things with other

educators. Topics like: how do you do a good review with a student? How do you

give effective feedback to a student? What methodologies help a student to

progress? Then the beauty part of teaching every year is that you get the

opportunity to try it out…to see what goes well, what doesn’t, what would I do

differently next year? It’s a constant journey towards being a more effective

educator. (ATEd-1)

Although the perception of PK was found to be quite high in the questionnaires, conflicting findings emerged from the interviews. After analyzing the responses, a pedagogical distinction was observed between two groups of AT educators: 1) 10 educators (ATEd-2, 4, 8-15) appeared to follow the ‘traditional’ postsecondary teaching practice of articulating theory in a lecture format followed by demonstrating practical skills in laboratory settings; and 2) five educators (ATEd-1, 3, 5, 6, 7) used more innovative teaching strategies and pedagogies and were more likely to experiment in the classroom. Educators who followed the traditional lecturing practice were less likely to know about different pedagogies/teaching methods and have conversations about how these strategies could contribute to more effective instruction. One educator (ATEd-8) rationalized this lack of knowledge by commenting, “In AT-accredited institutions, most educators are ATs first and educators second. So we teach how we were taught and do not really know any other way”. Comparatively, the other group of educators appreciated the use of different pedagogies and understood how using different strategies could enhance learning and benefit AT students. For example, one educator (ATEd-5) spoke about their introduction to student reflection as a teaching strategy and shared their 106

personal journey of designing, implementing, and evaluating reflection into their AT classes. According to this educator,

To me, students need to be able to reflect on their own learning. What they know.

What they do not know. And through the years I needed to work with the students

so that they knew how to do an actual reflection of learning. What really made it

meaningful to you? Was it how it was presented? Was it the way you interacted

with the patient? There may be many things along the way that can add meaning to

the topic at hand. (ATEd-5)

This was just one example, but several others emerged from a group of educators that were clearly more knowledgeable and experimental in PK.

To identify the signature pedagogy of AT education, the sample of educators were asked to discuss their personal teaching philosophies and to describe different teaching strategies/methods that were most commonly applied in their classes. Again, a pedagogical distinction became apparent in these discussions. The same five educators described in the last paragraph were able to openly discuss different teaching strategies and demonstrated a clear understanding of how/when to effectively implement a particular strategy. Comparatively, the other 10 traditional educators were not as comfortable in these conversations. For example, when discussing CBL as a potential teaching strategy, the educators with a higher level of PK were able to provide different contexts of how they would integrate these activities into their classes, whereas the other educators just considered CBL to be simply using a case scenario as an example to add context to the content being taught.

The five educators that demonstrated a higher level of PK (ATEd-1, 3, 5, 6, 7) identified many different pedagogical strategies that they commonly used in AT classrooms, including: CBL; flipped classrooms; student critical reflection activities; 107

narratives and storytelling; self-directed learning; and cooperative learning. The other 10 educators described lecture-based learning as being the most commonly used teaching strategy that guided their entire curriculum design. Since the majority of educators shared this same belief, the traditional post-secondary lecture-based learning environment appeared to be the signature pedagogy of the AT profession. More specifically, this signature pedagogy of most CATA-accredited institutions can be described as using didactic methods to lecture about content theory and to then use separate laboratory sessions to teach hands-on practical skills. In the interviews, AT educators were asked to further comment on why they thought this was the signature pedagogy of the profession.

Responses included: 1) “Lecturing is an easy way to get a lot of information across to a lot of people. Because you can put a PowerPoint presentation together, stand up in front of the room and blast information at people.” (ATEd-13); 2) “Lecturing is how the students expect their education to be. They pay to have someone teach them the material as opposed to being mainly self-directed.” (ATEd-4); 3) “People teach the way they were taught. It is scary for some people to go outside their comfort zone to look for innovative strategies, or the risk of trying something new.” (ATEd-10). Although this traditional form of lecture-based learning was considered to be the current signature pedagogy of

AT education, some conversations suggested a potential pedagogical shift in the near future. For example, the AT program at Mount Royal University recently revamped their entire curriculum delivery model and instituted an innovative curriculum based on the clinical presentations model that identifies specific clinical presentations that are essential for an entry-level AT to know (Thomas, Kern, Hughes, & Chen, 2016). These presentations can take the form of patient history points (e.g., an athlete felt a pop in a knee), physical examination signs (e.g., diffuse swelling), or orthopedic abnormalities

(e.g., laxity with a Lachman special test for the knee). Each clinical presentation is then 108

organized into specific frameworks suggesting how they would be presented to an AT.

The teaching faculty then creates a classification system (called schemes) of clinical problem-solving pathways that form the framework for building knowledge of basic and clinical sciences throughout the curriculum (Thomas et al., 2016). Other than this clinical presentations example, there was at least one educator from each CATA-accredited institution who shared future ambitions of improving AT education as a whole. These educators also expressed a high level of passion towards improving their personal PK by experimenting and growing as educators. Therefore, future studies may observe an evolutionary shift in the signature pedagogies of the AT profession.

To summarize, the questionnaire results suggested that the AT educators in this sample perceived their PK to be quite high. However, further analysis of the individual interviews suggested there was a pedagogical distinction between those educators who followed a more traditional didactic teaching practice of lecture-based learning and those who used more innovative teaching strategies and pedagogies.

4.1.4 Pedagogical content knowledge (PCK). As described in the Introduction chapter, the concept of PCK was first expressed by Shulman as the knowledge of pedagogy for teaching specific course content (Shulman, 1986a). This type of knowledge includes: knowing what teaching strategies/approaches fit the specific course content; knowing when to use different teaching strategies; knowing how the elements of the content can be arranged for better teaching; knowing what makes concepts difficult or easy to learn; and knowing students’ prior knowledge (Mishra & Koehler, 2006).

The majority of the AT educators that were surveyed in this study felt confident that they demonstrated a high level of PCK by agreeing with the following statements: 1)

“I feel confident designing assessments for my area of specialization” (4.33); 2) “I feel confident selecting the appropriate teaching strategy for specific learning objectives” 109

(4.00); and 3) “I make a conscious effort to integrate my content area within other course of the student’s program” (4.24). Further evidence emerged from the interviews suggesting that AT educators felt especially comfortable in designing curriculum that considered the specific sequencing of knowledges, theories, concepts, and skills.

The presence of a comprehensive list of CATA competencies (Appendix A) appeared to assist in the sequencing process by providing educators with a general outline for curriculum design and planning. When designing courses and programs in CATA- accredited programs, AT educators have to consider how each competency will be taught

(since it is necessary for accreditation of the program and for the students seeking professional certification) while also reflecting on how to sequence a series of knowledges, concepts, and skills. For example, for AT students to learn how to complete a comprehensive orthopedic assessment, they must have previously developed a foundational base that includes orthopedic anatomy, biomechanics, injury conditions, and basic assessment principles. These topics need to be taught in earlier courses so that an educator can build upon the prior experiences by developing more advanced assessment knowledge and skills. Within an accredited institution, it is important for all educators to be aware of this sequencing process for each course, building upon prior knowledge and learning from previous courses.

Several examples emerged from the interviews describing the sequencing processes that are currently implemented by CATA-accredited institutions. At Mount

Royal University, the full-time AT educators meet quite regularly throughout the semester (usually on a bi-weekly basis) to discuss course content and pedagogical issues.

During these sessions, educators discussed what was being taught in each course, whether or not there were any overlaps, what seemed to be working, what was not, etc. This information was shared with all faculty to ensure that important competencies, concepts, 110

and skills were logically sequenced in such a way that benefited AT student learning.

Similar discussion-based models were also well-established at other CATA-accredited institutions to allow for all full-time educators to comment on what was being taught and in which courses.

One significant issue surrounding course sequencing that was identified during the interviews was related to the presence of part-time educators in CATA-accredited programs. Each institution in my study had a least a couple of part-time faculty members teaching core courses within the AT program. Seven AT educators made reference to the differences between full-time and part-time faculty members at CATA-accredited institutions and commented on how part-time educators were not contractually obligated to participate in academic retreats and/or formal faculty meetings. Therefore, there was the potential for disconnect in the sequencing of theories, concepts, and skills if the part- time faculty were not included in the same pedagogical discussions as the other AT educators. As one educator (ATEd-7) noted, “part-timers are not always included in the on-going curriculum conversations of our department so it makes it difficult for us to plan for what to teach in our future courses.” Another educator from a different institution agreed by stating,

Part-time hiring seems to be preferred by the administration because they are not

committing to someone for a long period of time but it makes it difficult to

provide high quality, consistent teaching. When we have someone different

teaching each year then there is always the risk of having someone teach different

concepts, slightly different skills, that do not align with our overall curriculum

plan. (ATEd-1)

This study only elicited feedback from full-time AT educators so part-time educators were excluded from participating in the questionnaire or interviews. Therefore, future 111

studies should compare the PCK differences between full-time and part-time faculty to explore if these differences have a negative impact on AT teaching and learning.

Another important component of high PCK is knowing what teaching strategies fit the course content and understanding when to incorporate different teaching strategies. It appeared that the majority of the AT educators interviewed in this study taught the same way as they always did (using the same teaching strategies) regardless of the course content. As discussed earlier, the lecture-based learning signature pedagogy was most often used by AT educators, regardless of the course content being taught, even though another strategy may have been more beneficial to facilitate student learninig.

However, five educators (ATEd-1, 3, 5, 6, 7) demonstrated a higher level of PCK by understanding when to use different teaching strategies. Corresponding to what was discussed in the PK section, there was also a pedagogical distinction found in this particular component of PCK. The ‘traditional’ postsecondary AT teachers (those who divided their courses by articulating theory in a lecture format and demonstrating skills in a practical setting) had a more superficial understanding of pedagogy and were less likely to use different teaching strategies compared to those who demonstrated a higher level of

PK. The five AT educators who demonstrated a higher level of PK were able to: have deeper conversations about different teaching strategies; give more detailed examples of when they used different teaching strategies; and describe what factors they considered when making these pedagogical decisions. For example, an educator from Sheridan

College described their personal PCK growth of transitioning from using a content-driven approach to placing a greater emphasis on the teaching and learning. According to this educator,

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Before, the discipline was the most important thing and I was very content driven.

Now I just want to guide and encourage learning and use a more active-learning

approach. I want to ensure that learning becomes real to my students. (ATEd-6)

This educator continued by describing how they used specific active-learning examples such as flipped classrooms, reflective activities that stimulated critical thinking, CBL, and

PBL. When deciding upon what teaching strategies to use, this educator said,

The content of the course drives my selection of teaching strategies. There are

some courses (e.g., therapeutic modalities) that from a safety perspective, I need

to teach important pieces of content first so that the students know the basics so

they do not harm a patient. In these cases, I still use the traditional lecture to get

the content across. But in other courses (e.g., assessment courses), it is useful to

implement more flipped classroom models, or learner centred activities to really

allow the students to build upon their prior experiences and to integrate what they

may have seen at a placement or in other classes. (ATEd-6)

Two other AT educators (ATEd-3, 7) who represented a higher level of PCK, made additional comments about Bloom’s Taxonomy and described how these principles guided their selection of different teaching strategies. These educators stated that different strategies were employed when the objective was to develop higher levels of learning within Bloom’s Taxonomy (analysis, synthesis, or evaluation) compared to if the main objective was to stimulate the lower levels of knowledge (rote memorization) and comprehension. When the goal was to encourage higher levels of learning, more learner- centred teaching strategies were implemented such as CBL, PBL, and student reflection.

When the course objective was focused on knowledge acquisition and factual recall, the traditional lecture-based approach was typically used.

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In summary, the AT educators included in this sample felt confident that they demonstrated a high level of PCK. However, based on the themes that emerged from the interviews, it appeared that the participants demonstrated a high level of PCK in certain areas (e.g., knowledge of sequencing important concepts/knowledges/skills) but a wider range was also apparent in other areas of PCK (e.g., understanding different pedagogies and knowing when to implement different teaching strategies). The same pedagogical distinction discussed in the PK section was also apparent in this construct as those AT educators with a higher level of PK also demonstrated an increased level of PCK.

4.1.5 Technological content knowledge (TCK). TCK is defined as the manner in which technology and content are reciprocally related (Mishra & Koehler, 2006).

Effective technology integration does not mean implementing technology just to appease students’/institutional demands. Rather it involves thinking about how the course content can be changed through the application of a particular technology (Mishra & Koehler,

2006).

When analyzing the results of the questionnaire, it appeared that the sample of AT educators did not perceive their TCK to be as high as the other constructs of TPACK.

When asked the question “I am aware of the technologies that are commonly used in teaching in my discipline”, the respondents neither agreed or disagreed with this statement (3.48). Additionally, the sample suggested that they were not likely to experiment by using new technologies, unless they were confident that these technologies would definitely work in the classroom (3.10).

In the individual interviews, this construct was further examined by inviting educators to give specific examples of how various technologies were incorporated into their AT classes and what was considered when making these decisions to integrate technology. Eleven of the AT educators (ATEd-1, 2, 4, 8-15) appeared to have a more 114

superficial understanding of technology integration and did not reflect on how the content would be impacted through the application of innovative technologies. These educators described basic examples of technology integration (e.g., videos, images) and seemingly used technology to delivery material or to add context to a particular piece of course content. The most common example referenced in these interviews was using videos or images in a course so that the students could observe how to perform a particular technique, see an anatomical structure, or see a particular sign/symptom. Other educators commented on using technology to simply ‘break up’ a lecture to limit the amount of time that a student had to sit and listen to the educator. Although these practices can be useful approaches for some students, they do not consider how the technology actually enhances the course content. Therefore, in my opinion, these are not examples of effective technology integration.

Four other AT educators (ATEd-3, 5, 6, 7) gave more detailed examples of technology integration that considered how technologies enhanced the course content.

All of these individuals were also identified as having a higher level of PK. One educator

(ATEd-7) described how they used digital technologies to create realistic/authentic simulations in the classroom to demonstrate to the students that these injuries actually occur in real-life. According to this educator,

I like to use various technologies to make real-life connections with the students.

Because you can tell them over and over again that these scenarios happen but it

is harder for them to make personal connections with what you are saying, if they

cannot relate to it. So they may play it off as not being as important or something

that they will not need to be prepared for because there is an unlikely chance of

them experiencing it. Technologies (especially videos) can be used to create

realistic connections instead of just a verbal story. They get to experience the 115

injury and how it actually happened, appeared to a responding therapist.

(ATEd-7)

Another educator (ATEd-3) from a different institution described using high-fidelity training manikins to enhance chest injury content (e.g., pneumothorax, heart conditions, breathing compromise). This educator discussed how difficult it was to mimic abnormal findings such as different breathing patterns, accelerated/decelerated heart rates, and abnormal breathing sounds in the traditional laboratory setting (using student partners as simulated patient models). Students could be told that these abnormal findings were present in a simulated patient but they would not experience what it felt or sounded like.

Therefore, the educator decided to implement high-fidelity training manikins into the course because these technologies could be used to simulate more advanced scenarios.

Cardiopulmonary sounds and rates could be modified by the educator so that the students felt and heard the differences when checking for vital signs on the manikin. These students were able to further refine their skills and critical thinking abilities while inferring what these findings actually represented.

In summary, most AT educators in my study were less comfortable with their level of TCK. The majority of educators appeared to have a very superficial understanding of TCK and did not often consider how digital technologies could enhance or impact course content. Instead, most educators incorporated technology to simply add context to a particular topic or to show something in a different way. However, a few educators in the sample demonstrated an increased level of TCK by describing detailed examples of how technology integration enhanced AT-specific course content. All of these educators also appeared to have higher levels of PK and PCK.

4.1.6 Technological pedagogical knowledge (TPK). TPK is defined as knowledge of the existence, components, and capabilities of various technologies as they 116

are used in various teaching and learning settings (Mishra & Koehler, 2006).

Furthermore, TPK also refers to knowing how teaching might change as a result of integrating particular technologies (Mishra & Koehler, 2006). This type of knowledge requires a high level of PK and the concomitant critical evaluation skills to assess the impact of various technologies on the selection of different pedagogical strategies.

According to the questionnaire results, the sample of AT educators perceived their

TPK to be high, but not as high as the CK, PK, or TK constructs. The questionnaire asked three questions that were uniquely representative of the TPK construct.

Collectively the respondents, “felt confident in their ability to choose appropriate technologies to coincide with their teaching objectives” (3.86), but did not agree or disagree with the statement “when I become aware of technologies used in the teaching of other disciplines, I am able to see ways that leverage that technology for my own objective purpose” (3.52). Furthermore, respondents were neutral with their response to the statement “I find it easy to abandon a particular technology that is not working well with my teaching” (3.27).

The interviews further deconstructed the TPK construct by questioning AT educators about how various technologies were used to support different teaching strategies. An additional discussion focused on what factors were considered when making these pedagogical decisions. As discussed in the PK and PCK sections, many AT educators appeared to use the same teaching methods/pedagogies regardless of what content was being taught in a course. Correspondingly, the same was found with regards to technology selection as pedagogical decisions seemed to be solely content driven.

Athletic therapy educators appeared to use the same technologies without considering how these tools could influence the selection of different teaching strategies.

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The same 11 educators (ATEd-1, 2, 4, 8-15) identified in the TCK section as having a superficial understanding of technology integration, also did not appear to pay attention to the pedagogical implications of implementing different digital technologies.

These individuals seemed to incorporate technology just for the sake of using it, to simply deliver content, or to provide context to a particular topic. During the interviews, these 11 educators had difficulties answering the TPK questions and could not engage in the deeper conversations required to demonstrate a full understanding of this construct.

For example, all 11 educators described using an online course management platform

(e.g., Moodle) in their courses, but they did not comment on how these platforms enhanced or influenced their preferred pedagogical strategies. Instead, these platforms were used to simply highlight expectations, submit assignments, provide students with foundational theory lectures, and act as a repository for course readings. Conversely, the four educators (ATEd-3, 5, 6, 7) who demonstrated a higher level of PCK (those with a deeper understanding of pedagogical decision making) discussed how these same course management platforms had a significant impact on their selection of different teaching strategies and activities. One educator (ATEd-5) gave a detailed example of the creation of a new class activity that asked students to upload a case study description from their field/clinical experiences. Each student had to provide a self-reflective piece that included how the injury presented itself, what management steps were carried out, how they felt it was handled, and a plan for future improvement. Other students were able to see these submissions on the course management platform and were expected to comment and provide feedback to each other’s posts. This educator designed this activity by thinking about the course management platform technology itself and wondering how it could be applied to enhance student learning.

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Another example from an educator (ATEd-7) with a higher level of PK/PCK described how they used digital videos in their classroom for critical analysis activities.

According to this educator,

We are in the information age but there is so much out there on the web that is

garbage. So we need to show our students why it is garbage. They need to learn

the skills to be able to sift through all of this information and to figure out

themselves why it is accurate or why it is garbage. (ATEd-7)

This educator went on to describe the specific in-class activity that was used in their orthopedic assessment courses. During this activity, students found orthopedic assessment videos on YouTube and critiqued the techniques that they saw. In such an example, the digital videos allowed the educator to change their traditional teaching style of just showing the students a technique and then telling them some common things that people do wrong when performing that particular technique. The digital videos critique enhanced the learning experience by placing the students in a problem-based learning environment and allowing them to develop critical analysis and critical thinking abilities.

In summary, the sample of AT educators in my study perceived their level of TPK to be high (although not as high as perceived level of CK, PK, and TK) but a more in- depth analysis uncovered yet another pedagogical distinction between two groups of educators. The majority of educators demonstrated a superficial understanding of technology integration by not considering the pedagogical impact of integrating different digital technologies. The other minority group of educators (those with higher levels of

PK) engaged in deeper conversations around TPK and gave detailed examples of how technology empowered the use of different teaching strategies.

4.1.7 Technological pedagogical content knowledge (TPACK). TPACK, an emergent form of educational knowledge that considers the complex interplay between 119

CK, PK, and TK, requires an understanding of: the representation of concepts using technologies; pedagogical strategies that use technologies in constructive ways to teach content; what makes concepts difficult or easy to learn and how technology can help address some of the problems students face; and how technologies can be used to build upon existing knowledges (Mishra & Koehler, 2006).

As with many of the other constructs presented in Phase 1, there were notable differences observed between the perceived level of TPACK in AT educators (as indicated by the questionnaire results) and the actual level of understanding that emerged from the interviews. According to the questionnaire findings, AT educators felt confident in their abilities “to choose technologies that make the content easier to understand”

(3.81) and “to choose technologies that motivate students to learn the course content”

(3.79). Educators also appeared comfortable with finding instructional technologies for their teaching specializations by disagreeing with the statement, “I find it difficult to find instructional technologies for my teaching specialization” (2.57). Based on these findings alone, it appeared that AT educators perceived their level of TPACK to be high.

However, when this construct was further deconstructed in the qualitative interviews, it became clear that there was a wide range of TPACK among the sample of AT educators.

The same pedagogical distinction that was described in the PK, PCK, and TPK sections was also apparent in the discussions centred around TPACK. The majority of

AT educators did not consider the pedagogical implications of technology integration and continued to describe educational technology use in superficial terms (e.g., using technology to simply deliver course content or to add additional context to a topic).

Conversely, those educators with higher levels of PK appeared to use technology in more constructive ways while considering the pedagogical impact of their technology integration decisions. For example, one educator (ATEd-5) that was identified as having 120

a high level of PK, described how they integrated technology into their CATA-accredited curriculum,

I am absolutely a big believer in using technology for teaching but it has to be

used at the right time and in the right place. Also, as an educator, I need to know

why I am using it. And I think it really is dependent on the topic that I am

presenting on. If I am trying to describe how to assess the shoulder, I think about

if it is better to show them a video. Would it be better to demonstrate in person?

Would it be better to show a picture while discussing relevant anatomy? A

combination of all these things? To be used effectively, technology needs to be

used in the right place and the educator needs to consider why they are using

it…does it fit into their teaching strategy? How does it impact student

learning? These are all important questions that should be considered. (ATEd-5)

Another educator (ATEd-7) from the higher level of PK group described their personal four-step process for integrating technology,

First, I think about the learning objectives/outcomes for the course or unit. Then I

think about the depth of content by reflecting on what level of Bloom’s

Taxonomy does the student need to be at by the end of the unit/course. Then I

think about the types of pedagogical strategies/activities that I can use to help

facilitate learning the content. And then I think about how technology can be

used to enhance those strategies and accomplish those objectives. (ATEd-7)

These examples epitomize a high level of TPACK thinking and highlight what should be considered by AT educators to integrate educational technology effectively. However, this level of inquiry was not present in all AT educators. Rather, it appeared that the majority of AT educators did not regard the complex interplay between CK, PK, and TK, and instead, thought about each as an isolated construct. 121

4.1.8 Phase 1 summary. Overall, the collective sample of AT educators appeared to enjoy using technology as a part of their teaching and expressed interest in learning more about how advanced digital technologies could enhance the student learning experience. However, the interview findings showed that there was a wide range of technology integration experience in the current sample of AT educators.

Through a mixed-methods approach to research, I was able to uncover many inconsistencies between the perceived level of knowledge in each construct (as indicated by the questionnaire responses) and the actual level of knowledge that emerged from the interview discussions. The main inconsistency proved to be the pedagogical distinction that divided the sample of AT educators into two groups: those who followed the traditional practice of teaching theory in a passive lecture format followed by practical skills in laboratory settings; and those who had a higher level of PK and incorporated more innovative teaching strategies. It became clear that those educators with higher levels of PK were able to have deeper and more enriched conversations around pedagogical decision making and how these concepts applied to effective technology integration.

Based on the findings from Phase 1, the TPACK model graphic was modified to depict how most of this sample of educators viewed technology integration in an AT context (Figure 4.1). Instead of including three even-sized circles, the CK circle was drawn bigger to signify that the majority of AT educators were considered to be content experts. It was found in the current sample that all educators were more comfortable in discussions that were centred around content, compared to conversations about technology or pedagogy. Also, instead of an even intersection between all three types of knowledges (as depicted in the original TPACK framework), the only observed overlap

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was between CK and PK (PCK). All other overlaps of TPACK were affected by the previously described pedagogical distinction.

PK CK

Figure 4.1. Modified framework depicting the level of TPACK in the majority of the sample of AT educators.

By establishing AT educators’ initial attitudes and views towards technology in

Phase 1, I could better understand the current context of technology integration in AT education. This enabled me to further explore how technology fits into the overall AT educational landscape and to investigate the specific factors that influenced these technological/pedagogical decisions. However, before exploring these areas, the findings from Phase 1 triggered a reflection of the M-CBL SIAET itself to see what was missing from the original design and what could be added to help educators to think critically about incorporating technology-assisted pedagogies in AT education. These modifications and additions are presented in the next phase of the study, Phase 2.

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4.2 Phase 2 – Improving the M-CBL SIAET

The purpose of Phase 2 was to use the feedback and themes that emerged from

Phase 1 (and earlier pilot projects) to make modifications and improvements to the M-

CBL SIAET and accompanying pedagogical model. Furthermore, essential principles of

TPACK theory (Mishra & Koehler, 2006) and R2D2 instructional design (Willis, 2009) were also considered to ensure that the tool was a pedagogically-sound example of effective technology integration. In the ensuing sections, each modification/improvement that was made during this stage is presented, including a rationale as to why it was changed or added to the technology-assisted pedagogical tool.

4.2.1 Development of student and educator versions of the educational tool.

As described in the Introduction chapter, research findings from my previous pilot studies

(Pilot Study #1 and #2) recommended the design of a new instructional model to accompany my educational tool. Previous participants from these pilot studies emphasized the importance of having an instructional model that established how the educational tool was intended to be used (King et al., 2014; MacKinnon & King, 2012).

Responding to these recommendations, a three-step instructional model was developed, grounded in well-established teaching practices (Chickering & Gamson, 1987). The first step of the instructional model recommended an initial case study example led by the course instructor so students could observe how the educator worked through the questions/activities. In addition, students would be able to observe the necessary systematic approach required to complete a thorough orthopedic injury assessment.

Next, it was suggested that students worked collaboratively in small groups through two case scenarios by sharing experiences, practicing techniques, and interacting with one another. Finally, the last step of the instructional model was for each student to complete

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an independent case scenario to test what they had learned about the process involved in a detailed orthopedic assessment.

In my earlier pilot studies (King et al., 2014; MacKinnon & King, 2012), students and teachers were provided with the same version of the M-CBL SIAET with the only difference being that teachers had access to all answers posed by the multimedia tool.

Separate answer key documents were distributed to the teachers and were absent from the educational tool template itself. Therefore, students did not have access to any of the answers, unless they were provided by the educator. This format presented complications with the introduction of the recommended instructional model. When students were working through their collaborative scenarios, they did not have a way to check their own answers or see if they were following the correct systematic approach. Responding to this significant issue, I created two separate versions of the educational tool (during Phase

2) for use in this study: a student version, and an educator version.

Both new versions of the educational tool followed the same template with a couple of distinct differences. The educator’s version included all answers for each of the four scenarios, whereas the student version only included the answers to three of the four scenarios. Since the fourth scenario was intended to be completed independently

(and potentially be used as an assignment component for the course), the student version did not provide answers to any of the questions in the final scenario.

After designing the answer keys for each scenario/section, they were embedded directly into both versions of the educational tool by hyperlinking answer buttons which opened separate .pdf documents (as seen in Figure 4.2). Therefore, the answers did not appear on the same screen as the initial questions. In order to view the answers, the student needed to click on the link, opening up a different window, instead of just scrolling down below the questions to see the answers. By taking these steps, it 125

encouraged students to work through the scenarios themselves, without being distracted by the correct answers being given after each set of questions.

Figure 4.2. Screenshot showing the hyperlinked answer keys in the student’s version of the M-CBL SIAET.

The other key differences between the two versions of the educational tool were that the educator’s version also included: 1) more detailed instructions about how to lead the first case scenario; 2) how to approach the concept map activity when discussing the important components of an orthopedic assessment; and 3) specific teaching recommendations for each section included within the scenario template. Due to findings from my two pilot projects and the wide range of PK in AT educators that emerged from

Phase 1, these steps were deemed necessary so that educators had systematic instructions for employing the tool. Furthermore, the specific teaching recommendations gave

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additional concepts and ideas for educators to consider when implementing this educational tool in AT classrooms.

4.2.2 Development of educator’s instructional guide. Another addition that was deemed necessary following the findings from Phase 1, was the development of an instructional guide to further inform AT educators about the M-CBL SIAET. Due to the pedagogical differences that were observed in the sample of AT educators, an instructional guide was designed to provide background information about the development and design of the educational tool itself, and how the tool was intended to be used in an AT classroom. A complete copy of the instructional guide is included as

Appendix J.

The instructional guide was designed using the same template as the M-CBL

SIAET to allow for consistent navigation by users. The guide included: 1) detailed written instructions outlining how to use the educational tool; 2) a tutorial video outlining how to use the educational tool; 3) background information into why and how the educational tool was designed and developed; 4) a detailed description of the instructional model that accompanied the educational tool; 5) a thorough description of

CBL as a pedagogical strategy including why there is a need for CBL in AT education, why CBL would be an effective strategy for AT educators to consider, the differences between CBL and PBL, examples of CBL in AT education, key points for using CBL effectively, and suggested references; 6) thorough descriptions of the other pedagogies embedded within the educational tool (Socratic method of teaching, instructional scaffolding, peer-assisted learning, and critical reflection); and 7) learning outcomes for the educational tool.

To be able to explore the impact of the M-CBL SIAET during Phase 3 of the current project, it was imperative that all AT educators knew how the technology-assisted 127

educational tool was intended to be used. Additionally, the instructional guide acted as a resource for AT educators so they could read more about pedagogy, effective teaching practices, and examples of what to consider when integrating technology-assisted pedagogies in their own classrooms.

4.2.3 Embedded 3dRx® anatomy animations. When designing the original M-

CBL SIAET, I wanted to include more advanced digital animations to help stimulate critical thinking around various anatomical structures and movements. Unfortunately, I did not have the expertise to make my own animations nor the resources required to enter a formal relationship with an animation company. Therefore, I relied on my existing resources and developed rudimentary 3D manipulatives using the Object2VR® software.

While working through the early stages of my PhD, I was introduced to a series of animations that were produced by 3dRx®, a sub-company of Kinduct Technologies

(based in Halifax, NS). When I contacted them about the possibility of integrating their animations within my educational tool, they expressed interest in my project. Kinduct allowed me to use any of their anatomy animations within my educational tool, as long as recognition was credited to the 3dRx® animation developers.

For each case scenario in the M-CBL SIAET, I embedded these 3dRx® anatomy animations that correlated with each particular joint. For example, in the elbow injury scenario, two anatomy animations (Figure 4.3) incorporated critical thinking questions about the elbow area (e.g., describe what is happening in this animation. What anatomical structures would have to be damaged in order for this displacement to happen?).

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Figure 4.3. 3dRx® anatomy animations for the elbow case scenario in the M-CBL

SIAET.

All animation video sections included specific questions, individual activities, and/or peer activities to get students to think about the underlying anatomical structures that related to the site of injury implied by each case scenario. To successfully complete any detailed orthopedic assessment, students must have a foundational understanding of the musculoskeletal anatomy and knowledge of more advanced applied anatomy principles (e.g., what muscles are contracting to flex the elbow?) (Starkey & Brown,

2015). These 3dRx® animations allowed me to ask more advanced applied anatomy questions, compared to the other anatomy models that were developed through the

Object2VR® software (as used in the pilot studies). By combining the 3dRx® animations with the Object2VR® videos from the original educational tool, I was able to ask questions about fundamental anatomy concepts (e.g., what are the origins and insertions of this muscle?) as well as more applied based questions (e.g., what movement is happening in the video and what muscles are contracting to cause that movement?).

4.2.4 The addition of critical reflection questions/opportunities. During the individual interviews with AT educators in Phase 1, several participants discussed the importance of integrating critically reflective questions into AT educational activities.

According to one educator, “by getting our students to be more critically reflective, it 129

enables them to take ownership of their own learning. They can think back on what they did, why they did it, and then formulate a plan for improving specific knowledges or skills” (ATEd-3). Another AT educator added,

I like to use reflective activities in my classes but some students really struggle

with writing a meaningful reflection. Many of these students have undergraduate

degrees but they were not exposed to these types of mature reflective pieces

before. So I have to work through this by actually teaching them how to write an

actual reflection of learning…what made the experience meaningful to them. It

always amazes me when you see them evolve so that they learn about their own

learning and meaningful experiences. (ATEd-5)

Based on this input from the AT field, I added a critical reflection section to the end of each scenario within the M-CBL SIAET. In this critical reflection section, students were asked to answer the following questions: 1) after completing the case scenario, with what component(s) of the orthopedic assessment process were you the most confident with? 2) why were these the areas that you felt most confident with? 3) after completing the case scenario, what component(s) of the orthopedic assessment process need the most improvement? 4) in the component(s) identified in the answer to

Question #3, list the specific reasons why you had problems or struggle in that particular area; 5) what can you do to help improve or deepen your understanding of that particular area (the areas identified in Questions 3 and 4)? 6) what did you learn during the peer activities in this scenario? and 7) after reviewing all of your answers (to the reflection questions as well as questions throughout the scenario), develop a detailed study plan/outline addressing the areas of necessary improvement.

Students were encouraged to keep a written log or electronic record of their answers so they could be reviewed later while studying for tests, completing assignments, 130

and/or studying for the CATA national certification exam. Furthermore, within the newly-developed instructional guide for M-CBL SIAET, AT educators were given additional guidelines about how to encourage student critical reflection and how to make these activities truly meaningful learning experiences.

4.2.5 Filmed and embedded mechanism of injury videos and special test videos. One of the key recommendations that emerged from the participants of Pilot

Study #2 (a sample of athletic training students from the University of Technology,

Jamaica) was to integrate additional digital videos to each scenario to create a more realistic experience of the simulated injuries (King et al., 2014).

In response to this feedback, specific mechanism-of-injury videos were embedded into each scenario. In the two original pilot studies, students were only shown a series of pictures, or given a detailed description of a mechanism, and were then asked to make a list of potential injuries that coincided with those descriptions. By including specific videos that presented the mechanisms of injury (as seen in Figure 4.4), it eliminated some of the subjectivity that could arise from student interpretations of a picture or brief description. For example, if a picture showed an athlete falling on the tip of the shoulder, then students may form different opinions about how hard the athlete fell, exactly where the athlete hit, how the athlete landed after the fall, etc. When students watch the mechanism of injury video, they will all see the exact same event, decreasing the likelihood of subjective interpretations.

The participants from Pilot Project #2 further suggested that special test videos also be added to the educational tool to solve some of the accessibility issues associated with not having reliable high speed internet. Special tests are a series of orthopedic tests that are used to assess joint function and integrity of joint structures (e.g., muscles, ligaments, joint capsule) (Anderson & Parr, 2013). Based on participants’ 131

recommendations, I filmed, edited, and embedded a database of special test videos into each scenario (see Figure 4.5).

Providing special test videos in the multimedia tool mitigated the problem of poor internet access as well as ensured that students were learning about the tests from the same resource. If these videos were not embedded within the tool, then students would often refer to other resources (e.g., YouTube) to find out how to perform a particular test.

Therefore, it would be difficult for the educator to regulate where the students were learning about these important skills.

When designing the special test section for the M-CBL SIAET, I decided to incorporate critical reflection questions to link with the videos. Students were asked to answer the following questions for each special test video: 1) what structure(s) are being tested in each video? 2) describe what is happening in the video, anatomically and biomechanically; and 3) identify what constitutes a positive finding in each particular test. In addition to answering these questions, students were instructed to share their answers with a partner so they could discuss their experiences with one another. For example, one student may have performed a particular special test with one of their athletes and felt certain sensations (e.g., an anterior translation of a bone on another) that could be described to their partner.

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Figure 4.4 Sample mechanism of injury video section for the shoulder injury scenario in the M-CBL SIAET.

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Figure 4.5 Sample special test videos for the shoulder injury scenario in the M-CBL

SIAET.

Students were also instructed to videotape/record themselves doing each test with a partner so that they could critique and provide specific comments on hand positioning, direction of force, amount of force, description to patient, etc. This activity encourages technology use with the main goal of improving critical self-reflection and creating meaningful learning experiences.

4.2.6 Filmed and embedded tutorial videos. As discussed in the findings of

Phase 1, there was a wide range of TK found in the current sample of AT educators.

Correspondingly, it was assumed that there would be a similar TK range in AT students

(based on findings from my previous pilot studies). Therefore, I wanted to provide several ways for an individual to learn how to navigate through the M-CBL SIAET.

Using Screencast-o-matic® software, I filmed my screen as I worked through a sample case scenario. Using these screenshot videos, I demonstrated how to navigate through each scenario (in multiple ways), and showed how to use the various digital technologies.

All tutorial videos were embedded at the beginning of each disc on both the student and educator versions.

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4.2.7 Updated each case scenario template. The final modification made during this phase was to ensure that each case scenario in the educational tool followed the same template. All of the additions/modifications that were presented in Phase 2 were applied across all scenarios, creating a universal and consistent flow. This step was important because it helped to reduce the risk of user disorientation while navigating through the multimedia tool. Webster and Ahuja (2006) defined user disorientation as the tendency to become disoriented and losing one’s sense of location while navigating through a particular technological tool. User disorientation is very common in hypertext environments (such as the one used in the current educational tool) and can result in automatic frustration, loss of interest, disengagement, or a measurable decline in user efficiency (Roselli, 1991; Webster & Ahuja, 2006). Understanding that there are differing levels of TK in students and educators, and that some people are more familiar with Adobe Acrobat® Reader than others, I wanted to ensure that there were several ways to navigate through the educational tool, therefore reducing the risk of becoming disoriented. I created multiple ways to move between sections and scenarios (as seen in

Figure 4.6) giving the user multiple options. One of the navigation options featured in

Adobe Acrobat® Reader is to organize content through a bookmarking system. By clicking on a specific bookmark, it takes the user to the bookmarked page. Using this feature, I created bookmarks for each scenario/section so that individuals could use that feature to move from section-to-section and from scenario-to-scenario. Another way to navigate in Adobe Acrobat® Reader is to use hyperlinked buttons. With this feature, users can click on the button to move to a defined page (e.g., Home page). I inserted buttons at the end of each scenario/section that could be used to move to the next section or bring the user back to the original home page. Each of these navigation features were further described in the tutorial videos. 135

Figure 4.6 Navigation options (bookmark and buttons) within the M-CBL SIAET.

4.2.8 Phase 2 summary. The main objective of Phase 2 was to make modifications to the M-CBL SIAET to ensure that it was appropriate for investigation in

CATA-accredited institutions. As described earlier, the R2D2 ID framework grounded this entire process by eliciting feedback from multiple stakeholders at different points in time. The findings from newer stakeholders (AT educators from CATA-accredited institutions) were blended together with the findings from older stakeholders (participants from the two original pilot studies) to improve the educational tool in an iterative process.

In addition to modifying the educational tool itself, feedback from Phase 1 also prompted the design and development of additional resources that helped AT educators understand the educational tool, its intended use, and the different pedagogies embedded within the tool. Once these improvements were completed, I moved on to Phase 3 of my research which explored the impact of this educational tool on the nature of teaching and learning within a CATA-accredited institution.

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4.3 Phase 3 – Case Study – Sheridan College

The purpose of Phase 3 was to investigate the implementation of the updated version of the M-CBL SIAET in a single case study from a CATA-accredited institution.

More specifically, I explored the impact this educational tool had on the nature of teaching and learning at Sheridan College. Sheridan College was chosen for this case study because the CBL framework that guided the M-CBL SIAET closely aligned with the teaching style employed at this institution. In addition, Sheridan College is also known as an institution that actively promotes the use and development of innovative technologies, and encourages its educators to employ active, engaging pedagogies.

During this case study, both students and educators were recruited for feedback to gain an enhanced understanding of how the technology-assisted teaching tool impacted learning and teaching. The findings from Phase 3 are presented in two sections, beginning with the impact of the educational tool from the students’ perspective; followed by a discussion of the impact of the educational tool from the educators’ perspective.

4.3.1 Impact of the educational tool – students’ perspective. As described in the Methodology chapter, the updated M-CBL SIAET (complete with additions and modifications from Phase 2) was distributed to a class of 47 fourth-year students from the

Bachelor of Applied Health Sciences (Athletic Therapy) program at Sheridan College in

Brampton, Ontario. The course instructor from this class was also instructed on how to use the educational tool and how to present the tool to students through the suggested pedagogical model (Figure 1.6). Following the introduction of the educational tool to the students, the cohort was sent a link to complete an online questionnaire. This questionnaire was designed to elicit feedback on: 1) prior experiences using technology for learning; 2) the educational tool itself (including questions about the difficulty of scenarios, presenting information in an understandable format, ease of navigation, 137

relevance to curriculum, etc.); and 3) further suggestions for improvement for the educational tool/teaching model. In addition, the overarching objective of the questionnaire was to identify trends in responses so that specific interview questions could be designed to yield a more complete understanding of the relative impact of the educational tool on student learning.

The first seven questions from the questionnaire identified the students’ initial predispositions towards technology and whether or not the participants were intimidated by using technology to support learning. These questions were significant to ask of the group because if the students were intimidated by digital technologies, or had prior negative attitudes towards using technology for learning, then it would prove difficult to accurately assess the impact of the M-CBL SIAET.

For the questionnaire, a Likert Scale was used that ranged from a score of 1 = strongly disagree to a score of 5 = strongly agree in response to each statement. The mean results (n=15 respondents) from the questionnaire are summarized in Table 4.2.

Table 4.2

Summary of Phase 3 Questionnaire Responses – Initial Predispositions Towards Using

Technology

Survey Question Mean (/5) I enjoy using technology to support my 4.47 learning I am intimidated by using technology 1.73 I would prefer to use more technology as a 3.80 part of this course I have completed text-based case studies from 3.67 textbooks before I think that using technology to present case 4.00 studies is more motivational than textbook cases I think that using technology to present case 4.07 studies is more engaging compared to textbook cases Using technology to learn is distracting 1.87

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Clearly, the answers to these questions suggested that the sample of fourth-year

AT students enjoyed using technology to help support their learning and did not consider instructional technology to distract their learning. It was therefore assumed that there were no apparent predispositions that suggested that the participants might automatically dislike the M-CBL SIAET just because it contained various digital technologies.

The questionnaire was also designed to elicit specific feedback about the educational tool itself (Table 4.3) and the pedagogical model that accompanied the multimedia tool (Table 4.4). The findings from these areas suggested that the tool was relevant to the curriculum of the current course and was considered to positively connect with the AT students’ preferred style of learning. Furthermore, the tool did not include scenarios that were considered too difficult for students’ current knowledge base. The respondents also agreed (average score = 4.00) with the statement, “I would recommend that the instructor use the multimedia teaching tool in the next offering of the course”.

Therefore, it appeared that the sample of AT students believed the M-CBL SIAET was an effective learning tool that helped them to learn/practice important orthopedic assessment theory and skills.

Table 4.3

Summary of Phase 3 Questionnaire Responses – Feedback Concerning the M-CBL

SIAET

Survey Question Mean (/5)

The DVD case studies were presented in an 3.80 understandable format The DVD case studies were easy to navigate 3.20 The DVD case studies followed a different 1.80 orthopedic assessment protocol than I would normally follow The detail of the anatomy models helped me 3.93 better respond to the questions The anatomy models were good substitutes for 3.33 hands-on anatomy models 139

The DVD case studies did not provide enough 1.47 information to be able to provide an accurate index of suspicion The DVD case studies did not provide enough 2.00 information to make a decision regarding the most appropriate rehab plan The case studies were too difficult for my 1.40 current knowledge base The level of analysis required in these case 1.60 studies was too high Having the DVD to play on my computer 2.87 made learning more accessible I would recommend that the instructor use the 4.00 DVD case study in the next offering of the course

Table 4.4

Summary of Phase 3 Questionnaire Responses – Feedback Concerning the Pedagogical

Model that Accompanied the M-CBL SIAET

Survey Question Mean (/5)

I think that the teaching model that 3.87 incorporated the DVD educational tool was an effective way to help me learn I found the teaching model that incorporated 2.13 the DVD educational tool to be confusing I think that the teaching model that 4.00 incorporated the DVD educational tool was a good fit for my personal learning style

Following the completion of the questionnaire, all students were invited to participate in a 30-minute individual interview, with 10 students responding and agreeing to participate (eight female; two male). An analysis of the questionnaire responses was completed to identify any trends and/or themes that could be further deconstructed during the interviews. These trends/themes were considered when designing the interview question schedule (Appendix F), used to explore the nuances of multimedia pedagogical tool use. All interviews were audio-recorded, manually transcribed, and organized via general coding categories. To corroborate the results and to triangulate any emerging

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themes, two small focus group interviews (each consisting of two females and one male) were completed with groups of students from the individual interview sample.

Several themes emerged from these individual and focus group interviews regarding students’ perceived impact of the M-CBL SIAET. These included: 1) creating a contextually-enriched scenario for studying/learning about athletic injuries; 2) engaging students in critical thinking/reflection opportunities; 3) simulating higher levels of analysis/clinical decision making; 4) organizing semi-structured peer interactions; and 5) extending learning outside of the traditional classroom setting. In the ensuing sections, each of these themes will be further discussed, complete with specific illustrative examples from interviews with the sample of AT students.

4.3.1.1 Creating a contextually-enriched scenario. Throughout the individual and focus group interviews, students shared the importance of using practice scenarios to evaluate their personal level of injury assessment competence. As future certified ATs, students need to know how to integrate multiple theories, knowledges, concepts, and skills to conduct a complete and comprehensive orthopedic assessment. Practising scenarios is an exercise designed for students to assimilate and accommodate ideas and to further consider areas of improvement. Although it appeared that scenario practising was incorporated in many of the AT courses at Sheridan College, this sample of students often commented that the scenarios were less structured, less detailed, and required a lot of assumptions. These students felt that it was difficult to connect with these hypothetical activities that lacked purpose, detail, and structure. For example, many students felt that it was difficult to visualize the mechanism of injury, or understand how the injury presented itself, during text-based scenarios or verbal situations explained by an educator. As one student described,

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When we are given written cases in class, it is tough to picture what the teacher is

describing. They try to explain it but you have to assume so many things; did the

athlete land this way? How did they fall afterwards? What was the amount of

force? Where was the forced applied? (ATStu-3)

This sample of AT students felt that the M-CBL SIAET improved upon this pitfall by creating a realistic, visual, and consistent context to define each injury situation.

Students in this current study commented on having the ability to watch the mechanism of injury videos over-and-over again to really gain a sense of what happened to the injured athlete in each scenario. According to ATStu-10,

When you actually have a video of the mechanism, you are able to watch it over

and over again and look at something different each time. This is really important

when we are learning about these types of injuries because we do not have the

experience to make a lot of assumptions. Therefore, we can watch the video of

the injury, slow it down, look at different areas each time, to think about what

could potentially be injured.

When working through text-based scenarios, students are often forced to make subjective interpretations about what happened to an athlete, where the forces were applied to an area, how the athlete landed, etc. Having access to a video allows a student to critically analyze the mechanism so they can truly understand and visualize what happened during the injury scenario. This arguably is not a realistic exercise in the sense that if the student was doing a real assessment, then they would not always have access to videos depicting the specific injury. However, for the purposes of learning, creating a contextually-enriched scenario assisted these students in critically analyzing mechanisms of injury and relating these mechanisms to other important factors of an orthopedic injury assessment. 142

According to the simulation literature, contextually-enriched scenarios can help students reach the higher cognitive domain levels (as indicated in Bloom’s Taxonomy) when compared to poorly structured problem-solving scenarios (Parker & Myrick, 2009).

Additionally, other researchers suggest that regardless of the fidelity, students still experience a hypothetical case as being artificial (Preston, Carter, Jack, & Bray, 2017).

Therefore, less emphasis should be placed on creating realistic high fidelity experiences compared to designing scenarios that are contextually-authentic and representative of the realities of the intended profession (Munshi, Lababidi, & Alyousef, 2015).

4.3.1.2 Engaging students in critical thinking/reflection. This sample of fourth- year AT students also appeared to appreciate the general design of the M-CBL SIAET because it resembled the reflective capstone projects that were already imbedded within the Bachelor of Applied Health Sciences (Athletic Therapy) curriculum at Sheridan

College. For instance, both the M-CBL SIAET and the capstone projects at Sheridan

College were designed to evaluate competence and to encourage critical thinking in simulated practical situations commonly faced by ATs in field and clinical settings. Each student at Sheridan College completed two capstone projects in the fourth-year of the AT program to serve as formative evaluation components of their final practicum courses.

These projects were also designed to build upon the skills of meaningful reflective practice, with the intentions of preparing the student for certification and benefiting them beyond graduation/certification.

To further elaborate, capstone projects at Sheridan College consisted of each student completing an injury assessment (either field or clinical) on a standardized model, with each session being videotaped and observed by a faculty facilitator. Immediately following the scenario, the student met with their facilitator to go through a one-on-one debrief and feedback session. The student was then provided with the video recording of 143

their assessment to watch and complete personal reflections. After writing a reflective paper, students were matched up in small peer group settings (e.g., all students who completed one particular scenario were grouped together in the same peer group) to discuss their scenario and create a presentation. Each small group then presented its respective scenario to the rest of the class during a seminar session, followed by an open class discussion.

As alluded to above, this sample of AT students felt that the M-CBL SIAET was a useful learning tool because it followed a familiar format as the capstone projects. Rather fortuitously then, the multimedia educational tool could be incorporated into this AT program to encourage critical thinking/reflection and to help prepare the students for their capstone projects. According to one student,

[in the M-CBL SIAET] I really enjoyed the section that asked us to videotape

ourselves while doing the special tests because that is how I learn. I am my own

toughest critic. I know that my teacher or friends will give me feedback but I

need to be able to make those intrinsic reflections myself. I need to be able to

realize when I am doing something wrong and why it is wrong. This tool helped

me to work towards this. (ATStu-1)

Similarly another student commented,

Similar to our capstone assignments, this tool suggested that we rationalized our

answers and explained why we thought so. For example, in the rehab section, we

were tasked to select the correct treatment option but to also rationalize why the

other programs were wrong. It is one thing to just recognize and select the correct

answer, but you really need to know your stuff and to think critically to prove

why some other option is wrong. This practice will help to distinguish between

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what you are really confident about and what you are just agreeing with because

you think you are supposed to. (ATStu-10)

Upon graduating from a CATA-accredited institution, AT students are expected to be critical thinkers and to make informed decisions while working in various field and clinical environments. According to Leaver-Dunn, Harrelson, Martin and Wyatt (2002), the ability to perform meaningful critical reflections is what separates expert health professional practitioners from their non-expert peers. Instituting more meaningful reflective activities within the AT curriculum (such as the capstone projects at Sheridan

College or the M-CBL SIAET) could potentially provide AT students with the necessary skills and learning experiences required to be considered competent, reflective, expert practitioners.

4.3.1.3 Stimulating higher levels of analysis/clinical decision making. Another theme that emerged from the interviews/focus groups was how the educational tool helped to stimulate higher levels of thought/clinical decision making skills that are expected of competent certified ATs. Related to this theme, five students (ATStu-2, 4, 5,

7, 9) commented about how this educational tool was beneficial for preparing them to make clinical decisions during their practicum placements. According to one student,

During our practicum placements we are almost thrown into these situations

anyways (although there is some form of supervision) but we are expected to

work with real people and assess and treat their injuries. And oftentimes, we are

trying to assess an area or injury that we have not covered in class yet so it can be

difficult to be confident in your skillset. This tool helped because it gave us the

flow of what should be included in a comprehensive orthopedic assessment and a

framework to help guide our thought processes and decision making. (ATStu-9)

Another student added, 145

It is really only during the end of fourth-year that we get a chance to put it all

together and to consider doing an entire assessment and rehab program. And

oftentimes we do not even practice both. Instead, we often complete an

assessment of one particular injury and then develop a rehab program for a

completely different injury. I guess this is so we learn and practice a wide range

of injuries but we very rarely do the entire process for a single specific injury. So

I liked how this tool made us think about an entire scenario, from the beginning of

the assessment to the initial rehab plan. (ATStu-4)

Participants also discussed the importance of the M-CBL SIAET in encouraging students to actually think and learn instead of being told what to do. As one participant noted,

This tool helped to get us in the habit of rationalizing our thinking. By

understanding why this test was positive or justifying why I thought something

was injured. This approach will probably help me to learn better but will also

help me to become a better therapist. (ATStu-6)

According to Jensen, Rensik, and Haddad (2008), well-developed clinical decision making skills (also known as clinical reasoning skills) are essential in becoming recognized as an expert health practitioner. Therefore, AT educators should be aware of the importance of these clinical reasoning skills and design lesson plans, activities, and educational tools to help stimulate these higher-order skills in health professional students.

4.3.1.4 Organizing peer interactions. Many AT students in the sample also made reference to the benefits of the peer interaction components of the M-CBL SIAET. In particular, they commented on how helpful these activities were in organizing the sharing of knowledge and experience. More specifically, several students thought that peer 146

interactive activities were a valuable component of the educational tool because each student brought unique experiences, skills, and knowledges to the various injury scenarios. As one student explained,

Sometimes working on a case scenario by yourself is stressful because you may

not know the answers yourself. By working with someone else, you are able to

help each other through the scenario, get better ideas, and share your different

experiences. For example, if we are working through a basketball scenario and I

have never really followed basketball or covered a game than I may not really

grasp all the concepts about the injury and how it would impact the athlete. Then

if my partner has a lot of experience in the sport of basketball than they can share

some of those experiences with me. I can then learn about how to analyze a sport

that I am not too familiar with. I think that is a really valuable part of the tool

because we all have unique experiences and skills to bring to the table. (ATStu-3)

Another student provided further insights by stating,

At this point in our AT careers, we all have different levels of comfort and

definitely have joints/injuries that we prefer to assess. I worked a lot of soccer so

therefore I am very comfortable with ankle and knee injuries but not so much

with the shoulder and elbow. By having these structured peer activities in the

practice scenarios, we could learn from one another and share some of those

experiences/knowledges with each other. If my partner saw more shoulder

injuries than they could take the lead on that scenario and I could offer more to

the other joints that I am more comfortable with. I know that eventually we all

need to be comfortable assessing all joints/injuries but at this point in time, it can

be useful to work together and to learn from one another. (ATStu-5)

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Although the majority of AT students appeared to value the peer interactive activities, two students described themselves as being “completely independent learners” who did not enjoy working with others in these types of scenarios. Even though these two students did not value the recommended peer interaction, they still appreciated the

M-CBL SIAET and considered it to be a useful learning tool. Per one participant,

With regards to the peer activities, I liked how it was technically optional. I am

completely an independent learner and I don’t like getting together with others to

practise scenarios. So the fact that these activities were suggested within the tool

was ok because I could still benefit from the scenarios without working with a

partner. I could still read the peer interaction questions and think about what I

would do with a partner but I could still benefit from working through the

scenario by myself. (ATStu-10)

Another student added,

When working through these scenarios, your partner does not need to be in your

class or even an AT at all. It obviously helps if they are but you are not limited to

only working with them. With our hectic placement schedules it is hard to find

times to practice with others in class so we could use these scenarios to practice

with an athlete, friend, someone else in a class above or behind us, and they may

even be able to offer a fresh perspective to the scenario that you never considered

before. (ATStu-7)

Recognizing and allowing for differences in learning styles, structured peer interactive activities can support the learning process by providing opportunities for shared experiences and knowledge translation. As described in this section, the majority of AT students from this sample truly valued these opportunities to share knowledge with one another. Research has shown that structured peer interactions can help to: improve 148

communication skills; increase self-confidence; promote critical thinking skills; enhance the learning of course material; and improve organizational skills (Buckley & Zamora,

2007; Kurtz, Constance, & Alverson, 2010; Wyrich, Schrauth, & Kikendei, 2009) when used in educational settings. Therefore, AT educators should be aware of the potential benefits of structured peer interactions and think about the important factors required to implement peer interactive activities effectively (Buckley & Zamora, 2007; Kurtz et al.

2010).

4.3.1.5 Extending learning outside the classroom. The final theme that emerged from the interviews was concerned with how the M-CBL SIAET helped to extend learning opportunities outside of the classroom. This sample of AT students viewed scenario practice as being an essential component of developing orthopedic injury assessment competence, however this same group felt that their practice sessions were often very generalized and non-specific. For example, the most commonly used scenario practice, as described by the sample of AT students, involved one person making up an injury and acting out the injury as a standardized patient. The other individual, playing the role of the therapist, then performed an orthopedic assessment and made an index of suspicion based on what they found. Although this is a useful exercise, the students felt that the M-CBL SIAET provided supplementary structured learning activities to these injury scenarios that would ultimately enhance critical thinking skills, clinical reasoning, and overall competence as an AT. To elaborate, said one student,

Having all of the extra questions and peer activities really made me think about

why I was doing something and gave me practice in rationalizing my decisions.

When we normally practice our scenarios, we wouldn’t do that. We would just

use this test because that’s what I was taught to use in the situation. By working

through these extra stimulating questions, I am able to really understand the 149

material and become confident in making decisions. This is the type of learning

that I should be focusing on as a student and not just memorizing tests or

information. (ATStu-1)

During the interviews, several AT students also shared how the M-CBL SIAET could extend learning outside of the classroom by structuring practice scenarios during practicum placements that are required for Sheridan College’s AT program. Each student is required to complete seven field practicum courses and four clinical practicum courses throughout the degree that place the students in various high-schools, private therapy clinics, colleges/universities, and professional sport team environments. During these practical placements, it appeared that students often had downtime while travelling with teams or waiting for practices/treatment times to start and these would be optimal times to practise injury scenarios. As one student commented,

Instead of sitting in rush hour traffic for two hours, I just go to my placement

early and then do some work when I get there. Sometimes we practise scenarios

at placement with one another but they are not really structured sessions and we

just make them up on the spot. This educational tool would be useful during these

informal study sessions and I could benefit by working through the scenario with

my placement supervisor. My supervisor may have a completely different

perspective on the various questions than what I have learned from Sheridan

which could benefit my learning and help improve me as a therapist. (ATStu-3)

AT students are expected to perform in both classroom and practicum settings, therefore it is important for AT educators to encourage and promote learning outside of the traditional classroom. Although there is a large amount of experiential learning that occurs during the practicum placements, AT students could also benefit from structured

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learning activities as posed by the educational tool to develop the skills and knowledges required to become a competent, certified AT.

4.3.1.6 Summary. Overall, the sample of fourth-year AT students from Sheridan

College considered the M-CBL SIAET to be an effective learning tool that assisted in the development of orthopedic assessment competence. Moreover, AT students felt the educational tool contributed to student learning by: 1) creating a contextually-enriched scenario for studying/learning about athletic injuries; 2) engaging in critical thinking/reflection opportunities; 3) simulating higher levels of analysis/clinical decision making; 4) organizing semi-structured peer interactions; and 5) extending learning outside of the traditional classroom setting.

4.3.2 Impact of the educational tool – educators’ perspective. Following the interviews and focus groups with AT students, additional individual interviews were conducted with four full-time educators (three females and one male) from the Bachelor of Applied Health Sciences (Athletic Therapy) program at Sheridan College. All educators in the sample were certified ATs, possessed a Master’s degree (one educator was also an osteopath), and had at least 10 years of experience teaching at the undergraduate level. The main objectives of these interviews were to: 1) explore the impact of the M-CBL SIAET on the nature of teaching within a CATA-accredited institution; 2) identify the specific factors that influenced technology integration in the

AT program at Sheridan College; 3) have a wider discussion on the potential role for technology in AT education; and 4) identify the specific factors that should be considered when making pedagogical decisions of what and how to teach with technology within an

AT program.

The main themes that emerged from these interviews centred around the perceived impact of the multimedia pedagogical tool on the nature of teaching. These 151

main themes included: 1) highlighting the importance of thinking about the potential roles for technology in AT education; 2) using technology to empower, or enhance, course content/pedagogy; and 3) promoting critical thinking around implementing different pedagogies in the AT curriculum. In the ensuing paragraphs, each of these themes will be elaborated upon, including specific illustrative comments taken from transcripts of the interviews with Sheridan College AT educators.

4.3.2.1 The role of technology in AT education. During the interviews, all AT educators in the sample described their participation in this study as a means of stimulating more thought about the potential roles for technology integration in AT education. The group suggested that most AT educators taught the same way regardless of advancements in digital technologies, and did not consider how technology could benefit student learning. The sample felt that most AT educators used traditional teaching methods because it was within their pedagogical comfort zone, combined with the fact that most AT educators self-identified as being discipline experts with high levels of content knowledge. According to one educator,

We [AT educators] start by being discipline experts first, so we have the content

knowledge. Not a lot of us learned specific pedagogical techniques, unless we

have taken some additional pedagogy courses. Teaching in how you were taught

is usually your fall back plan. Then you have this other new piece, technology,

and you know that you should be using technology in the classroom because the

students are expecting it but that is the challenge. Thinking about how can

technology can help me do something differently than what has been done. To

see where technology fits in to helping students with deeper learning. (SCEdu-2)

While discussing the potential benefits for innovative technologies during the interviews, educators at Sheridan College felt that today’s students are being raised in a 152

technology-infused society and that all educators should be cognizant of the resulting impact on student learning. According to Dede (2005), rapid advancements in information technology can complement the traditional educator/student interface by exposing students to augmented realities, simulated contextual scenarios, technologically- enhanced experiential learning opportunities, multimedia fluency, and multiuser virtual environments. These changing interfaces and emerging technologies can enhance instructional delivery but educators also need to consider the resulting impact on student learning (Dede, 2005). Therefore, educators should adapt their teaching practices to prepare for evolving learning styles, advancements in technology, and preferred methods of instructional delivery (Dede, 2005; Dobbins, 2005; Hartman, Moskal, & Dziuban,

2005).

As identified during Phase 1 of the current project, AT educators throughout

Canada shared a general positive attitude towards using technology for teaching and appeared to be interested in learning more about how technology integration could potentially enhance the AT classroom experience. Effective technology integration does not mean using digital media to convey information to students (e.g., using a PowerPoint presentation to deliver course content). Rather, the notion of technology integration involves using various digital technologies as mindtools to help students to construct knowledge and to think critically (Jonassen, 2000). Effective technology integration engages students by getting them to think about what they know in different, meaningful ways (Jonassen, 2000). Technology-assisted teaching tools should be designed so that students learn with them, not from them.

Within the sample of Canadian AT educators in Phase 1, there was a large technological disparity with regards to the level of TK and comfortability with technology integration concepts. There was also a wide range in how educators 153

integrated technology in AT classrooms and how they rationalized its use. Many educators thought that simply using digital technologies to convey information to AT students (e.g., delivering content through a PowerPoint presentation) was considered effective integration of those technologies. The same disparity was also apparent within the group of AT educators interviewed during Phase 3, as two educators (SCEdu-1, 2) appeared to be much more comfortable with technology integration discussions compared to the other two (SCEdu-3, 4).

The two educators who were more comfortable with technology integration concepts were part of more elaborate discussions surrounding the potential roles for technology in AT education. During the interviews, these educators highlighted the potential for technology to: augment the practical components of the profession; make learning more learner-centred; facilitate the active-learning process; extend learning outside of the classroom; and create a sense of realism with regards to athletic injuries and sporting situations. According to one of the educators who demonstrated a higher level of TK,

Technology can make teaching more learner-centred which means we do not need

to tell the students everything. Rather we can facilitate learning so that they come

to it themselves. This is where deeper learning occurs and that should be the goal

of an AT program. I think this is where technology can really be useful by

augmenting this type of self-directed learning. (SCEdu-2)

Although there were differing levels of comfortability when discussing technology integration, all AT educators from Sheridan College expressed a need to integrate various technologies within the AT classroom, based on demands from the student and/or institutional levels. These educators also stated that it was important to

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integrate technology with a specific pedagogical purpose in mind. As described by another educator with high TK,

For educators, technology can be a very useful tool but we need to use it for a

particular reason. We need to think about how it can actually enhance or improve

something that we are doing in the classroom. That is when we can fully benefit

from integrating technology. (SCEdu-1)

All educators in this sample described the M-CBL SIAET as a practical example that demonstrated how to integrate technology for such a specific purpose. The sample felt the tool established a way to embed various digital technologies into commonly used athletic injury scenarios to enhance active-learning strategies. The group of AT educators also considered the multimedia tool to be a valuable resource that encouraged proper technology integration by helping students to construct knowledge and think critically about orthopedic injury assessment scenarios. More specifically, educators described the impact of integrating digital technologies with critical thinking questions, peer activities, and a reflective piece during each scenario. The group felt that this level of integration helped to provide students with a comprehensive injury scenario and a situated learning environment that helped to facilitate learning about orthopedic injury assessments.

Based on these findings, the M-CBL SIAET appeared to benefit teaching at

Sheridan College by stimulating self-reflection about the potential roles for technology in

AT education.

4.3.2.2 Using technology to empower, or enhance, course content/pedagogy.

Related to the broader discussions surrounding the potential roles for technology in AT education, educators from Sheridan College were also asked to reflect on how technology integration could enhance course content and/or empower the selection of pedagogical 155

strategies. The sample of AT educators felt that after being introduced to the M-CBL

SIAET, they would use technology differently in future course offerings. They suggested that exposure to the educational tool promoted critical reflection around what technology integration means, how to integrate technologies effectively, and the resulting impact that technology integration has on course content and pedagogical decisions. For instance, instead of using technology for purely superficial reasons (e.g., as a means to break-up the lecture component of the class), they would think about the rationale for integrating various technologies and reflect on how/why a particular piece of technology enhances the course content or empowers a pedagogical approach. Educational technology should not be implemented to simply do something differently; rather it should enhance the delivery of the content and/or provide unique possibilities for learning that could not be accomplished without that technology (MacKinnon, 2005). Throughout the interviews,

AT educators discussed the importance of this realization after being exposed to the multimedia tool. According to one of the educators with lower TK,

I use technology as a part of my course but I have never really thought about why

I use it. I guess I think I am supposed to just because of our technology-driven

society. After using a tool like this and being introduced to the underlying

concepts, I can see the true value of using technology in my AT classes. I

shouldn’t use technology just for the sake of using, but rather to enhance

something that I am doing. It sounds pretty common-sense but I never really

thought about it before. (SCEdu-4)

This educator went on to describe specific components of the M-CBL SIAET and described how the tool helped to transform their thinking about using technology in the classroom.

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I really liked all the videos embedded in the tool. That way the student can really

get a full understanding of the injury scenario at hand. They don’t have to fill in

as many blanks as they do when just making up a scenario. I also really liked the

suggestion for the students to videotape themselves when practicing the special

test. You are often your own worst critic so getting into that practice enables a

student to critique their own techniques and to understand why they are doing

something wrong. I think this would really benefit them and help develop them

into more competent ATs. In the future, I’m more likely to think about how I can

use technology to improve my teaching and to improve student competence.

(SCEdu-4)

This sample of AT educators shared similar opinions as the AT students from

Sheridan College as they felt that the technologies embedded within the M-CBL SIAET helped to enhance course content by: 1) creating a contextually-enriched scenario so that students could truly experience and understand the injury scenario being presented; 2) stimulating higher levels of clinical reasoning skills by asking the students to rationalize their answers; and 3) extending learning outside of the classroom by providing students with a detailed case scenario that students could practice to identify their strengths and weaknesses of orthopedic assessment.

During the interviews, AT educators were also asked to identify the most important factors to consider when implementing technology in pedagogically meaningful ways. This sample of AT educators felt that the following factors were the most important to consider when integrating technology: 1) completing a needs-based assessment (e.g., identifying a course concept that could be enhanced through various digital technologies); 2) reviewing the accessibility of the technologies (e.g., will all students have access to the same technology? What happens if a student cannot afford the 157

particular technology? How will that impact their learning?; 3) the comfortability of the educator with the technologies (e.g., to be used effectively, the educator needs to be able to use the technologies and troubleshoot potential issues with students); 4) dedicating time to design lesson plans and embed technologies within these plans; and 5) purposeful integration (e.g., using technology for a specific purpose, that cannot be achieved without technology). Based on these findings, the M-CBL SIAET appeared to benefit teaching at

Sheridan College by emphasizing the importance of using technology to enhance course content and/or teaching strategies. The underlying theory of the multimedia pedagogical tool was also described as being transformative in that it showed educators how to use technologies in pedagogically meaningful ways.

4.3.2.3 Promoting critical thinking about different pedagogies in the AT curriculum. The final theme that emerged from the interviews with AT educators was related to critical thinking about the implementation of different pedagogies within the

AT curriculum. The educators felt that exposure to this multimedia pedagogical tool made them reflect on their own teaching practices, to think about how their course content was currently being delivered, and to look for areas that could be enhanced using different pedagogical strategies and/or digital technologies. This sample of AT educators admitted to being complacent with regard to implementing different pedagogies and felt that they taught the same way each year. As one educator stated,

I am comfortable and confident that I know my content…that is my comfort zone.

But I am still growing in the area of pedagogical knowledge. I understand the

importance of using different pedagogies, of choosing the best strategies that will

help the students learn, but I am still not comfortable or knowledgeable enough to

make significant changes. But I know that if I don’t grow as a teacher then I

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won’t accomplish my main goal of graduating students who can become really

good athletic therapists. (SCEdu-1)

The AT educators felt that the design of the M-CBL SIAET provided a creative way to incorporate many effective pedagogical strategies to help guide students through the active-learning process. In addition, this sample of AT educators felt that the accompanying instructors guide was a useful resource because it described the different pedagogies making use of the multimedia pedagogical tool and highlighted the important factors to consider when implementing such strategies. Therefore, the AT educators felt that these resources would help them to grow as educators by integrating effective pedagogical strategies for evolving student ATs.

During the interviews, all AT educators were also asked the question, “if you were to use the M-CBL SIAET in your class, how would you use it?”. The intention of these discussions was to elicit feedback on the suggested pedagogical model and to evaluate the versatility and volatility of the educational tool. According to Squires

(1999), the design of educational technologies should be inherently volatile enough to provide learning environments that can be tuned to the idiosyncratic needs/environments of teachers and learners. Effective technological interventions are not contextually- limited and are able to be integrated into varying situated learning environments (Squires,

1999). This sample of AT educators felt that the educational tool was volatile enough to be implemented in numerous ways, including: 1) a PBL model where the students were responsible for their own learning. In this learning environment the students would not have covered any of the material in class and instead use the educational tool to facilitate learning and to guide their personal self-directed learning; 2) a flipped classroom model where the students review content/lectures outside of the traditional class time and then use this educational tool to lead in-class discussions and activities; and 3) structured self- 159

directed scenarios where the students are able to “learn at their own pace”. This approach can help to extend the learning outside of the walls of the classroom because they can practice at home, see the videos that were showed in class, complete a detailed scenario while practicing at placement, etc.

Based on these findings, the M-CBL SIAET appeared to benefit teaching at

Sheridan College by emphasizing the potential of incorporating different pedagogical strategies into the AT curriculum. The multimedia pedagogical tool was also thought to be contextually versatile enough to be integrated in multiple ways.

4.3.2.4 Summary. Overall, the sample of AT educators from Sheridan College considered the M-CBL SIAET to be an effective teaching tool that forced them to reflect on their own teaching strategies/philosophies. Moreover, AT educators felt the educational tool was an effective teaching resource by: 1) highlighting the importance of thinking about the potential roles for technology in AT education; 2) using technology to empower, or enhance, course content/pedagogy; and 3) promoting critical thinking around implementing different pedagogies in the AT curriculum.

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CHAPTER 5: DISCUSSION

Chapter 5 Outline

This Discussion chapter, building upon the findings presented in my Results chapter, situates these results within the existing literature by revisiting the noteworthy gaps in the literature (as identified in the Literature Review chapter) and summarizing the significant contributions that my study made to these areas. Following this discussion, I focus more on explaining why it is important for AT educators to consider a TPACK framework when integrating technology into the AT curriculum. Moreover, a detailed description is presented demonstrating how AT educators can enhance their personal

TPACK knowledge and development. Finally, the last section of this Discussion chapter presents the conclusions from my study, discusses potential implications for future research, and provides practical implications for AT educators.

5.1 Significant Contributions of the Current Research Project

One of the most significant contributions of my study was the recognition of pedagogical differences amongst AT educators throughout Canada. These differences separated the sample of AT educators from Phase 1 into two groups: those who followed traditional didactic, passive lecturing pedagogies; and those who implemented more innovative, active-learning pedagogies. These later AT educators demonstrated a higher level of PK and were also able to better recognize: 1) when to use different teaching strategies; 2) the important factors to consider when making pedagogical decisions; 3) how technology could be integrated to enhance course content; and 4) when to integrate technologies that coincided with their pedagogical choices. To integrate technology in pedagogically meaningful ways, AT educators need to first have a certain baseline level of PK, and then need to be familiar with different types of pedagogies (Banister &

Vanatta, 2006). Athletic therapy educators also should understand when/why a particular 161

strategy should be implemented, be aware of the important factors that influence these pedagogical decisions, and the resulting impact that these decisions have on student learning (Banister & Vanatta, 2006). With foundational PK being essential for effective technology integration, a lack of PK results in using digital technologies superficially

(e.g., as a means to simply deliver the content) without considering how these technologies help students to construct knowledge and/or think critically (Jonassen,

2000).

AT educators should also consider improving their personal PK because of the pedagogical changes that are occurring in other health professional education programs.

For example, many medical schools have reacted to changes in medical knowledge, preferred learning styles of students, and effective teaching practices by decreasing the amount of factual knowledge that is passively lectured to students (Dent & Harden,

2009). As an alternative, these medical educators are fostering more learner-centred approaches by emphasizing self-directed learning and problem solving skills, leading to the development of critical thought (Dent & Harden, 2009). Similar pedagogical changes are also on the horizon for the AT profession. According to a consensus statement released by a CATA education task force, by the year 2020, all CATA-accredited programs will be expected to have a plan in place to move their individual program designs to a competency-based educational model (Lafave et al., 2016), an approach to teaching and learning that focuses on the development of specific core competencies

(Thomas et al., 2016). In this type of learning model, students work on developing one core competency at a time and only move on to others when they have demonstrated mastery of the original competency (Thomas et al., 2016). To be progressive in their approach, AT educators need to be aware of innovative pedagogical approaches and be able to evaluate how these new strategies fit into a competency-based educational model. 162

Other significant contributions from this study resulted from addressing the gaps in the literature as previously identified in the Literature Review chapter (Table 2.1).

Within the TPACK literature there were several key areas that were incomplete including: 1) using TPACK as a framework to investigate technology integration in health professional programs; 2) using alternative methods and methodologies (e.g., mixed-methods research) to gain an enriched understanding of pedagogically sound technology integration; and 3) exploring the importance of context in relation to the

TPACK framework. All three of these gaps informed the methodological design of my study and the findings helped to contribute to a deeper understanding within the existing literature.

Primarily, my research study complemented the existing literature by using multiple lenses to inform the overall methodological design, where TPACK was used: 1) to describe AT educators’ initial attitudes towards using technology in AT education; 2) to design/build the multimedia educational tool; 3) as a framework to guide the data analysis; 4) to promote critical thinking about pedagogically meaningful technology integration in AT education; and 5) to provide practical/applied implications for AT educators. According to Koehler and Mishra (2015), the TPACK framework can be researched through multiple conceptual lenses to explore the phenomenon of effective teaching with technology in different ways. More specifically, research of the TPACK framework can be done via a(n): 1) descriptive lens by providing concepts and terminologies which describe the complex relationships that exist when educators integrate technology into the teaching of specific course content; 2) inferential lens by predicting and inferring the specific contexts by which effective technology integration occurs; 3) analytical lens by using TPACK to guide the design and analysis of research through mapping out specific constructs to be measured; and 4) applied lens by providing 163

pragmatic insights into applied educational settings to help build effective learning contexts (Koehler & Mishra, 2015). Throughout the TPACK literature, most previous studies used only a single lens to inform the overall research design. For example, research by Archambault and Crippen (2006) employed an analytical TPACK lens to examine the validity and reliability of their tool’s measurement of TPACK knowledge.

However, combining research lenses to inform the methodological design of a study can help to explore particularly complex phenomena, especially when there is limited prior research (Lewis & Grimes, 1999). Very few TPACK studies combined research lenses when exploring the use of technology integration in pedagogically meaningful ways, and no known studies explored this phenomenon in a health professional education setting.

Therefore, my study combined both descriptive and applied lenses to develop an enriched understanding of the impact of using pedagogically sound educational technologies in AT education.

My study used a descriptive TPACK lens to describe AT educators’ initial views towards using digital technologies for teaching in an AT context. During Phase 1, I employed the TPACK framework to analyze all questionnaire and interview data to describe AT educators’ experiences with each construct of the TPACK model. This descriptive analysis helped to better understand the contextual landscape of technology use in CATA-accredited institutions and demonstrated a starting point of where AT educators viewed themselves in relation to the different constructs of TPACK. A descriptive lens also informed the exploration into the impact of my multimedia tool, as the findings from Phase 3 described how the M-CBL SIAET actually benefited student learning and teaching at Sheridan College.

My study also used an applied TPACK lens by analyzing all findings to provide pragmatic insights and further recommendations for AT educators regarding integrating 164

pedagogically meaningful educational technologies in AT education. The essence of using an applied research lens assisted in demonstrating the potential for technology

(through the application of TPACK) to enhance student learning in AT classrooms.

Emerging themes from participants’ responses described the impact that the M-CBL

SIAET had on teaching and learning in a CATA-accredited institution, providing further insights and recommendations for AT educators about how to integrate technology more effectively. These pragmatic insights will be further discussed throughout this chapter.

Other significant gaps in the AT education and TPACK literature are presented in

Table 2.1 of the Literature Review chapter, along with the mode in which my study was designed to address these areas. In the ensuing sections, each individual gap is presented, including how the findings from my study contributed to each area.

5.1.1 What are the signature pedagogies used in Canadian AT accredited

institutions? As discussed in the Literature Review chapter, no previous educational researchers investigated the types of signature pedagogies that were most prevalent in CATA-accredited institutions. Similarly, there was sparse pedagogical research undertaken in AT programs in the United States. The limited research that was available from the NATA in the United States focused on identifying the preferred pedagogies in AT education (according to students), rather than signature pedagogies that were used by educators. The results from these NATA studies suggested that AT students considered CBL, collaborative/peer activities, injury simulations/scenarios, and active-learning strategies to be the most effective pedagogies in AT- accredited programs

(Mazerolle & Yeargin, 2010; Mensch & Ennis, 2002; Walker, 2003). However, it was not determined how frequently these pedagogies were implemented by AT programs.

My study found that AT educators throughout Canada employed a wide variety of pedagogical strategies in AT-specific courses. Some educators preferred active-learning 165

approaches because they believe that these strategies assist in developing more competent and critically reflexive students. AT educators felt that active-learning approaches facilitate the learning process by tasking students to think critically about the course content, instead of just relying on rote memorization. These educators also suggested that field/clinical competence as an AT was directly associated with the ability to think critically because they felt that critical reflection was a necessary attribute to demonstrate competence when assessing or rehabilitating athletic injuries.

Similar to the findings of the preferred pedagogies of AT students in the NATA, those AT educators who demonstrated a higher level of PK in my study were also more likely to implement a variety of pedagogical strategies to engage students, including:

CBL, flipped classroom activities; critically reflexive activities; narratives and storytelling; self-directed learning; and cooperative learning. According to Le Fevre

(2014), effective teaching involves understanding and implementing different pedagogies, combined with the willingness to experiment in the classroom to enhance student learning. Therefore, AT educators should be more experimental in the classroom by evaluating their current approach to teaching, familiarizing themselves with what else is being done in AT classrooms, and changing their pedagogical practices to enhance student learning (Le Fevre, 2014).

Although some educators were more experimental in their pedagogical delivery, most AT educators (10 out of 15 educators interviewed during Phase 1 of my study) used didactic methods to lecture content theory and separate laboratory sessions to teach hands-on practical skills. This trend suggested that the traditional passive delivery method was most probably the signature pedagogy of AT education in CATA-accredited institutions.

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5.1.2 What are the potential benefits and limitations of using CBL in CATA-

accredited institutions? Since there were no apparent prior studies that explored the use of CBL as a pedagogy in CATA-accredited institutions, the potential benefits and limitations of this pedagogy remained undefined. Through anecdotal evidence and informal conversations with educators at the onset of this study, it was assumed that AT educators often used some form of scenarios, simulations, or cases, as a part of their teaching. However, the explicit benefits and limitations associated with CBL were not articulated in this context. In other health professions (e.g., medicine and nursing), CBL was found to: 1) be a stimulating, interactive, and motivating pedagogical strategy that was effective in bridging the gap between theory and practice (Van Dijken et al., 2008);

2) develop a deeper understanding of course material, helping to improve critical thinking skills (Hofsten et al., 2010); and 3) provide students with a forum to integrate content theory with clinical hands-on skills (Williams, 2006). Similar findings emerged from my study as AT students during Phase 3 felt that practising scenarios through CBL helped to integrate foundational theories with specific practical knowledges and skills, while identifying areas of necessary improvement in various levels of orthopedic assessment competence. It was also suggested by students that CBL as a pedagogical strategy helped to encourage critical thinking about simulated practical scenarios that are commonly faced by ATs in field and clinical settings. Therefore, AT students felt that they could use these case simulations to self-evaluate their personal level of competence and identify any areas of weakness. However, to be considered effective for learning, the sample of

AT students in my study felt that CBL activities should be contextually-enriched, structured, and provide students with a clear sense of purpose.

The only limitation related to CBL that emerged from my study referred to the ways that case scenarios were traditionally delivered in AT courses. The AT students at 167

Sheridan College felt that many educators used vague scenario-based activities that lacked purpose, detail, and structure. Students described a poorly structured scenario as one that provided brief descriptions of the injury (e.g., a basketball player was landing from a jump, stepping on an opponent’s foot, and rolled their right ankle) and how it presented itself (e.g., there was immediate swelling around the lateral malleolus), leading to less authentic examples. Students also described a lack of instructional support as being associated with poorly structured scenarios, resulting in difficulty to connect with these hypothetical activities and being forced to make a lot of assumptions about the injury scenario. Vygotsky (1978) described this lack of instructional support by defining the zone of proximal development as, “the distance between the actual developmental level as determined by independent problem solving and the level of potential development as determined through problem solving under adult guidance or in collaboration with more capable peers (Vygotsky, 1978, p.86). According to Vygotsky

(1978), educators should be able to evaluate students current developmental level, and to then provide them with different activities and problems to advance their individual learning. Instructional scaffolding is one such way to promote a deeper level of understanding, by guiding and supporting each student towards their individual learning potential (Holton & Clark, 2006). Educators can use a variety of supports (e.g., multimedia technologies, flow charts, concept maps) to scaffold student learning and to gradually remove these supports once the student demonstrates competence or autonomous learning (Holton & Clark, 2006). Athletic therapy students in my study appreciated the level of instructor involvement in the case scenarios and valued the opportunities to work with fellow students through the various peer activities. These results coincided with the findings from my previous work (King et al., 2014), which

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rationalized the importance of having instructional involvement with the M-CBL SIAET, to scaffold the learning experience and to help develop student competence.

5.1.3 What is the contextual landscape for AT educators in CATA-accredited

institutions? As identified in the Literature Review chapter, the successful integration of digital technologies in pedagogically meaningful ways is dependent on how educators understand and adapt within their unique contexts (Kelly, 2010).

However, previous literature has shown that teaching context is one of the least understood components of the TPACK framework (Kelly, 2010; MacKinnon, 2017;

Rosenberg & Koehler, 2015). Due to the established importance of understanding context, my study of AT education employed the TPACK model to analyze the data collected during Phase 1. This step was deemed necessary at the onset of the study so that the M-CBL SIAET could be modified to align with any contextual differences, as evidenced from the findings of my Pilot Project #2 (King et al., 2014).

The majority of AT educators considered themselves to be content experts and were much more comfortable in conversations related to content when compared to discussions surrounding digital technologies or different types of pedagogies.

Pedagogical differences also emerged and separated this sample into two groups: 10 AT educators who defaulted to a lecture format and practical laboratory settings; and five educators with higher levels of PK who utilized innovative, constructivist, active-learning teaching strategies. The AT educators with higher levels of PK (identified through individual interview analysis) contributed to more in-depth interview conversations about effective technology integration in AT education and demonstrated an enriched understanding about pedagogical decision making and how these concepts related to technology integration.

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Grounded in these contextual findings from Phase 1, the TPACK graphic was modified to depict how most AT educators viewed technology integration (Figure 4.1).

Instead of including three identical circles, as in the original TPACK model, the CK circle was made bigger to signify that most AT educators considered themselves to be content experts while being less knowledgeable in TK and PK. In addition, instead of an even intersection between all three types of knowledges (as depicted in the TPACK framework), the only observable overlap was between CK and PK (PCK). All other overlaps of TPACK were affected by the previously described pedagogical differences in

AT educators.

Based on these contextual findings, the M-CBL SIAET was modified during

Phase 2 by: 1) developing student and educator versions of the educational tool; 2) developing a educator’s instructional guide; 3) embedding 3dRx® anatomy animations;

4) adding critical reflection questions/activities; 5) embedding mechanism of injury videos; 6) filming and embedding special test videos; 7) filming and embedding tutorial videos; and 8) ensuring that all case scenarios followed a consistent template. These modifications were made, and additional resources developed, to help AT educators to understand the nature of the educational tool, its intended use, and the different pedagogies embedded within the tool. The modified multimedia tool also served as a practical example for AT educators, demonstrating how technology could be integrated to enhance learning in sports injury assessment courses. This practical example helped to encourage educators to think about their own technological and pedagogical decisions, and to consider how to integrate technology in more pedagogically meaningful ways in future course offerings. These contextual factors were important to identify and address during this phase of research before exploring the perceived impact of the multimedia tool on the nature of teaching and learning during Phase 3. 170

5.1.4 What is the impact of using technology-assisted pedagogies in CATA-

accredited institutions? The main purpose of Phase 3 in my study was to explore the impact of the updated version of the M-CBL SIAET (complete with additions and modifications as identified in the contextual findings of Phase 1) on the nature of teaching and learning in Sheridan College’s AT program, wherein students and educators were recruited during this phase to yield an enriched understanding of how the multimedia tool impacted both student learning and teaching.

Much of the previous research in this area focused on the impact of various technology-assisted pedagogies on student learning, and found that: 1) multimedia technology can be used to create more authentic, realistic, and complex case scenarios

(Boltz, 2002); 2) multimedia technology can be combined with CBL to present a more accurate depiction of the complexities required to work through a case scenario (Han et al., 2013); 3) digital technologies increased student motivation and engagement (Wikstein et al., 2002); and 4) advanced technologies further developed critical thinking abilities which ultimately a more effective health professional (Payne et al., 2012). Similarly, in my study, I used a mixed-methods approach to show that the M-CBL SIAET helped to:

1) create a contextually-enriched situation for learning/studying about athletic injuries; 2) provide opportunities to engage in critical thinking/reflection; 3) stimulate higher levels of analysis/clinical decision making; 4) organize semi-structured peer interactions; and 5) extend learning outside of the traditional classroom setting. The qualitative component of my research allowed for more detailed explanations of how this educational tool established these positive outcomes.

These findings were consistent with the previous CBL research from other health professions. One of the main advantages of learning through cases is that it helps to encourage higher order thinking and stimulate critical reasoning when compared to 171

traditional didactic teaching approaches (Berry et al., 2012). Kaddoura (2011) suggested that CBL was an effective method of teaching for nursing students because the collaborative learning environment and shared learning goals assisted in developing important critical thinking skills related to improving patient outcomes. Fiddler,

Robinson and Rudd (2016) also proposed that creating constructivist-based case scenarios assisted in the development of critical thinking skills and clinical reasoning capabilities in physiotherapy students. Similarly, a pilot project by Burke (2017) found that virtual interactive case studies were an effective tool in improving students’ diagnostic reasoning and clinical decision making skills in a nurse practitioner program.

The health care environment in the 21st Century is very complex and requires effective critical thinkers and decision makers (Burke, 2017). Therefore, health professional educators should explore, design, and implement effective teaching methods that encourage the development of critical thinking skills to allow for a successful transition into real-life practice (O’Rourke & Zerwic, 2015).

Furthermore, there is a dearth of research investigating the impact of technology- assisted pedagogies on teaching practices, thus prompting my study to explore the impact of the M-CBL SIAET on teaching. The use of the multimedia tool was found to have a profound impact on teaching, according to the sample of AT educators from Sheridan

College. When considering the multimedia tool, AT educators suggested it caused them to: 1) think about the potential roles for technology in AT education; 2) think about how technology can empower, or enhance, course content/pedagogy; and 3) promote critical thinking about how to implement different technology-assisted pedagogies in the AT curriculum. This metacognitive process of ‘thinking about thinking’ as it is related to teaching and articulating pedagogical rationale was a unique experience for many of these educators. The multimedia tool itself was valuable because it encouraged the 172

consideration of the potential roles for technology in teaching and learning in AT education.

5.1.5 What are the factors that influenced technology integration in AT

education? While exploring the impact of the M-CBL SIAET on the nature of teaching and learning in AT education, my primary interest was to establish the factors that influenced the use of technology-assisted teaching tools in AT education. The objective was to identify what educators considered when deciding to integrate various technologies into their classrooms. The findings from Phases 1 and 3 of my study exposed several important factors that influenced AT educators’ implementation of instructional technologies as a part of their teaching.

The main factors that influenced the usage of instructional technologies were the levels of TK and PK in AT educators. Similar to previous research (Ertmer & Ottenbreit-

Leftwich, 2013; Hunter, 2015; Kim et al., 2013), the findings from my study suggested that those AT educators with higher levels of TK and PK were also more likely to use more advanced technology-assisted teaching tools in their teaching. These educators appreciated the potential for innovative technologies to improve AT education and gave examples of how technology could be effectively integrated into the AT curriculum. One such example (provided by ATEd-5 during Phase 1), described how private blog sites were integrated into a course to provide students with a forum to describe and comment on each other’s practicum experiences. This AT educator provided further commentary on each of these posts to help stimulate further critical reflection and higher-level thinking about each situation. By using blog posting technology, the educator in this example was able to enhance student learning through the sharing of unique experiences and by using these situations to structure future lectures, skill practice sessions, and debriefing sessions. Conversely, AT educators with lower levels of TK and PK appeared 173

to use digital technologies more superficially, as a means to simply convey information to students. When discussing different digital technologies implemented in AT education, educators with lower levels of TK and PK described PowerPoint, word processors, spreadsheets, and email as their most commonly used technologies. These educators did not appear to use more advanced technology-assisted teaching tools as a part of their teaching nor did they consider how technology could potentially enhance their course content or preferred pedagogy. Based on these findings, the levels of TK and PK appeared to be positively correlated with the educators perceived value of technology integration. Athletic therapy educators with higher levels of TK and PK understood the nature of effective technology integration and valued the role of digital technologies in enhancing learning through higher-level thinking and critical reflection. Athletic therapy educators with lower levels of TK and PK did not perceive technology to be as useful in

CATA-accredited programs and instead focused on using technology to deliver course content to students.

Institutional factors, such as the size and type of institution, also impacted the use of technology-assisted teaching tools in CATA-accredited programs, as notable differences were observed between AT educators from college/smaller university settings and AT educators from larger universities. The majority of AT educators from larger universities thought of effective technology integration as using various digital technologies (e.g., PowerPoint) to deliver course content or to simply make lectures more interesting (to match student expectations of delivery methods). Comparatively, educators from colleges/smaller universities provided a greater number of examples of how to use digital technologies in more pedagogically meaningful ways. Another institutional factor that influenced technology usage was the availability of pedagogical training/support. As described in Phase 1 of my Results chapter, there was a wide range 174

of formalized pedagogical training/support readily available for AT educators from

CATA programs in college settings compared to those from universities. The CATA programs in college environments provided many more opportunities for faculty to improve their PK, including formalized sessions on innovative teaching methods, connecting effective teaching methods to match differing learning styles, and cooperative learning. The findings from my study suggested that AT educators with higher levels of

PK were also more likely to consider the impact that digital technologies had on course content and preferred pedagogies, therefore implementing more advanced technology- assisted tools that empowered student learning.

Other factors that influenced the use of technology-assisted teaching tools in AT education emerged from the interviews with AT educators during Phase 1 of my study.

These educators described several barriers that limited technology usage in the AT classroom including: time constraints associated with learning new technologies and the necessary skills to implement these technologies; a lack of awareness of available technologies to benefit AT educators; the costs associated with technology implementation (for educators and students); fear of technology replacing traditional classroom interactions between teachers and students; and uncertainty of why technologies were actually being used. As discussed in the Results chapter, all these factors were identified by AT educators as being influential in their decision-making process when considering the integration of various technologies into AT classrooms.

5.1.6 How can the TPACK model promote critical thinking amongst

educators around technology integration and the resulting impact on

pedagogy? Although there were many factors that influenced technology implementation in AT education, one of the main themes that emerged from my study was that exposure to the TPACK framework, and my multimedia pedagogical tool that 175

aligned with the TPACK model, promoted critical thinking amongst AT educators about effective technology integration and the influence that technology integration had on various pedagogical decisions. Critical thinking is a fundamental component of higher- order thinking and can be defined as a level of thinking that analyses itself, evaluates itself, and as a result improves future thought and/or practices (Hughes & Lavery, 2004).

According to Garrison, Anderson, and Archer (2001), the ultimate value of a pedagogical tool is to assess its impact on higher-order thinking and to encourage educators to reflect on changes to actual educational practice (also known as reflective practice). This sample of AT educators felt that exposure to the educational tool itself made them reflect upon their personal teaching philosophies, how their content was currently being delivered, and to look for areas that could be enhanced by implementing different pedagogical strategies and/or digital technologies in the future. Because AT educators considered themselves to be content experts, they felt that the course content was the driving force behind all pedagogical and technological decisions. These findings were similar to another interpretivist TPACK study that considered course content to be the contributing factor that controlled the selection of digital technologies and how these tools supported the learning process (Harris & Hofer, 2011).

Promoting critical thinking about technology integration was considered a significant finding in my study because it demonstrated an example of transformative learning in AT educators that could potentially benefit future teaching at Sheridan

College. According to Mezirow (2000), an important part of transformative learning, and actual behavioural change, is for individuals to change their frames of reference through critical reflection of personal assumptions and beliefs, and then consciously making changes and implementing new ideas. Athletic therapy educators at Sheridan College felt that being introduced to TPACK and experiencing the M-CBL SIAET, made them reflect 176

on their personal attitudes and opinions about technology integration, and they would consider making changes in the future to use technology in more pedagogically meaningful ways. The M-CBL SIAET also served as a practical example for AT educators by demonstrating how technology could be effectively integrated into sports injury assessment courses. Therefore, AT educators could use this example to identify the important factors to consider when implementing technology in more pedagogically meaningful ways in the future.

5.1.7 Summarizing AT students’ experience with the M-CBL SIAET.

Overall, the AT students who participated in my study enjoyed using the innovative CBL approach and considered the M-CBL SIAET to be a useful teaching/learning tool.

However, there is contrasting evidence in the medical education literature surrounding the effectiveness of this type of learning. Some researchers have suggested that students enjoy learning through case scenarios because of a general distaste for traditional didactic teaching or because of the type of learning independence that this type of learning promotes (Bate, Hommes, Duvivier, & Taylor, 2014). Conversely, other researchers have found that learning through case scenarios can be a shock to the novice learner, resulting in anxiety about missing key learning objectives or filling in important knowledge gaps (Maudsley, Williams, & Taylor, 2008). Case-based learning involves more preparation on the part of the student and that is often why it is considered less popular than passive modes of receiving lecture information

This type of learning is considered new to most students and requires a completely different learning approach from what the students are familiar with. The goal of these innovative methods is to shift away from a syllabus-and-examination focused learning approach towards a much more open-ended and self-directed learning.

Therefore, students will respond differently to these new challenges, depending on their 177

preferred learning styles, personalities, previous learning experiences, motivation, and need for autonomy (Bate et al., 2014).

The general positivity for learning through cases experienced by the students in my study was attributed to several factors. The M-CBL SIAET was designed to answer a very specific pedagogical problem in AT education of a lack of structure in traditional

CBL activities. All students interviewed in this study appeared to have the same constructions about this issue and felt that my educational tool helped to create a more contextually-authentic learning experience. In addition, this innovative CBL approach was a completely new experience to all participants. These individuals were familiar with using traditional text-based scenarios (e.g., case scenarios at the end of chapters in text-books) but not a hybridized approach that integrated technology, important content/theory, and established pedagogical methods. Therefore, the novelty of this new approach could explain the general positivity from participants. Finally, the sample of students in my student included fourth-year students who were nearing graduation from a

CATA-accredited institution. These students were all attempting the national certification exam in the near future and valued the significance and practicality of the M-

CBL SIAET by facilitating full orthopedic assessments in detailed case scenarios.

5.2 Why Should AT Educators Consider TPACK When Integrating Technology?

Teaching, like the profession of AT, is not an exact science. Instead, effective teachers should consider their profession to be a balance between an art and a science, especially when considering how to effectively integrate technologies into educational settings (Haq, Steele, Marchand, Seibert, & Brody, 2004). The art of effective teaching involves the understanding that there is no universal blueprint that all effective teachers must follow to teach a certain topic or course (Klapper, 1995; Marzano & Brown, 2009).

Teachers can experiment by exploring new methods, observing the implementation of 178

these methods in the classroom, evaluating the successes of these methods with students, and making any necessary changes for future classes/offerings of the course (Parsons &

Brown, 2002). The science of effective teaching refers to evaluating and implementing the pedagogical strategies that have been shown over time to have a high probability of enhancing student achievement (Marzano & Brown, 2009). Although teaching is not considered an exact science, teachers should be aware of important factors such as: the course content to be covered; the most beneficial sequencing of these topics/concepts; effective methods of evaluation to assess students; the benefits of using different teaching strategies; and the benefits of integrating different digital technologies to help deliver course content (Marzano & Brown, 2009).

In the 21st century, students and educators live in a society that is engrained with innovative emerging technologies. Therefore, educators should also be equipped with the knowledges and skills to critically assess the potential roles for technology integration in enhancing classroom learning (Adams Becker et al., 2017). The TPACK framework uncovers these important factors and encourages effective teaching through justifying all pedagogical and technological decisions. Critics of the TPACK model (Brantley-Dias &

Ertmer, 2013; Gomez, 2015) raise two important questions about the framework: 1) how does understanding the TPACK model impact thinking about pedagogy and get reflected in actual teaching practices? and 2) why should educators consider the TPACK framework when integrating technology? These opponents of TPACK argue that technology is so automatic in present-day teachers that it has become a part of their personal pedagogy. According to Brantley-Dias & Ertmer (2013), Shulman’s original

PCK framework described educators’ curricular content knowledge as the knowledge of instructional materials that are useful for teaching specific course content (visual materials, films, etc.). These authors also suggested that there is no need to separate 179

technology from pedagogy as all digital technologies would fit into Shulman’s earlier description of curricular content knowledge. Other researchers claim that innovative digital technologies (which are constantly being advanced, updated, and modified) are not transparent and ubiquitous and therefore should not be considered a part of the PCK definition (Doering, Veletsianos, Scharber, & Miller, 2009; Voogt et al., 2013). These researchers also suggest that considering TK as a part of the PCK model increases the likelihood of ineffective technology integration by using technology in superficial ways.

Furthermore, Mishra and Koehler (2006) argued that the increased role of technology integration in education, combined with the rapid advancements of available educational technologies, warrants TK to be recognized as a separate knowledge domain from the

PCK overlap. Separating technology from the original PCK model allows for a more detailed analysis of how technology interacts with content and pedagogy, in both simple and complex ways, by exploring the factors that impacts the technological and pedagogical decisions that educators make (Mishra & Koehler, 2006). Therefore, educators should be cognizant of why they are using different educational technologies and consider how these technologies impact student learning (Abbitt, 2011; Archambault

& Barnett, 2010; Doering, Veletsianos, Scharber, & Miller, 2009).

Phase 1 of my study identified a wide range of TK amongst the sample of AT educators. Further analysis also uncovered a wide variety of digital technologies being implemented in AT programs throughout Canada. All educators in this sample described how they used technology as a part of their teaching but most examples referred to using digital media to simply convey information to students (e.g., using PowerPoint to deliver lectures). Few AT educators provided examples of effective technology integration by using digital technologies as mindtools to help students construct knowledge and think critically (Jonassen, 2000). These findings (the wide range of TK, and lack of 180

substantive technology integration), suggested that TPACK could help all teachers, including AT educators, to reflect upon and validate their teaching practices (Vibert &

MacKinnon, 2015). The TPACK framework represents a way of thinking that integrates digital technologies in pedagogically meaningful ways. It encourages educators to not use technology just for the sake of using it (to meet student, institutional, or societal expectations) but rather to think about how technology integration empowers or enhances the pedagogy and/or content. Using TPACK as analytical tool helps to make visible what may not be readily apparent when digital technologies are integrated in the classroom

(Hofer, Bell, Bull, Barry, & Cohen, 2015). By following TPACK, educators make instructional design decisions, choose a particular pedagogical strategy (e.g., CBL), and think about how technologies can support teaching of this particular content. This process also reinforces the importance of thinking about specific learning outcomes more carefully. Reflecting on these difficult decisions helps to respond to the complexity of teaching and learning in an AT setting by deliberately thinking about technology, pedagogy, and content, and how each of these enhance or constrain one another (Hofer et al., 2015).

5.3 How Can AT Educators Apply TPACK Principles in Practice?

A common theme from the interviews with AT educators was that they were interested in using more technology as a part of their teaching, but the sample did not know where to start to integrate technology more effectively. The development of

TPACK in AT education can take many forms, given the multifaceted factors and complexities of CATA-accredited institutions. There is no universal template for

TPACK development and factors such as the type of institution (college or university), leadership structures, number of faculty, experience level of faculty members, workload, number of students, student demographic, and student access to technology all have a 181

significant impact on an educator’s ability to integrate technology in pedagogically meaningful ways. Regardless of these complexities, there are two key areas required to promote TPACK development in higher education settings: 1) the creation of leadership structures that promote TPACK; and 2) specific TPACK faculty development practices

(Herring, Meacham, & Mourlam, 2016).

5.3.1 Creating leadership structures that promote TPACK. In 2011, work by the American Association of Colleges for Teacher Education Committee on Innovation and Technology, the National Technology Leadership Coalition, and Microsoft’s Partners in Learning Higher Education identified the necessary learning opportunities and supports that were required to motivate faculty to participate in TPACK development

(Thomas, Herring, Redmond, & Smaldino, 2013). These committees developed a

‘TPACK Leadership Theory of Action’ (Table 5.1) that described the process of how change should happen, including what was within the program leader’s control, and what supports needed to be in place for change to occur but were outside of the leader’s control

(Herring et al., 2016).

To promote TPACK development, program leaders should first understand the meaning of effective technology integration and establish a clear vision, in conjunction with faculty members, that is compelling to all stakeholders (the institution, administrators, faculty, and students) (Herring et al., 2016). This vision should define specific TPACK knowledges and skills that fit program components and be related to creating effective student learning experiences (Herring et al., 2016). The expectations for performance and assessment should also be established so that educators can consider how these technological decisions impact student evaluation.

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Table 5.1

TPACK Leadership Theory of Action (Herring, Meacham & Mourlam, 2016)

How will change happen? What can we control? Zone of wishful thinking

Leadership Team’s Learning Human Resources (faculty, Creating a favourable policy (TPACK) staff, etc.) environment (institutional & external) Leadership Practice Fiscal Resources (allocation & Access to additional incentives) resources (incentives, operating funds, etc.) Faculty Learning (TPACK) Personal Resources (time, Having a faculty that is messages, political capital, willing to allocate time & attention, etc.) attention to learn about TPACK Faculty Practice Engagement with Creating a culture of partner internal/external schools, who are conducive initiatives/partners to the goal of effective technology integration Teachers’ TPACK Learning and Practice

Following setting a vision, program leaders must develop a specific action plan that guides faculty learning about TPACK and effective technology integration. Thomas et al. (2013) suggested that any TPACK action plan should include: 1) setting an example of effective technology integration by demonstrating an innovative technology that follows TPACK principles; 2) providing professional development opportunities for faculty to learn about different technologies; 3) identifying the resources available for

TPACK development (e.g., available incentives for faculty members or resources for new equipment); 4) developing a peer support network for faculty members (locally, regionally, nationally); and 5) organizing an inter-school community collaborative for faculty members. An effective action plan should also coincide with the larger institutional strategic plan to make it easier for program leaders to make requests for additional resources. For example, the academic vision and mission of Sheridan College is to be recognized as a world class provider of innovative and creative learning and to

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provide students of all ages with the knowledge and skills to thrive in a rapidly changing world (Sheridan College, 2013). Therefore, AT administrators from Sheridan College can demonstrate how TPACK aligns with this institutional vision and use this as leverage when negotiating additional resources to design innovative technologies and/or help to develop faculty TPACK.

Athletic therapy program leaders can also promote TPACK development by responding to potential barriers and formulating individualized strategic plans. In Phase

1 of this study, AT educators identified time restrictions and the associated costs of learning and implementing technology as limiting barriers for increasing their TK.

Athletic therapy program leaders could respond to these barriers by: 1) organizing professional development sessions to teach AT faculty about TPACK and effective technology integration; 2) decreasing AT faculty workload to allow for TPACK professional development; 3) providing additional resources to purchase innovative technologies and/or training on how to use these technologies; and 4) organizing technology collaboratives with other programs within the institution that are interested in using technology in pedagogically meaningful ways.

5.3.2 TPACK faculty development. Within the TPACK literature there are several different approaches describing how to develop specific TPACK knowledge in post-secondary educators. The most common methods include: 1) the workshop approach; 2) the mentoring approach; 3) a workshop/mentoring hybrid approach; and 4) the Learning by Design approach (Herring et al., 2016).

The workshop approach introduces educators to the different constructs of the

TPACK model using various workshop sessions. The sequencing of topics within these workshops often begins with increasing fundamental PK and TK, progressing to informing educators about how to select/design technologies that enhance specific 184

pedagogies commonly used to teach in a specific content area (Herring et al., 2016). One of the main critiques of the workshop approach is that the sessions often involve faculty members who teach in different subject areas, therefore making it difficult to teach about

TPACK integration to all attendees (Herring et al., 2016).

The mentoring approach partners up educators with an individual mentor who is both familiar with the specific subject area and well-versed in TPACK/effective technology integration principles (Herring et al., 2016). This approach assists in overall

TPACK development by integrating discipline-specific examples so that the educator can appreciate the important factors to consider when integrating technology in pedagogically meaningful ways. However, one of the main critiques of the mentoring approach is that educators often miss out on the amount of foundational knowledge that is covered in more detailed workshops (Herring et al., 2016).

The workshop/mentoring hybrid approach blends the two approaches described above by using workshops to teach the foundational knowledges (technological and pedagogical) and then providing educators with an experienced mentor to help facilitate the overlaps between the different constructs (Herring et al., 2016). These mentors can streamline the process required to use technology in a way that enhances a particular pedagogical strategy and/or course content (Herring et al., 2016).

In the Learning by Design approach, faculty work alongside graduate students to design instruction for their specific courses, while considering all the potential interactions between technology, pedagogy, and course content (Koehler & Mishra,

2005). This approach encourages the faculty member to be aware of the complex interplay between these three types of knowledge and cognizant of their technological decisions and the resulting impact on pedagogy (Koehler & Mishra, 2005).

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Currently, all CATA-accredited programs are delivered at the undergraduate level, so AT educators have limited interactions with graduate students. Therefore, due to these limited interactions, the Learning by Design approach would not be considered appropriate for this population. As an alternative, AT program leaders should explore the use of workshops, mentoring, or a workshop/mentoring hybrid approach to help develop faculty TPACK knowledge.

Regardless of the approach used, TPACK development should align with the overall institutional vision, mission statement, and specific program goals (Herring et al.,

2016). For example, if a goal of an AT program is recognized as developing competent therapists and critical thinkers, then workshops or mentorship interactions can focus on demonstrating how effective technology integration can assist in achieving this goal. To build on the higher constructs of the TPACK model, faculty must first have a foundational base of PK and understand the importance of facilitating learner-centred instruction through effective technological integration (Herring et al., 2016). Therefore, each faculty member’s individual needs should be assessed to identify baseline knowledges and detect any areas that would require additional supports. If a strong foundational base is not present, then workshops or mentors can focus on growing this introductory knowledge. Similarly, a needs assessment should also look for any potential barriers to technology integration to increase the likelihood of participation (Herring et al., 2016). These barriers can be addressed by reviewing them with program administrators and formulating a strategic plan to overcome any hurdles. The final suggestion for developing faculty TPACK is to establish collaborative ongoing supports for educators (Herring et al., 2016). For example, a national collaborative could be created for AT educators whereas individuals share ideas and resources with one another.

This can assist AT educators to see what others are doing in the same field, see what 186

pedagogies are being implemented elsewhere, see how other educators are making learning more learner-centred, and providing examples of how technology is being integrated in pedagogically meaningful ways.

5.3.3 Example for AT educators – how TPACK informed the design of the

M-CBL SIAET. Because there is no universal template for TPACK development, it is impossible to create a simplified checklist establishing a step-by-step approach of how to integrate TPACK in an AT classroom. However, the M-CBL SIAET was designed using TPACK principles (Mishra & Koehler, 2006) and can be considered a practical example for AT educators of how to initiate TPACK in their teaching. The findings from my study demonstrated how to design an effective technological tool

(using TPACK theory and R2D2 ID process) and how to implement such a tool in the AT classroom (according to the accompanying pedagogical model) (Figure 5.1). The purpose of this section (and Figure 5.1) is not to create a step-by-step design process to explain how to systematically design an effective tool but rather to describe some of the important factors for AT educators to consider when using TPACK to design technological educational tools.

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Identify a pedagogical problem

Reflect on how technology can empower the solution to a pedagogical problem

Choose technologies that enhance student learning

Reflect on how the educational tool will be implemented

Design the educational tool

Figure 5.1 A graphic outlining how to use TPACK to design pedagogically meaningful technology tools. This graphic is not meant to be a step-by-step design process but rather outlines important factors to consider when designing effective educational tools.

5.3.3.1 Identifying a pedagogical problem. To use TPACK theory effectively, an educator must first identify a pedagogical problem within their field of teaching (Kim,

Kim, Lee, Spector, & DeMeester, 2013). In the Introduction chapter, I shared my experiences as an AT student and junior educator, reflecting on CBL as a learning activity. From my experiences, case scenarios were not being implemented as structured learning activities. Instead, AT educators often assigned a case scenario by simply providing a brief description of an athletic injury and asking students to come up with an index of suspicion. In this instructional context, little guidance was given by the instructor and effective pedagogical strategies (e.g., Socratic interactions, peer-assisted learning) were not being used to facilitate student learning and/or critical thinking. As I learned more about effective pedagogical strategies and reflected on these experiences as an AT student, I realized that more could have been done to enhance student learning in a

CBL environment. Therefore, this realization became my pedagogical problem.

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Once a problem has been identified, it can then be used to define specific learning goals/objectives and provide a starting point for curriculum development and/or the design of an educational tool (McTighe & Thomas, 2003). For the M-CBL SIAET, I created a structured learning activity by using the CATA competency list to define the expected learning goals of my tool. These learning outcomes were divided into four main areas: 1) communication skills; 2) professional competence and application of performance; 3) professional decision making and critical thinking; and 4) ethical decision making. A detailed list of all learning outcomes can be found at the end of the

Instructor’s Guide for the M-CBL SIAET (Appendix J).

5.3.3.2 Reflecting on how technology can empower the pedagogical problem.

After identifying the pedagogical problem, I thought about how technology could be integrated into a CBL environment to enhance learning about orthopedic assessment skills. I decided to design structured scenarios that brought students through the different components of an orthopedic assessment (beginning with history taking, all the way to interpreting assessment findings). Digital technologies were implemented along the way to create a more contextually-enriched example for the student. Technologies included:

1) mechanism of injury videos so that students could see exactly how the athlete was injured; 2) anatomy animations to review important anatomical structures; and 3) special test videos to evaluate student knowledge, psychomotor skill, and critical thinking ability.

When students are given a less authentic scenario (e.g., a brief word description of a particular injury), they are often left to make many assumptions about what happened and how the injury actually presented itself. Oftentimes, students have not reached the level of competence (or accumulated enough experience) to be able to make these comprehensive inferences. Based on these assumptions, I felt that technologies could be

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implemented into the educational tool to ensure that all students were provided with the same detailed information and contextually-authentic experience.

5.3.3.3 Thinking about how the tool will be implemented in the classroom.

Educators cannot design an educational tool without thinking about its intended use. AT educators need to identify the specific learning outcomes of the tool (potentially matching these outcomes with the CATA competencies), think about how it will be presented to the students, identify the pedagogical approach to implementation (e.g., using a flipped classroom model or a PBL model), think about how learning will be scaffolded, and think about how student learning will be evaluated or assessed. This approach was not taken in my first Pilot Project #1, as the multimedia tool was simply distributed to students for their personal use. The overwhelming response from these participants was that the tool needed more instructor involvement to help facilitate student learning. This first pilot project was my personal introduction into the importance of considering the pedagogical impact of technology integration, which is essential to using educational technologies effectively.

5.3.3.4 Thinking about the design process as non-linear, recursive, and reflexive. As discussed in the Introduction chapter, there are many different ID models that can be used to design educational tools. A popular model, the R2D2 model (Willis,

2009), encourages the design process to follow an iterative process, allowing the designer to make refinements and revisions at any time, using feedback from multiple stakeholders and not just the designer (Richey et al., 2011). Athletic therapy educators should not think about the educational tool design process as being a rigid, linear, step-by-step process. Rather, feedback should be elicited from students and other educators at different points in time to help continuously improve the tool. Because there are so many complexities associated with teaching and learning in an AT context, this recursive and 190

reflexive approach to the design process will assist in developing effective pedagogically sound technology tools that are constantly evolving and improving.

5.3.3.5 Understanding that TPACK does not advocate for a particular technology. Although TPACK can be implemented to help design a specific educational tool (as it was in the case of the M-CBL SIAET), the model itself does not advocate for

(or against) a particular technology (Koehler, Mishra, & Zellner, 2015). Due to technological advancements, an innovative educational technology that was shown to be effective today can quickly be considered outdated. Therefore, TPACK is not about recommending one technology over another, rather it demonstrates the critical stance educators should take when choosing technologies with due consideration of the resulting impact on pedagogy and course content. Athletic therapy educators should recognize the importance of being a reflective practitioner and value the importance of using digital technologies in pedagogically meaningful ways as an example of effective technology integration (Harris et al., 2009; Pierson, 2001). Many researchers recognize the importance of encouraging teachers to be self-reflective of their own teaching methods and recommend that teachers actively explore the impact of their pedagogical decisions

(Beaulieu, 2013; McKernan, 2013). According to Carr & Kemmis (1986), “[self- reflective enquiry] helps to improve the rationality and justice of their own [teaching] practices, their understanding of these practices, and the situations in which the practices are carried out” (p. 162). In theory, this practice would help to improve instruction and enhance student learning in AT education programs.

5.4 Conclusions

The purpose of my study was to explore the impact of the M-CBL SIAET on the nature of teaching and learning in a CATA-accredited institution. The findings suggested that my multimedia tool contributed to student learning at Sheridan College by: 1) 191

creating a contextually-enriched scenario for studying/learning about athletic injuries; 2) engaging students in critical thinking/reflection opportunities; 3) stimulating higher levels of analysis/clinical decision making; 4) organizing semi-structured peer interactions; and

5) extending learning outside of the traditional classroom setting. Furthermore, the multimedia tool also benefited AT teaching at Sheridan College by: 1) highlighting the importance of thinking about the potential roles for technology in AT education; 2) using technology to empower, or enhance, course content/pedagogy; and 3) promoting critical thinking about implementing different pedagogies in the AT curriculum. Athletic therapy educators felt that being introduced to TPACK and experiencing the M-CBL SIAET, made them reflect on their personal teaching outcomes and pedagogical approaches, and consider making changes in the future to use technology in a more pedagogically meaningful manner.

Furthermore, my study attempted to establish the factors that influenced the use of technology-assisted teaching tools in AT education. The most noteworthy factors that influenced technology usage were identified as the: 1) level of TK in AT educators; 2) level of PK in AT educators; 3) AT educators perceived value of technology integration;

4) CATA-accredited institutional influences (size, type, amount of pedagogical support);

5) time constraints associated with learning new technologies; 6) lack of awareness of available technologies; 7) costs associated with technology implementation; 8) fear of technology replacing traditional classroom interactions between educators and students; and 9) uncertainty of why technology was actually being used. These findings helped to fill in gaps within the literature by establishing the factors and barriers that influenced the use of technology-assisted teaching tools in CATA-accredited institutions.

Finally, though the M-CBL SIAET was shown to provide benefits to both student learning and teaching, the importance of this study extends beyond these findings 192

because of the demonstration of how TPACK theory and the R2D2 ID approach can be integrated to design an effective, pedagogically sound technological tool. A similar approach can be used by AT educators to reflect on their own practices to evaluate whether or not technologies are being used in pedagogically meaningful ways and to make any necessary changes to future course offerings.

5.5 Limitations of the Study and Implications for Further Research

Several limitations within this study were noted. One potential limitation was related to the quality of students who volunteered for this study. All student participants in Phase 3 possessed excellent grade point averages so the constructions of positive feedback could be simply representative of a strong cohort of students. Top students often like to be challenged and may prefer these learner-centred or self-directed learning approaches. On the other hand, weaker students may share different opinions and may not consider the multimedia tool to be conducive to their learning. Future research should consider these potential differences and explore whether multimedia tools are beneficial to all AT students, or just those who are engaged, motivated, active learners, that prefer this type of learning.

When discussing the impact that the multimedia tool had on teaching, AT educators described how experiencing this tool (and the surrounding theory behind its design) would make them use technology differently in the future. Although this was considered a significant finding, it was simply subjective statements made by the educators. There were no mechanisms in place to see if educators actually used technology differently in the future or if they demonstrated an actual improvement in

TPACK knowledge and/or effective technology integration. Therefore, future research could invite AT students to evaluate their educator’s level of TPACK knowledge (based on how technologies are integrated in the courses) or researchers could observe 193

classroom interactions and evaluate educators’ TPACK in practice. Another approach would be to have AT educators design and develop their own technology-assisted pedagogies to see if these tools reflected an increase in TPACK knowledge and effective technology integration principles.

Case scenarios in CBL activities also have the potential to inform AT students about the types of complex social issues that may arise for ATs in the workplace. In the current study, the representation of the specific hypothetical patients did not encourage discussion about important social factors such as social class, gender identity, ethnicity, material and cultural factors, psychosocial factors, social support, and life events

(MacLeod, 2011). Careful writing of future case scenarios can help to expose students to some of these social complexities, to stimulate thought about very important factors that are often overlooked when teaching AT students.

Finally, as described earlier, AT education is undergoing a pedagogical/curriculum shift in the near future. By the year 2020, all CATA-accredited programs will be expected to have a detailed plan in place to move their program structure towards a competency-based educational model (Lafave et al., 2016). Future research with the tool described herein should explore how compatible learner-centred pedagogies and effective technology integration impacts this competency-based model.

In addition, researchers should investigate the impact that this pedagogical shift has on

PK and the other constructs included within the TPACK framework.

5.6 My Doctoral Research: A Narrative Leading to Recommendations for AT

Educators

When reflecting on the findings of my study, the M-CBL SIAET was found to be a positive experience for both teaching and student learning environments at a CATA- accredited institution. However, the purpose of this research was not to verify that my 194

tool statistically improved the attainment of specific objective learning outcomes through valid and reliable means. Rather, the primary interest of my study was to explore the factors governing the impact of using a multimedia pedagogical tool in AT education.

This was done within the context of emphasizing the importance of scaffolding student learning through integrating technology in pedagogically meaningful ways. Based on these findings, several important recommendations emerged from this study that AT educators should consider to help improve future AT instruction.

In Section 1.1 of my Introduction chapter, I described my personal lack of PK as I started out on my doctoral journey. Like the majority of AT educators who participated in my study, I knew very little about different pedagogies and defaulted to teaching in a way that I was taught by using didactic methods. I did not consider different pedagogical approaches nor did I explore the potential benefits of these methods. Before starting my doctoral studies, if I was presented with a multimedia tool like the M-CBL SIAET, I would have used it in the same manner as other AT educators who were identified as having a decreased level of PK. I would have used the technology in a very superficial way, without considering how the technology could potentially empower, or enhance, the course content or innovative teaching strategies. Technology would have been thought of simply as an ‘add-on’ to my traditional didactic approach.

As I progressed through my doctoral work, and became familiar with concepts like PCK (Shulman, 1986a), TPACK (Mishra & Koehler, 2006), using technology as mindtools (Jonassen, 2000), and effective technology integration (Davies & West, 2013),

I noticed a transformation in my own teaching practice. This personal increase in PK lead to integrating technologies in more pedagogically meaningful ways, resulting in more effective instruction in my classes. For example, this past year I integrated an interactive teaching platform (TopHat™) into my ‘anatomy’ and ‘care and prevention of 195

athletic injuries’ courses. Five years ago, I would have just used this interactive polling platform to quiz students on material covered in class. When finishing a particular unit, I would have created questions and got students to assess their level of ‘knowledge’ in that particular area. However instead of using this approach, I reflected on everything I learned over the course of my doctoral work, and thought about how this specific technological tool could be implemented into my teaching to engage students in critical thinking and to enhance the learning environment across Bloom’s Taxonomy of cognitive domains (Bloom et al., 1956). These reflections led to using the TopHat™ technology in more pedagogically meaningful ways (e.g., using the polling software to quiz students on their prior knowledge on a topic, to then change the way that the content was delivered to them), resulting in positive student feedback. Within my teaching evaluations, students frequently commented on my approach to using this technology, how it was completely different compared to how the same technology was used in other classes, and how my approach benefited student learning. Students felt that my approach helped them to actually learn the material, instead of depending on rote memorization.

Similarly, the findings from my study can serve as a practical example for AT educators, demonstrating how to experiment and integrate technology in a pedagogically meaningful way. The M-CBL SIAET established an example of how to integrate technology with a specific purpose in mind to facilitate student learning in sports injury assessment courses.

For a long time, technology tools have been thought of as a supplement to traditional instructional methods. Educators have been compelled to ‘keep up with the times’ and use technologies that their students are familiar with (e.g., PowerPoint). From my own experiences as a post-secondary educator, students often ‘demand’ the use of technologies to deliver the course content. However, the lack of prolonged engagement 196

of tools like PowerPoint demonstrates that the fad of new technologies gains little traction even though educators claim motivation as a rationale for ‘doing it the technological way’. In my opinion, it is not enough to teach differently with technology by simply using digital media to convey information to students; if a particular technology does not enhance instruction, educators should be more reflective and move on to re-engage with pedagogical approaches that are tried and true. It remains that a good measure of traditional instruction has significant impact without the integration of technology.

The essence of my research is to promote the use of a TPACK framework to put pedagogy first (instead of course content) and to demonstrate the potential for technology as one of the many possible tools for the AT classroom. I have discovered that, just as other teaching tools have very specific and useful ways of empowering learning, technology, when appropriately implemented, has the potential to improve understanding and the attainment of educational goals. I believe the culmination of my studies has shown that hybrid pedagogical approaches that nest technologies within a strong interactive, student-centred, scaffolded, constructivist teaching and learning environment

(Figure 1.5) offers great promise for emerging technologies to assist AT educators in reaching their instructional goals. It is time to leave the ‘technoromantic’ age (Beynon &

Mackay, 1989) and assume a critical stance to how various digital technologies might be integrated effectively into AT classrooms.

It is especially important for AT educators to take a critical stance towards effective technology integration as the profession moves towards a competency-based educational model (Lafave et al., 2016). Referring to competency-based learning,

Voorhees (2001) stated,

197

The pathways to learning no longer lead automatically to traditional institutions of

higher education. Instead they lead most directly to learning opportunities in

which competencies are defined explicitly and delivery options are multiple.

This new paradigm with ultimately redefine the roles of faculty, institutions and

accreditors (p. 5)

Therefore, AT educators would benefit from experimenting with different constructivist and/or active-learning pedagogies, while considering the potential for technology to empower these pedagogical approaches (Voorhees, 2001). Although there is no known research in AT education related to effective pedagogies for competency-based education, innovative pedagogical approaches have been shown to improve instruction in other health professions that have implemented competency-based models (Morcke,

Dornan, & Eika, 2013; Shin, Sok, Hyun, & Kim, 2015).

After reflecting on formal and informal conversations with AT educators throughout my doctoral research, this group appears to value the importance of developing competent ATs who think critically. During interviews, many AT educators described the ultimate goal of CATA-accredited programs of developing critically reflective students. Although AT educators deem this attribute as being important, few educators actually implemented specific pedagogical strategies that facilitated this development of critical thought. The findings from my study show how a technology- enhanced pedagogical tool can be designed and integrated into an orthopedic assessment course to engage AT students in critical thought. The findings also act as a practical example for AT educators to demonstrate how the TPACK model allowed me to take a systematic approach to investigating the factors that affected the impact of designing an effective technological tool.

198

The final recommendation for AT education that emerged from this study was that educators should not consider ID as a linear and sequential process. As an alternative, ID should be thought of in a similar manner as an ATs approach to the rehabilitation of an athletic injury. ATs know that many athletic injuries are not considered textbook examples as each injury is considered unique, contains many confounding factors, and impacts everyone differently. When designing a rehabilitation plan, an AT considers many unique factors, tries different techniques, elicits feedback from the patient, continuously reassess along the way, and progresses the plan based on how the injury responds to treatment. Correspondingly, the design of effective educational tools should follow a similar process. An R2D2 approach to instructional design encourages educators to use an iterative process of experimenting, reflecting, and making changes, with the ultimate goal of developing effective instructional practices that evolve over time. By following this approach, as was employed in the design of the

M-CBL SIAET, AT educators can elicit feedback from multiple stakeholders, at multiple points in time, to ensure that they are designing tools that are up-to-date and pedagogically effective.

199

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APPENDIX A

Competencies in Athletic Therapy

The Competencies in Athletic Therapy are divided into six (6) domains. These domains are:

Domain I Prevention Domain II Recognition and Evaluation Domain III Management, Treatment and Disposition Domain IV Rehabilitation Domain V Organization and Administration Domain VI Education and Counselling

Each Domain is subdivided into three (3) categories. The categories are:

Cognitive Domain

The cognitive domain reflects the knowledge and intellectual skills related to the basic and applied sciences in the area of Athletic Therapy. Topical areas include anatomy, physiology, exercise physiology, biomechanics, kinesiology, psychology, nutrition, therapeutic modalities, management science and so on.

Psychomotor Domain

The psychomotor domain involves the application of the tasks and skills derived from the cognitive domain. This includes skills such as the appropriate use of therapeutic modalities, directing a rehabilitation program, applying emergency procedures, record keeping, and so on.

Affective Domain

The affective domain expresses the professional’s values and attitudes related to the Canadian Athletic Therapists’ Association Scope of Practice and Code of Ethics in the application of the skills and practices of the profession.

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DOMAIN I: Prevention

Identifies injury/illness risk factors associated with participation in competitive athletics and plans and implements all components of a comprehensive athletic injury/illness prevention program.

Cognitive Domain (Knowledge and Intellectual Skills)

1. Basic components of a comprehensive athletic injury/illness prevention program including: a) physical examinations and screening procedures, b) physical conditioning, c) fitting and maintenance of protective equipment, d) application of taping, special pads, etc., and e) control of environmental risks.

2. Common risk factors and causes of athletic injuries in various sports as identified by contemporary epidemiological studies and athletic injury/illness surveillance systems.

3. Intrinsic risk factors associated with normal physical and psychological growth and development patterns of the pre-adolescent, adolescent and adult male and female athlete.

4. Risk factors associated with congenital or acquired postural abnormalities, physical disabilities and diseases (i.e. epilepsy, diabetes, asthma, congenital heart disease, absence of paired organs, visual impairments, etc.).

5. Sports specific risk factors associated with conditioning, coaching methods and motor skill performance.

6. Sports specific environmental risk factors associated with climatic conditions, facilities and equipment, sanitation, etc., and associated risk management procedures/safety guidelines.

7. Risk factors associated with biomechanical stress, extrinsic forces and physical demands inherent in the performance of motor skills common to various sports.

8. Role of physical examinations and screening procedures in the identification of intrinsic injury/illness risk factors and potential disqualifying conditions.

9. Recommended or required components of a pre-participation physical examination as established by institutional policy, governing athletic associations, medical associations or other authoritative groups.

10. Organization and administration of pre-participation physical examinations/screening including preparation of records and forms, scheduling of examining personnel, organization of examination site, etc.

11. Purpose of standard physical fitness tests and contemporary testing equipment and accepted test protocols for measurement of cardiovascular/respiratory fitness,

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body composition, posture, flexibility, and muscular strength, power and endurance.

12. Role of personal health habits in the prevention of injuries/illnesses including personal hygiene, nutrition, weight control, etc.

13. Basic components of in-season and off-season physical conditioning programs for development of cardiovascular/respiratory efficiency, flexibility and muscular strength, power and endurance specific to the needs of individual athletes and to the physical demands of specific sport activities.

14. Purposes and effects of contemporary isometric, isotonic and isokinetic strength training equipment.

15. Techniques and physiological effects of cardiovascular endurance training and weight training (isometric, isokinetic and accommodating resistance exercise) on the musculoskeletal, nervous, cardiovascular and respiratory systems of the human body.

16. Effects of various types of flexibility programs and stretching exercises (static, passive, active, PNF techniques) on normal contractile and non-contractile tissues of the human body (muscles, tendons, nerves, fascia, etc.)

17. Safety precautions, contraindications and hazards associated with the use of various strength training equipment, conditioning methods and exercise routines.

18. Principles of an effective heat illness prevention program including those pertaining to acclimatization and conditioning, fluid and electrolyte replacement, selection of clothing, monitoring of weight loss and scheduling and organization of practice sessions.

19. Normal thermoregulatory mechanisms of the human body including methods of heat dissipation and the associated effects of exposure to high environmental heat and humidity.

20. Recommendations, guidelines and policy statements published by professional associations and agencies regarding athletic participation during extreme weather conditions.

21. Principles of organization of practice sessions with regard to minimization of injury/illness risk factors.

22. Principles of energy absorption and force dissipation as applied to protective capabilities of commercial padding materials and various types and models of standard protective equipment.

23. Comparative qualities of various types of protective sports equipment, clothing and commercial padding materials with regard to their effect on body heat dissipation. 229

24. Standards for design and construction, maintenance and reconditioning of protective sports equipment (CSA, NOCSAE, etc.).

25. Legal concepts and considerations associated with the purchase, fitting and maintenance of protective sports equipment including those pertaining to product liability, personal liability, shared responsibility, etc.

26. Rules and regulations pertaining to the use of special protective equipment, braces, splints, etc. as established by governing athletic associations.

Psychomotor Domain (Manipulative and Motor Skills)

1. Use of commercial fitness testing equipment, administration of standard physical fitness tests, and recording and interpretation of test results.

2. Operation of contemporary isokinetic, isotonic and isometric strength testing devices.

3. Administration of static and dynamic postural evaluation and screening procedures including functional testing for muscle shortening.

4. Administration of anthropometric measurement techniques (skinfold measurement, underwater weighing, girth measurements, limb length measurements, height, weight, etc.) and other appropriate physical examination/screening procedures (blood pressure, pulse, etc.).

5. Operation and instruction in the use of commercial isometric, isotonic and isokinetic weight training equipment.

6. Collection and interpretation of climatic data (temperature, humidity) through the use of appropriate instruments (sling psycrometer, WGBT Index, etc.).

7. Selection and fitting of standard protective equipment and clothing consistent with the physical characteristics and needs of individual athletes and the demands of participation in specific sports activities.

8. Selection, fabrication and application of appropriate preventative taping, wrapping, splints, braces and other special protective devices consistent with sound anatomical and biomechanical principles.

Affective Domain (Attitudes and Values)

1. Acceptance of the moral and ethical responsibility to conduct safe athletic programs and to minimize injury/illness risk factors to the fullest extent possible. 230

2. Appreciation of the importance of developing and implementing a thorough, comprehensive injury/illness prevention program.

3. Appreciation of the need for cooperation among administrators, coaches, athletic therapists, athletic trainers, parents and athletes in the implementation of effective injury/illness prevention programs.

DOMAIN II: Recognition and Evaluation

Conducts and thorough initial clinical evaluation of injuries and illnesses commonly sustained by the competitive and recreational athlete or sports participant, and formulates an impression of the injury/illness for the primary purposes of (1) administering proper first aid and emergency care and (2) making appropriate referrals to physicians for diagnosis and medical treatment.

Cognitive Domain (Knowledge and Intellectual Skills)

1. Normal anatomical structures of the human body including the musculoskeletal (including articulations), nervous (central and peripheral), cardiovascular, respiratory, digestive, urogenital and special sensory systems.

2. Normal physiological functions of the human body including the musculoskeletal, nervous (central and peripheral), cardiovascular, respiratory, digestive, urogenital and special sensory systems.

3. A basic understanding of the normal histological structures and their functions within the muscular, skeletal, nervous and cardiovascular systems.

4. Anatomical and physiological growth and development characteristics as related to the pre-adolescent, adolescent and adult male and female athlete.

5. Principles and concepts of body movement including functional classifications of joints, joint biomechanics, typical ranges of motion, joint action terminology, muscular structures responsible for joint actions (prime movers, assistance movers, etc.), skeletal muscle contraction and kinesthesis/proprioception.

6. Common injuries to each major body part as indicated by contemporary epidemiological studies of injuries in various competitive sports.

7. Characteristic pathology of all common closed soft tissue injuries (sprains, strains, contusions, dislocation, etc.), open wounds (abrasions, lacerations, incisions, punctures, etc.) and fractures.

8. The human body’s normal immediate and delayed physiological responses to trauma (homeostasis, inflammation, etc.).

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9. Common etiological factors contributing to injury including congenital and/or acquired structural and functional abnormalities, inherent anatomical biomechanical characteristics, common injury mechanisms and adverse environmental conditions.

10. Relationships between etiological factors and resulting injury/illness pathologies.

11. Typical symptoms and common clinical signs associated with athletic injuries/illnesses including those associated with local tissue inflammation (cellulitis) and systemic infection (lymphangitis, lymphadenitis, bacteraemia).

12. Relationships between typical symptoms and clinical signs and injury/illness pathologies.

13. Commonly accepted techniques and procedures for clinical evaluation of common athletic injuries/illnesses including: a) history, b) observation, c) functional testing (active, passive, isometric resisted), d) special tests, and e) palpation.

Psychomotor Domain (Manipulative and Motor Skills)

1. Construction and phrasing of questions appropriate to obtaining a medical history of an injured/ill athlete including past history and a history of the present injury/illness.

2. Identification of observable clinical signs typically associated with common athletic injuries/illnesses including structural deformities, edema, discolouration, etc.

3. Administration of active and passive range of motion tests for all major joints of the body including the use of goniometric measurements.

4. Use of manual muscle testing techniques including application of the principles of muscle/muscle group isolation, segmental stabilization, resistance/pressure, grading, etc.

5. Administration of appropriate clinical laxity (stress) tests for ligamentous/capsular instability including application of the principles of joint positioning, segmental stabilization, pressure, etc.

6. Administration of appropriate sensory and motor neurological tests for intracranial injuries (conscious and unconscious athlete) and injuries to the spinal cord, nerve roots, plexuses and peripheral nerves.

7. Administration of commonly used “special tests” for the evaluation of athletic injuries to various anatomical areas (Thompson test, Apprehension test, etc.).

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8. Location and palpation of “key” anatomical structures commonly involved in injury pathology including bony landmarks, ligamentous/capsular tissues, musculotendinous structure, abdominal regions, etc.

9. Assessment of blood pressure through the use of a sphygmomanometer and evaluation of pulse rate, strength and regularity.

10. Incorporation of appropriate examination techniques and procedures into an effective systematic scheme of clinical evaluation.

Affective Domain (Attitudes and Values)

1. Acceptance of the professional, ethical and legal parameters which define the proper role of the certified athletic therapist in the evaluation of athletic injuries/illnesses and medical referral.

2. Recognition of the initial clinical evaluation by the certified athletic therapist as an assessment and screening procedure rather than a “diagnostic” procedure.

3. Appreciation of the practical importance of thoroughness in the initial clinical evaluation of the athlete’s injury/illness.

4. Respect for the injured athlete as an individual deserving of quality professional health care.

5. Acceptance of the injured athlete’s physical complaint(s) without personal bias or prejudice.

DOMAIN III: Management, Treatment and Disposition

Provides appropriate first aid and emergency care for acute athletic injuries/illnesses according to accepted standards (St. John Ambulance, Canadian Red Cross, Canadian Heart Foundation, or equivalent) and refers injured/ill athletes to appropriate medical/paramedical personnel for evaluation/diagnosis and follow-up care.

Cognitive Domain (Knowledge and Intellectual Skills)

1. Basic components of a comprehensive athletic injury emergency care plan including: a) personnel training, b) equipment, c) emergency care facilities, d) communication systems, e) transportation, f) game and practice coverage, and g) record keeping.

2. Typical community-based emergency health care delivery plans including communication and transportation systems.

3. Typical availability and capabilities of community-based emergency care facilities, common admission and treatment policies, etc. 233

4. Roles and responsibilities of various community-based emergency care personnel (paramedics, emergency medical technicians, emergency room physicians, etc.).

5. Legal, moral and ethical parameters which define the scope of first aid and emergency care and identify the proper role of the certified athletic therapist.

6. Typical administrative policies and procedures governing first aid and emergency care including those pertaining to parental consent, notification of parents, accident reports and record keeping.

7. Availability, purposes and maintenance of contemporary first aid and emergency care equipment and supplies and commonly recommended contents of emergency care field kits.

8. Current standards for first aid and emergency care and cardiopulmonary resuscitation (Canadian Red Cross, Canadian Heart Foundation, etc.).

9. Role and function of various medical/paramedical specialists and their respective areas of expertise in the definitive treatment of sports related injuries/illnesses.

10. Medical, legal and ethical protocol governing the referral of injured/ill athletes for medical services.

11. Standard nomenclature of athletic injuries and communication of identified clinical signs and symptoms to medical personnel using commonly accepted medical terminology.

Psychomotor Domain (Manipulative and Motor Skills)

1. Application first aid procedures for closed soft tissue injuries including the use of pressure bandages, ice and elevation.

2. Control of external bleeding including the application of direct pressure, arterial pressure and the application of dressing and bandages.

3. Application of aseptic techniques in the management of open wounds (sterilization procedures, wound cleansing/debridement, dressing and bandaging, etc.).

4. Application of immobilization devices including cervical collars, spine boards, fixation and traction splints, shoulder immobilizers, slings, etc. 5. Performance of cardiopulmonary resuscitation techniques according to current standards, including assessment of the level of consciousness and vital signs and identification and removal of airway obstructions due to anatomical or mechanical causes.

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6. Use of short distance transportation methods including walking assists, manual carries, transfers from ground/floor to stretcher/spine board and stretcher carries.

Affective Domain (Attitudes and Values)

1. Acceptance of the professional, ethical and legal parameters which define the proper role of the certified athletic therapist in the first aid and emergency care of athletic injuries/illnesses.

2. Appreciation of the importance of developing a thorough, comprehensive athletic injury emergency care plan and the need for continual review and practice of emergency care procedures.

3. Realization of the injured athlete’s physical, emotional and psychological dependence on the certified athletic therapist as an initial health care provider.

DOMAIN IV: Rehabilitation

Plans and implements a comprehensive rehabilitation/reconditioning program for injuries/illnesses sustained by the competitive and recreational athlete.

Cognitive Domain (Knowledge and Intellectual Skills)

1. Basic components of a comprehensive rehabilitation program including determination of therapeutic goals and objectives, selection of therapeutic modalities and exercise, methods of evaluating and recording rehabilitation progress and development of criteria for progression and return to competition.

2. Physical/physiological parameters to be evaluated as a basis for the development of individualized rehabilitation programs (muscular strength, muscular endurance, range of motion, etc.).

3. Contemporary measurement and functional testing equipment (isokinetic devices, goniometers, dynamometers, calipers, etc.).

4. Pathological responses of the human body to trauma, physiological process of wound healing and tissue repaid, effects of trauma and inactivity on specific body tissues (ligaments/capsules, muscles, tendons, bones, etc.) and resulting implication for selection and use of therapeutic modalities and rehabilitation exercises. 5. Commonly use techniques of primary and reconstructive surgery, associated anatomical and/or biomechanical alterations and resulting implication for the selection and use of therapeutic modalities and rehabilitation exercises.

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6. General physiological effects of inactivity and immobilization on the musculoskeletal, cardiovascular, nervous and respiratory systems of the human body and resulting implications for rehabilitation and reconditioning.

7. Role and function of commonly used prescription and non-prescription pharmacological agents in the medical treatment of common athletic injuries/illnesses.

8. Contemporary immobilization devices (casting materials, splints, etc.) and special protective/correction equipment (braces, special pads, modified taping procedures, orthotics, etc.).

9. Contemporary ambulation aids and ambulation techniques (crutch gaits, cane gaits, special ambulation techniques).

10. Contemporary therapeutic modalities (electrotherapy, hydrotherapy, etc.) and exercise equipment (isokinetic, isotonic and isometric devices, stationary bicycles, pulleys, etc.).

11. Prevailing pain control theories and associated rationale for the selection and use of physical agents and/or psychological techniques for the control of acute and chronic pain.

12. Systemic and local physiological effects of therapeutic heat and cold on normal and traumatized tissues of the human body.

13. Principles of electrophysics including basic concepts associated with the electromagnetic and acoustic spectra (frequency, wavelength, etc.) and electrical unites (amperes, volts, watts, ohms, etc.).

14. Principles of electrophysics and biophysics, specific physiological effects and therapeutic indications and contraindications associated with the use of, but not limited to, the following: a) electrotherapeutic modalities (transcutaneous electrical nerve stimulation, electrical muscle stimulation, galvanism, etc.), b) hydrotherapeutic modalities, c) cryotherapy, d) radiant energy, e) paraffin, f) intermittent compression units, g) cervical and lumbar traction units, h) massage, and i) other contemporary therapeutic modalities.

15. Mechanical physics as applied to the design and operation of rehabilitation exercise equipment (leverage, force, etc.).

16. Specific physiological effects, therapeutic indications and contraindications associated with the use of passive, active, active assisted and resistive (isokinetic, isotonic and isometric) exercise and specific rehabilitation equipment.

17. Theory and principles associated with the use of special evaluation/therapeutic exercise techniques including: a) manual muscle testing, b) proprioceptive

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neuromuscular facilitation (PNF), c) underwater/pool exercises, and d) joint mobilization.

18. Typical psychological and emotional responses to trauma and forced physical inactivity as factors affecting the rehabilitation process (motivation, anxiety, apprehension, etc.).

19. Comparative effectiveness of taping and bandaging, special padding and standard protective equipment as related to the safe return of injured athletes to competition.

20. Environmental risk factors affecting the safe return of injured/ill athletes to competition including those associated with weather conditions, facilities and playing surfaces, inherent physical demands of particular sports, coaching methods, etc.

Psychomotor Domain (Manipulative and Motor Skills)

1. Use of manual muscle testing techniques including application of the principles of muscle/muscle group isolation, segmental stabilization, resistance/pressure, grading, etc.

2. Measurement and recording of muscular strength, endurance and power through the use of contemporary isometric, isotonic and isokinetic testing devices.

3. Measurement of ranges of motion for all major joints of the body through the use of a goniometer or other commonly used techniques.

4. Anthropometric measurement including girth measurement, skinfold measurement, underwater weighting, limb length measurement, height, weight, etc.

5. Administration of static and dynamic postural evaluation and screening procedures including functional testing for muscle shortening.

6. Measurement and fitting of ambulation aids and proper instruction in the use of common crutch/cane gaits.

7. Clinical application of contemporary therapeutic modalities (see Cognitive Domain #14 above) including patient preparation, set-up, determination of dosage and operational procedures.

8. Application of passive, active, active assisted and resisted exercise through the use of manual exercise and contemporary commercial exercise equipment.

9. Application of proprioceptive neuromuscular facilitation techniques for the development and improved range of motion.

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10. Application of passive and resisted underwater/pool exercise for the improvement of joint range of motion, muscular strength, etc.

11. Application of special protective devices (braces, splints, special pads, etc.) and taping, bandaging and wrapping procedures.

Affective Domain (Attitudes and Values)

1. Acceptance of the professional, ethical and legal parameters which define the proper role of the certified athletic therapist in the treatment and rehabilitation of injured athletes including the use of drugs and therapeutic agents.

2. Acceptance of the moral and ethical obligation to provide for rehabilitation of the injured/ill athletes to the fullest extent possible.

3. Respect for the proper role of attending physicians and other medical and paramedical professionals in the treatment and rehabilitation of injured/ill athletes.

4. Respect for accepted medical/paramedical protocol involving confidentiality of medical information, medical/therapeutic prescriptions and health care referral as related to the rehabilitation process.

DOMAIN V: Organization and Administration

Plans, co-ordinates and supervises all administrative components of an athletic therapy/training program including those pertaining to: 1) health care services (physical examinations and screening, first aid and emergency care, follow-up care and rehabilitation, etc.), 2) financial management, 3) training/therapy room management, 4) personnel management, and 5) public relations.

Cognitive Domain (Knowledge and Intellectual Skills)

1. Basic legal concepts as they apply to the certified athletic therapist and his/her performance of job responsibilities (standard of care, liability, defense against negligence, informed consent, etc.).

2. Typical institution, local and regional health care delivery systems including health care services, medical/allied health care personnel and referral procedures.

3. Policies, guidelines and rules and regulations of governing athletic associations, professional associations and other authoritative groups pertaining to the health, safety and welfare of the athlete.

4. Local, provincial and federal safety and sanitation standards for health care facilities, therapeutic modalities and other equipment. 238

5. Current guidelines and recommendations for the conduction of athletic physical examination developed by governing athletic associations, medical groups or other related professional organizations.

6. Basic components of a comprehensive plan for physical examination and screening of athletes for competition including: a) medical history, b) physical examination, and c) medical authorization for participation.

7. Typical organizational plans for conducting individual and group physical examinations, their comparative advantages and disadvantages and the respective roles of various medical and paramedical personnel in each.

8. Basic components of an effective physical examination including commonly recommended health factors to be evaluated and potential disqualifying conditions.

9. Principles of organizing and coordinating group physical examination including scheduling of personnel, preparation of examination sites, etc.

10. Ethical and legal considerations associated with the conduction of physical examinations and treatment as related to confidentiality of medical information, medical authorization for participation, record keeping, as well as other duties association within the scope of practice.

11. Basic records and forms (medical history, physical examination, medical authorization, etc.) and filing systems pertinent to the conduction of athletic physical examinations.

12. Basic concepts of organizing and coordinating a drug testing and screening program.

13. Current banned drug lists published by various governing athletic associations (IOC, COA, CIAU).

14. Basic components of a comprehensive athletic injury/illness emergency care plan including those pertaining to: a) personnel training, b) purchase, maintenance and storage of supplies and equipment, c) identification of emergency care facilities, d) developments of communication and transportation systems, e) assignment of personnel for emergency care coverage, and f) accident reporting and record keeping.

15. Basic records and forms pertaining to the management of athletic injuries including those used for: a) securing emergency care information and parental consent, b) accident reporting, c) medical referral, d) documentation of treatment, e) recording of rehabilitation progress, and f) release of medical information.

16. Computer operations as related to data collection, record keeping and data analysis. 239

17. Typical policies and procedures associated with athletic health care insurance including those pertaining to common benefits and exclusions, preparation and submission of claims and financial restitution.

18. Current athletic injury/illness surveillance and reporting systems.

19. Principles of therapy/training room management related to the acquisition and maintenance of supplies and equipment including supply inventory and needs assessment, evaluation and selection of products, development and submission of budget requests and purchase orders, bidding procedures, etc.

20. Principles of training room management and operation including those pertaining to assignment of personnel, scheduling and supervision of therapy/training room services, storage and use of supplies and equipment, cleaning and maintenance, etc.

21. Federal and/or provincial regulations pertaining to safety and sanitary standards for health care facilities and the installation and maintenance of therapeutic equipment.

22. Basic architectural considerations pertinent to the design of safe and efficient athletic therapy/training rooms.

23. Purposes and functions of exercise equipment, therapeutic modalities and other equipment and supplies essential to equipping an athletic therapy/training room.

24. Principles of personnel management including: a) recruitment and selection of athletic therapy staff members (students and full-time), b) development of policies and procedures governing employment (job responsibilities, codes of conduct, operational procedures, etc.), c) development of work schedules and assignment of personnel for therapy/training room, practice and game coverage, and d) in- service training.

25. Principles in recruitment, selection, employment and utilization of team physicians and other medical/allied health care personnel in the deployment of athletic health care services.

Psychomotor Domain (Manipulative and Motor Skills)

Affective Domain (Attitudes and Values)

1. Acceptance of the professional, ethical and legal parameters which define the proper role of the certified athletic therapist in the administration and implementation of athletic health care delivery systems.

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2. Recognition and acceptance of the need for organization and conduction of athletic therapy/training programs on the basis of sound administrative policies and procedures.

3. Acceptance of the responsibility for completion of paper work and maintenance of records associated with the administration of athletic therapy/training programs.

4. Respect for the roles of medical personnel, administrators and other staff members in the organization and administration of athletic therapy/training programs and recognition of the need for cooperation among involved personnel.

5. Recognition and acceptance of the need for good interpersonal relationships between the athletic therapy staff and athletes, medical/paramedical personnel, coaches and other institution personnel.

6. Recognition and acceptance of the importance of good public relations with the media (radio, television, press), parents and the general public.

DOMAIN VI: Education and Counselling

Provides health care information and counsels athletes, parents and coaches on matters pertaining to the physical, psychological and emotional health and well-being of the athlete. Interprets the role of the certified athletic therapist as a health care provider, promotes athletic therapy as a professional discipline and provides instruction in athletic therapy/sports medicine subject matter areas.

Cognitive Domain (Knowledge and Intellectual Skills)

1. Role of coaches and athletes in reducing the risk of injury/illness including those related to physical conditioning, acclimatization, fluid and electrolyte replacement, care and maintenance of protective equipment, organization of practice sessions, coaching methods, etc.

2. Physiological effects of physical activity on menstruation (oligomenorrhea, amenorrhea, dysmenorrhea) and associated psychological considerations.

3. Principles of nutrition including the roles of carbohydrates, proteins, fats, vitamins, minerals and water as they relate to the nutritional needs of the competitive and recreational athlete.

4. Prevailing misconceptions regarding the proper utilization of foodstuffs including common food fads and fallacies, dietary supplements, weight control diets, etc.

5. Symptoms and clinical signs of common eating disorders (anorexia nervosa, bulimia, nervosa, etc.).

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6. Principles of weight control including methods of determining body fat percentage and caloric requirements and the effects of exercise and fluid loss.

7. Physiological processes and time factors involved in the digestion, absorption and assimilation of various foodstuffs as related to the design and planning of pre- game/pre-event meals including consideration of menu content, scheduling and the effects of pre-event tension and anxiety.

8. Physiological effects, comparative benefits and contraindications of the use of ergogenic aids (drugs, foodstuffs, physical agents, etc.).

9. Effects of commonly abused drugs and other substances on the athlete’s physical and psychological health and athletic performance (alcohol, tobacco, stimulants, steroids, narcotics, etc.).

10. General principles of health maintenance and personal hygiene pertaining to skin care, dental hygiene, environmental sanitation, immunizations, avoidance of infectious and contagious diseases, diet, rest, exercise, weight control, etc.

11. Risk factors associated with the exposure to blood and body secretions (AIDS, STDs, etc.).

12. Common signs and indications of mental disorders (psychoses, etc.), emotional disorders (neuroses, depressions, etc.), or personal/social conflict (family problems, school related stress, personal assault/abuse, etc.).

13. Contemporary personal and community health issues and commonly available school health services, community health agencies and community-based psychological and social support services.

14. Role and function of various community-based medical/paramedical specialists (orthopaedists, neurologists, internists, etc.) and other health care providers (psychologists, counsellors, social workers, etc.).

15. Accepted protocol governing the referral of athletes for medical, personal health, psychological or social services.

16. Availability of education materials and programs in health related subject matter areas (audio-visual aids, pamphlets, newsletters, workshops, seminars, etc.).

17. Techniques and methods for the dissemination of information about injury prevention and health care among athletes, coaches, parents and the general public (team meetings, parents’ night, workshops, seminars, etc.).

18. Physical requirements of various sport activities as related to the injured/ill athlete’s readiness to resume athletic participation. 19. History and development of athletic therapy and sports medicine in Canada.

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20. History of the Canadian Athletic Therapists’ Association including historical events and contributions of influential leaders.

21. Organizational structure, goals and objectives, professional activities, Constitution, Scope of Practice, Code of Ethics, and other documents of the Canadian Athletic Therapists’ Association.

22. Current activities and requirements pertaining to the professional preparation, credentializing (certification/licensure) and continuing education programs of athletic therapists in Canada.

23. Availability of continuing education opportunities and resources for certified athletic therapists.

24. Purposes, objectives and professional activities of major medical/paramedical organizations and other professional sports medicine groups in Canada.

25. Contemporary issues and problems confronting athletic therapy/sports medicine and their effects on athletic health care in Canada.

26. Comprehension of basic research design and statistical analysis and ability to interpret research in athletic therapy, sports medicine and related areas.

27. Tasks required for entry-level proficiency of athletic therapists within the six major domains as described in the document “COMPETENCIES IN ATHLETIC THERAPY”.

28. Theoretical concepts, knowledge and technical skills comprising the subject matter of athletic therapy (i.e. Competencies in Athletic Therapy).

29. Basic principles of learning and motivation and methods of classroom instruction including instructional techniques, use of audio-visual aids, test construction and evaluation of student competencies.

30. Principles of organizing laboratory/clinical experiences and techniques of instruction in applied skills.

31. Theories and techniques of interpersonal communication among athletic therapists, athletes, administrators, coaches, health care professionals, parents and others.

32. Principles of planning and organizing workshops, seminars and clinics in athletic health care for personnel, administrators, coaches and the general public.

33. Psychological parameters associated with performance enhancement and rehabilitation.

Psychomotor Domain (Manipulative and Motor Skills)

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Affective Domain (Attitudes and Values)

1. Acceptance of the professional, ethics and legal parameters which define the proper role of the certified athletic therapist in providing health care information and counselling.

2. Acceptance of the responsibility to provide health care information and counselling consistent with the certified athletic therapist’s professional training and expertise.

3. Recognition of the certified athletic therapist’s role as a liaison between athletes, coaches, health care professionals, parents and other involved individuals.

4. Acceptance of the moral and ethical responsibility to intervene in situations of suspected or known use and/or abuse of legal and illegal drugs and chemicals.

5. Acceptance of the professional, ethical and legal parameters which define the proper role of the certified athletic therapist as an educator.

6. Acceptance of the responsibility to interpret and promote athletic therapy as a professional discipline among allied professional groups and the general public.

7. Acceptance of the professional responsibility to remain abreast of current theory and practice in athletic therapy and sports medicine.

8. Acceptance of the responsibility to enhance the professional growth of athletic therapy students, colleagues and peers through a continual sharing of knowledge and skills.

9. Acceptance of the professional responsibility to create learning experiences which will provide athletic therapy students with an opportunity to develop the competencies necessary for effective functioning as a certified athletic therapist.

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APPENDIX B

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APPENDIX C

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APPENDIX D

Phase 1 – Individual Interview Question Schedule

Questions Related to Pedagogy

• What is your educational background and job title at your institution? • How long have you been teaching within an AT accredited program? • What courses do you currently teach? • How did you learn how to teach? • What is the most frequent critique you would receive of your teaching?

The responses from the initial survey showed that AT educators feel confident with the range of teaching strategies that they use in the classroom.

• What specific teaching strategies do you use most often? • Do you reflect on these strategies to see if they can be improved upon? If so, how often? What do you consider? o Do you think these methods are effective when you consider tangible learning outcomes? • How do you use different strategies for different courses?

Another trend in the survey showed that lecture based learning is the most commonly used strategy in AT education, followed by problem-based learning and case-based learning.

• Why do you think lecture-based is the most popular in AT education? • Do you see an evolution in the use of lecture-based learning in AT education? • PBL & CBL were also popular choices. Why do you think these have gained popularity? • In your opinion, what are some differences between PBL and CBL?

Questions Related to Technology

In the initial survey, it appeared that AT educators: 1) enjoy using technology for their teaching; 2) have a positive attitude towards learning new technologies; and 3) are not intimidated by its use.

• What digital technologies do you use most commonly in (insert course name here)? • How does technology impact how you teach? • What does effective technology integration mean to you? • What are some of the benefits of using technology for AT education? • What are some of the negative aspects of using technology for AT education? 261

• What is the rationale for ever trying technology in teaching? Isn’t it just more work?

The surveys also showed that PowerPoints were the most commonly used digital technology in AT education.

• What types of media do you use in your PowerPoints? • When do you use technology in your teaching? More specifically, how do you incorporate technology into your teaching? Give examples. • Where do you think is the most potential for technology to enhance learning in Athletic Therapy? • Does your administration encourage you to use technology in teaching? • Hoes does technology change the way you think about teaching? Are you apprehensive or excited to try new things? • How and why do digital technologies fit in with the instructional strategies used in your content area of specialization? • How can digital technologies be used to fit in with the delivery of CATA competencies?

Questions Related to Case-Based Learning

Case-Based Learning can be defined as a particular method of teaching that places the student into an active problem, centred on finding a solution to a real-life situation or hypothetical simulation.

• Case-based learning has been around for a long time: why do you think health professionals have found it useful for teaching? • If you had to identify the three most crucial parts of a good case study, what would they be? • How could technology be used to improve such case scenarios? • If you were to use a multimedia case scenario in your class, how would you go about using it?

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APPENDIX E

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APPENDIX F

Case-Study Interviews – Students at Sheridan College

General Questions

• What tools/resources do you consider to be the most effective for your learning? • Give me examples of how you normally use technology to support your learning • Do you feel that using technology aids in your learning? If so how? • Are you familiar with using a case study approach to learn about orthopedic assessment? • What are some advantages/disadvantages of using case studies to learn about orthopedic assessment? • How can AT educators set the context for creating realistic injury simulations?

Questions about the Multimedia CBL Sports Injury Assessment Educational Tool

• If you were to use the educational tool again how would you use it? E.g., would you use it as a study tool, as a part of your class, etc.? • What were some of the main pros/cons of using this technology-assisted pedagogy? Did it enhance certain things? If so, what? • Or did it just get in the way? If so, how?

• What did you like/dislike about the educational tool? • How fluent/streamlined was using this technology-assisted pedagogy compared to traditional text-based cases (e.g., from text books)? • In your opinion, how did this educational tool help to stimulate your critical thinking? Could it be done in a better/different way? How? • In your opinion, how did this educational tool help to improve problem solving skills? Could it be done in a better/different way? How? • In your opinion, did this educational tool incorporate enough time for cooperative learning opportunities? Could it be done in a better/different way? How? • What strategies in the educational tool were most beneficial to your learning?

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APPENDIX G

Case Study Focus Group Interviews – Students at Sheridan College

General Questions

• What tools/resources do you consider to be the most effective for your learning? (ask about specific teaching strategies like cooperative learning, case-based

learning, etc.)

• Do you feel that using technology aids in your learning? If so how? Give me examples of how you use technology to support your learning. • How can AT educators set the context for creating realistic injury simulation?

Questions about the Multimedia CBL Sports Injury Assessment Educational Tool

• Ask opinions on if the educational tool was presented in a different way (1) as a study tool; 2) in a flipped classroom format; 3) as a self-directed learning opportunity). • Get specific feedback re: the likes/dislikes question from the case study survey • Does the level of questioning used in the educational tool help to build on the higher levels of Bloom’s Taxonomy (e.g., analysis, synthesis, evaluation) (compared to rote memorization)? If not, how could they be modified so that they do? • What strategies in the educational tool were most beneficial to your learning? • Ask for suggestions for future improvements.

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APPENDIX H

Case Study Interviews – AT Educators at Sheridan College

Questions about the Multimedia CBL Sports Injury Assessment Educational Tool

• How would educators use the tool? Is the tool subversive and volatile enough in its design so that it can be used in multiple ways? If they were to use it again, how would they use it? • What impact did using this tool have on attitudes towards technology integration? • How can educators set the context for creating realistic injury simulations? • How did the educational tool impact the nature of student learning? Did it contribute to any of critical thinking, problem solving, cooperative learning, etc. or was it just a neat innovation? • Are there improvements that can be made to the pedagogy? What was the missing pedagogical piece? • Does the level of questioning used in the educational tool help to build on the higher levels of Bloom’s Taxonomy (e.g., analysis, synthesis, evaluation)? If not, how could they be modified so that they do? • How fluent/streamlined was using this technology-assisted pedagogy compared to traditional text-based cases? • What were some of the main pros/cons of using this technology-assisted pedagogy? Did it enhance certain things? If so, what? Or did it just get in the way? If so, how? • In your opinion, how did this educational tool help to stimulate critical thinking? Could it be done in a better/different way? How? • In your opinion, how did this educational tool help to improve problem solving skills? Could it be done in a better/different way? How? • In your opinion, did this educational tool incorporate enough time for cooperative learning opportunities? Could it be done in a better/different way? How?

Specific Questions about Future Technology Integration

• If you were to use this tool again in the future, how would you use it? • How does understanding the TPACK framework impact your thinking on using technology in the classroom? • After reviewing this tool, did it change how you would use technology in the future? How? Did this tool help you to understand the importance of how technology can empower learning?

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APPENDIX I

CATA Accredited Institution Curriculum Summary Table

Sheridan College – Bachelor of Applied Health Sciences (Athletic Therapy)

Year 1 BIOL 100000 – Introduction to Cell and System Physiology SCIE 12941 – Introduction to Biomechanics SCIE 17893 – Nutrition ATHL 10000 – Introduction to Athletic Therapy ENGL 17889GD – Introduction to Composition and Rhetoric BIOL 14717 – Human Physiology for Athletic Therapy ATHL 20082 – Protective Equipment and Bracing PHYG 20025 – Exercise Physiology for Athletic Therapy FLPL 20111 – Seminar in Athletic Therapy FLPL 26529 – Sports Injury Clinic FLPL 20113 – Field Practicum 1 2 – 3 credit electives

Year 2 ANAT 23672 – Anatomy of the Lower Quadrant ATHL 24998 – Emergency Conditions 1 ATHL 27900 – Conditions of the Lower Quadrant PHYG 23672 – Growth, Development and Physical Activity FLPL 20082 – Sports Injury Clinic 1 FLPL 20123 – Field Practicum 2 ANAT 27545 – Anatomy of the Upper Quadrant ATHL 20001 – Emergency Conditions 2 ATHL 20000 – Conditions of the Upper Quadrant PHYG 27900 – Pathophysiology PSYC 10025 – Statistical Methods in Behavioral Science FLPL 23314 – Field Practicum 3 2 – 3 credit electives

Year 3 ANAT 38448 – Anatomy of the Spine ATHL 37545 – Injury Treatment Modalities ATHL 37370 – Therapeutic Exercise 1 ATHL 30001 – Clinical Assessment and Rehabilitation 1 FLPL 36529 – Field Practicum 4 ATHL 30199 – Clinical Biomechanics of the Lower Quadrant ATHL 38263 – Therapeutic Exercise 2 ATHL 33314 – Clinical Assessment and Rehabilitation 2 ANAT 33672 – Anatomy of the Head, Thoracic Cavity, and Abdomen FLPL 36367 – Field Practicum 5 ATHL 38100 – Psychology of Injury and Performance 277

2 – 3 credit electives

Year 4 ATHL 30000 – Emergency Conditions 3 ATHL 46048 – Clinical Biomechanics of the Upper Quadrant ATHL 40102 – Clinical Assessment and Rehabilitation 3 ATHL 49999 – Independent Research Proposal FLPL 30009 – Sports Injury Clinic 3 FLPL 40172 – Field Practicum 6 ATHL 45586 – Manual Therapy Techniques ATHL 40001 – Clinical Assessment and Rehabilitation 4 FLPL 40001 – Sports Injury Clinic 4 FLPL 43314 – Field Practicum 7 ATHL 45777 – Current Trends in Athletic Therapy 2 – 3 credit electives

University of Winnipeg – Bachelor of Science in Kinesiology (Athletic Therapy) KIN-1101(3) – Introduction to Kinesiology BIOL-1112(6) – Human Anatomy & Physiology PSY-1000(6) – Introduction to Psychology BUS-1201(3) – Introduction to Business 1 KIN-2202(3) – Prevention and Care of Sport Injuries KIN-2301(3) – Human Anatomy KIN-2304(3) – Scientific Principles of Fitness and Conditioning KIN-2500(3) – Practicum 1 – AT: Field/Clinical KIN-2501(3) – Nutrition for Health and Wellness KIN-2503(3) – Athletic Taping & Splinting Techniques KIN-3106(3) – Exercise Physiology KIN-3107(3) – Therapeutic Modalities in Sport Medicine KIN-3201(3) – Biomechanics KIN-3304(3) – Advanced Resistance Training KIN-3500(6) – Practicum II – AT: Field KIN-3501(3) – Assessment of Upper and Lower Body Sport Injuries KIN-3502(3) – Rehabilitation of Upper and Lower Body Sport Injuries KIN-3503(3) – Massage Techniques in Sport KIN-3504(3) – Sport First Responder KIN-3505(3) – Pathology in Sport Medicine KIN-4301(3) – Applied Anatomy KIN-4500(6) – Practicum III – AT: Clinical KIN-4501(3) – Sports Injuries of the Spine KIN-4502(3) – Drugs and Ergogenic Aids in Sport

At least one of: KIN-2305(3) – Issues in Health KIN-3105(3) – Psychological Skills in Sport and Life

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At least one of: KIN-3103(3) – Adapted Physical Activity KIN-3208(3) – Physical Activity and Aging KIN-4207(3) – Motor Learning and Control

Statistics Requirement – at least 3 credit hours from: PSYC-2101(3) – Intro to Data Analysis STAT-1302(3) – Statistical Analysis II STAT-1501(3) – Elementary Biological Statistics 1

Research Design and Methods Requirement – at least 3 credits hours from: PSYC-2102(3) – Introduction to Research Methods SOC-2126(3) – Introduction to Research Design and Qualitative Research

University of Manitoba – Bachelor of Kinesiology – Athletic Therapy

Year 1 STAT 1000M – Basic Statistical Analysis PSYC 1200 – Introduction to Psychology BIOL 1XXX – BIOL 1020 & BIOL 1030 OR BIOL 1000 & BIOL 1010 PERS 1200 – Physical Activity, Health, and Wellness HNSC 1210 – Nutrition for Health and Changing Lifestyles PERS 1500 – Foundations of Phys. Ed and Kinesiology 1 – W Course (1000 level of above)

Year 2 BIOL 2410 – Human Physiology 1 BIOL 2420 – Human Physiology 2 PERS 2100 – Introduction to Professional Practice PERS 2200 – Program Planning Principles KIN 2320 – Human Anatomy KIN 2330 – Biomechanics KIN 3320 – Advanced Human Anatomy KIN 3200 – Basic Trauma and Life Support KIN 2750 – Athletic Therapy Skills (ELC) PERS 3350 – Introduction to Research 1 – 3 credit elective

Year 3 PERS 3100 – Inclusive Physical Activity and Leisure KIN 3470 – Exercise Physiology PERS 3340 – Philosophy of Physical Activity and Leisure KIN 3740 – Resistance Training and Conditioning (ELC) KIN 3330 – Functional Assessment and Restoration A KIN 3332 – Functional Assessment and Restoration B KIN 3400 – Therapeutic Modalities KIN 3160 – Pathology and Sports Medicine

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KIN 3512 – Principles of Fitness Training KIN 3912 – Athletic Therapy Practicum KIN 3914 – Clinical Block Placement 1 – 3 credit elective

Year 4 KIN 2540 – Psychology of Sport and Physical Activity PERS 4100 – Current Issues KIN 4160 – Advanced Pathology and Sport Medicine KIN 4500 – Physical Activity and Aging KIN 4330 – Advanced Biomechanics KIN 3450 – Motor Control and Learning KIN 4400 – Therapeutic Exercise Rehabilitation KIN 4910 – AT4 Practicum 1 – 3 credit elective

Concordia University – Bachelor of Science in Athletic Therapy

Year 1 CATA 262 – Emergency Care in Sport and Exercise CATA 263 – Principles of Athletic Therapy EXCI 210 – Introduction to Adapted and Therapeutic Physical Activity EXCI 250 – Research Methods EXCI 252 – Introduction to Physical Activity, Health and Fitness EXCI 253 – Human Anatomy I: Musculoskeletal Anatomy EXCI 254 – Human Anatomy II: Systemic Anatomy EXCI 257 – Human Physiology I: The Neurological, Bio-energetic and Endocrine Systems

Year 2 CATA 337 – Assessment of the Upper and Lower Extremities CATA 339 – Rehabilitation of the Upper and Lower Extremities CATA 348 – Therapeutic Modalities in Sports Medicine CATA 365 – Athletic Therapy Field Internship 1 EXCI 351 – Introduction to Biomechanics of Human Movement EXCI 352 – Essentials of Exercise Testing and Training in Athletic Populations EXCI 355 – Neural Control of Human Movement EXCI 357 – Human Physiology II: The Cardiovascular and Respiratory Systems EXCI 358 – Physiology of Exercise

Year 3 CATA 437 – Assessment of the Hip, Spine and Pelvis CATA 439 – Rehabilitation of the Hip, Spine and Pelvis CATA 475 – Athletic Therapy Clinical Internship I EXCI 445 – Nutrition in Exercise and Sport EXCI 451 – Clinical Biomechanics

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1 course chosen from: EXCI 420 – Physical Activity Epidemiology EXCI 422 – Pathophysiology in Clinical Exercise Science I EXCI 423 – Pathophysiology in Clinical Exercise Science II EXCI 440 – Current Developments in the Biochemistry of Exercise EXCI 461 – Pharmacology for Sport and Exercise

Year 4 CATA 441 – Concepts in Manual Therapy CATA 462 – Advanced Emergency Care CATA 485 – Athletic Therapy Field Internship II CATA 495 – Athletic Therapy Clinical Internship II EXCI 471 – Pain Management Strategies

2 courses chosen from: CATA 447 – Special Topics in Athletic Therapy EXCI 450 – Physical Fitness Assessment, Exercise Prescription and Rehabilitation in Special Populations EXCI 455 – Physical Activity, Health and Aging EXCI 458 – Pediatric Exercise Science EXCI 492 – Independent Study in Exercise Science MANA 300 – Entrepreneurship

Camosun College – Bachelor of Athletic & Exercise Therapy

Year 1 BIOL 143 – Anatomy for Sport Education EXW 120 – Lifetime Sports 1 PSYC 160 – Sport & Exercise Psychology 1 SPEX 110 – Fitness for Life BIOL 144 – Physiology for Sport Education EXW 121 – Lifetime Sports 2 EXW 130 – Life Cycle Fitness HLTH 110 – Health in Today’s World PHYS 160 – Biomechanics of Sport

One of: ENGL 151 – Academic Writing Strategies ENGL 161 – Literary Genres ENGL 163 – Intro to Literary Traditions

Year 2 AET 201 – Placement 1 AET 260 – Emergency Conditions 1 AET 272 – Field Prevention/Injury Care 1 EXW 220 – Lifetime Fitness Program EXW 230 – Behavioral Fitness SPEX 210 – Exercise Physiology

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AET 202 – Placement 2 AET 261 – Emergency Conditions 2 AET 273 – Field Prevention/Injury Care 2 CHEM 214 – Nutrition for Fitness EXW 240 – Fitness and Health Assessment EXW 241 – Exercise Prescription & Design

Year 3 AET 301 – Placement 3 AET 310 – Pathophysiology AET 320 – Human Motor Control AET 330 – Therapeutic Modalities AET 340 – Anatomy of the Lower Extremity AET 302 – Placement 4 AET 341 – Anatomy of the Upper Extremity AET 360 – Injury Prevention Equipment AET 381 – Clinical 1 Assessment of Orthopedic Injuries SPEX 350 – Health & Fitness Promotion SPEX 370 – Training for Performance

Year 4 AET 401 – Placement 5 AET 440 – Anatomy of the Spine AET 482 – Clinical 2 Rehabilitation of Orthopedic Injuries SPEX 400 – Chronic Disease Management SPEX 420 – Sport and Fitness Management AET 430 – Concepts of Manual Therapy AET 450 – Ergonomics AET 481 – Clinical 3 Spine AET 402 – Placement 6 SPEX 410 – Research Methods 2-300 level or higher elective course (SPEX 430 and 440 recommended)

Mount Royal University – Athletic Therapy Advanced Certificate

Students must have completed an undergraduate degree for entry into this program HPED 3110 – Musculoskeletal Assessment – Peripheral HPED 3120 – Therapeutic Modalities HPED 3130 – Rehabilitation Techniques I HPED 4110 – Musculoskeletal Assessment – Spinal HPED 4130 – Rehabilitation Techniques II HPED 4140 – Practical Clinical Management and Administration HPED 5100 – Senior Issues in Athletic Therapy PHED 3350 – Field Practicum I PHED 3352 – Field Practicum II PHED 3354 – Clinical Practicum I PHED 3356 – Advanced Clinical and Field Practicum

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York University – Athletic Therapy Certificate

Students must also complete the Kinesiology and Health Science core courses from York University to receive this certificate.

HH/KINE 2490 3.00 – Athletic Therapy I HH/KINE 3575 3.00 – Athletic Injuries – Extremities HH/KINE 3600 3.00 – Athletic Therapy II HH/KINE 3460 3.00 – Regional Human Anatomy I HH/KINE 4575 3.00 – Athletic Injuries – Body/Core HH/KINE 4590 6.00 – Advanced Athletic Therapy Assessment and Rehabilitation

Plus three credits, selected from the following courses: HH/KINE 3465 3.00 – Regional Human Anatomy II HH/KINE 4430 3.00 – Business Skills for Sport and Fitness Professionals HH/KINE 4460 3.00 – Occupational Biomechanics HH/KINE 4470 3.00 – Muscle and Joint Biomechanics HH/KINE 4472 3.00 – Low Back Performance and Disorders HH/KINE 4475 3.00 – Clinical Biomechanics HH/KINE 4565 3.00 – Epidemiology of Injury Prevention HH/KINE 4740 3.00 – Psychology of Sport Injury and Rehabilitation HH/KINE 4900 3.00 – Exercise Therapy for Chronic Diseases

Required Practicum Courses: HH/PKIN 0761 0.00 – First Responder for Athletic Therapy I HH/PKIN 0762 0.00 – First Responder for Athletic Therapy II HH/PKIN 0811 0.00 – Clinical Practicum for Athletic Therapy I HH/PKIN 0812 0.00 – Clinical Practicum for Athletic Therapy II HH/PKIN 0813 0.00 – Clinical Practicum for Athletic Therapy III HH/PKIN 0821 0.00 – Athletic Therapy Clinical Skills I HH/KIN 0822 0.00 – Athletic Therapy Clinical Skills II Kinesiology and Health Science Practicum Core

Kinesiology Core Courses: HH/KINE 3340 – Growth, Maturation and Physical Activity HH/KINE 3465 – Human Regional Anatomy II HH/KINE 3570 – Theory and Methodology of Training HH/KINE 3645 - Physical Activity and Health Promotion HH/KINE 4420 – Relaxation: Theory and Practice HH/KINE 4430 – Business Skills for Sport and Fitness Professionals HH/KINE 4451 – Biomechanical Analysis of Human Movement HH/KINE 4460 – Occupational Biomechanics HH/KINE 4470 – Muscle and Joint Biomechanics HH/KINE 4710 – Psychology of Health and Chronic Disease

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APPENDIX J

Instructor’s Guide for the Multimedia CBL Sports Injury Assessment Educational

Tool

Table of Contents

How to use the Multimedia CBL Sports Injury Assessment Tool

Development of the Multimedia CBL Sports Injury Assessment Tool

Our Pedagogical Model

Case Based Learning as a Pedagogy

Other Pedagogies

Learning Outcomes for the Multimedia CBL Sports Injury Assessment Tool

Instructor’s Guide Tutorial Video

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An Example of Socratic Questioning that can be used within the Various Components of this Educational Tool

Using Socratic questions can help to cultivate deeper learning by getting the students to dig deeper beneath the surface of their ideas. Structuring Socratic discussions in the following way can help to develop active thinking, independent learners:

1. Get students to clarify their thinking. e.g., “Why did you say that was a potential index of suspicion after watching the video?” Or, “could you explain further?”

2. Challenge students about their assumptions. e.g., “Why do you think that this assumption holds here?”; “Is this always the case?”

3. Use evidence as a basis for an argument. e.g., “Why did you say that…?”; “Is there a reason to doubt this evidence?”

4. Ask about alternative viewpoints/perspectives. e.g., “Did anyone else see this another way?” “Why do you think they did?”

5. Ask about implications and consequences e.g., “But if something else happened instead, what would result?”; “How does an ankle sprain effect their gait?”

6. Question the question e.g., “Why do you think that I asked that question?”; “Which of your questions turned out to be the most useful to you?”

Questions adapted from: Paul, R., & Elder, L. (2006). The art of Socratic questioning. Dillon Beach, CA: Foundation for Critical Thinking.

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Scaffolding Ideas to Help Support the Instructor-Led Case Analysis

• The instructor should outline the cognitive and procedural guidelines for each specific component of the assessment process (history taking, observations, etc.).

• The instructor should identify specific expectations so that the student can concentrate on the key characteristics for carrying out the scenario activities successfully.

• The instructor should ask questions to establish links between material learnt in previous courses and what is included in the educational tool. For example, links could be made between the educational tool and material from anatomy, emergency conditions, and/or athletic injury courses (just to name a few).

• Scaffolding questions can be developed for each specific component of the educational tool to help fill in the gaps of student understanding. For example, when watching the mechanism of injury video, the instructor can ask: “What are you looking at when first watching the video?”; “What specifically happened in the video?”; “What joint(s) could be potentially injured?” Questions should be designed in such a way that the instructor can help fill in the gaps by suggesting to go in certain directions (cognitively or procedurally). The idea is to break up the learning into chunks and to provide a tool, or structure, with each chunk.

• The instructor can provide additional explanations. But it is important to make sure that student initiative/creativity is not inhibited. The instructor can also direct the student towards additional resources (texts, journals, videos, etc.) to supplement learning.

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The Development of the Multimedia Case-Based Learning Sports Injury Assessment Educational Tool

Introduction

As an athletic therapy student, I began using some basic multimedia technologies to practice my assessment and rehabilitation skills. For example, when studying for emergency conditions class, I would watch a video of a specific athletic injury and then pretend that I was the therapist on site. I would go through all the steps that I would follow as if I were the attending therapist on site. Even though this activity could be classified as a type of case-based learning, it was not structured within a larger pedagogical framework.

Obviously, I did not notice this at that time because I was not familiar with different types of pedagogical strategies. However, once I learned more about pedagogy, and began exploring effective strategies, I appreciated the importance of pursuing more pedagogical knowledge. When it comes to teaching, there is no magic formula. But an effective educator is one who makes good use of a range of pedagogical methods, applying each method for the use to which it is most appropriate.

Why Use Multimedia?

In the example above, I did not realize it at the time, but I was using multimedia to help deepen my learning/understanding of the course content (somewhat). Well known cognitive theorist Richard Mayer calls this awareness the multimedia principle. Basically, according to this theory, people learn more deeply from words and images than from words alone. However simply adding pictures to words does not guarantee an improvement in learning. But if these multimedia tools are designed in light of how the human mind works (according to cognitive theorists), they are more likely to lead to meaningful learning. For meaningful learning to occur in a multimedia environment, the learner must engage in five cognitive processes: 1) selecting relevant words for processing in verbal working memory; 2) selecting relevant images for processing in verbal working memory; 3) organizing selected words into a verbal model; 4) organizing selected images into a verbal model; 5) integrating the verbal and pictorial representations with each other and with prior knowledge (Mayer, 2005).

Multimedia Technology in Athletic Therapy Education

Multimedia technologies can be used in athletic therapy education to create an enhanced contextual environment when completing simulated case studies. Previous 288

research has shown that these tools can potentially encourage critical thinking and student engagement/motivation. Another study by Boltz (2002) proposed that multimedia technology can create more authentic, realistic, and complex case scenarios that can have a positive effect on factors such as cognitive learning objectives, student motivation, and attitudes towards learning. Even though these proposed benefits sound promising, few researchers have actually explored the integration of technology-assisted pedagogies in an AT specific context. Since there are a limited number of research-based articles that have explored the use of technology-assisted pedagogies in AT, there is a need for further research and/or conceptualization in this area.

Multimedia Case-Based Learning Sports Injury Assessment Educational Tool

It was through these experiences as an AT student, educator, and researcher that led me to improve my own teaching through the development of a specific type of technology-assisted pedagogy. This tool, called the Multimedia CBL Sports Injury Assessment Educational Tool, uses multimedia-enhanced case studies (there are currently shoulder, elbow, knee, and ankle scenarios) to allow students’ to practice the necessary theory and skills required to perform a detailed orthopedic injury assessment.

The template for each case includes: a scenario; a video demonstrating the mechanism of injury; brain storming questions; interactive 3-D anatomical models that could be manipulated by the student (created using Object2VR® software); interactive 2-D anatomical models (created by Kinduct Technologies); an information section (patient history with probing questions, observations, assessment results); special test videos; the problem to be solved; proposed initial treatment plans; and a critical reflection section. This educational tool allows a student to work through an injury case study scenario by: 1) answering sets of probing questions (with the objective of deepening learning); 2) participating in semi-structured peer activities; 3) using the multimedia technologies to answer questions; and 4) ultimately deciding upon a possible index of suspicion for the potential injured structure(s) (based on assessment findings).

After developing the educational tool, it was piloted with two groups of students. First it was used with a sample of Kinesiology students from Acadia University, improvements were made based on their feedback, and then it was piloted with a sample of Athletic Training students from the University of Technology, Jamaica.

Pilot Study #1: Acadia University; Kinesiology Students

The Multimedia Sports Injury Assessment Educational Tool was originally piloted with a group of 14 undergraduate kinesiology students, who were enrolled in a sports therapy course at Acadia University (MacKinnon & King, 2012). The purpose of this project was to develop a supplemental educational tool that provided a venue for students to practice assessment and rehabilitation skills, outside of their regular face- 289

to-face lectures. After developing the educational tool, it was implemented in the sports therapy course and the instructor/students were approached for feedback through a survey, interviews, and focus groups.

In a general sense, the results suggested that the participants viewed the educational tool as being a useful resource. However, the overwhelming response from participants was that the multimedia tool needed to be embedded in a teaching and learning model that invoked more instructor involvement and scaffolding of the diagnosis and treatment processes. This led to the development of the detailed instructional model that is provided in “Our Pedagogical Model”. This hybrid model proposes a pedagogy that educators might use with this type of technology (or similar technologies/activities). The model includes a variety of effective pedagogical strategies including: Socratic interactions between teacher and student; peer interaction activities; critical reflection; hands-on learning/skill acquisition; and instructional scaffolding.

Pilot Study #2: University of Technology, Jamaica; Athletic Training Students After making improvements to the educational tool and constructing an instructional model to accompany it, a second pilot study was carried out with 15 students from the Bachelor of Science in Sports Sciences (Sport Athletic Training Stream) program at the University of Technology in Kingston, Jamaica (King et al., 2014). The main objectives of this study were: 1) to elicit student feedback on the effectiveness of multimedia CBL in a more specific context (Jamaican athletic training education); 2) to evaluate the effectiveness of the proposed teaching model; 3) to explore the best ways to integrate technology into injury case studies; 4) to investigate cultural differences in the way the curriculum and the learning process was perceived; and 5) to investigate cultural differences in the way students perceived or engaged with the educational tool.

The findings from this study suggested that the educational tool was effective in helping the participants to think critically about how to assess/react to injury simulations. The participants also provided suggestions of how to streamline the technology and ways to improve the instructional model. These participants thought that it would be advantageous to have videos that demonstrated the mechanisms of injury so they can see exactly what happened to the injured athlete. Additionally, the participants requested a more structured peer interaction section so that there was a list of activities for them to work on together as they moved through the scenario.

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Doctoral Research Study: CATA Accredited Institutions, Athletic Therapy Educators These two pilot projects allowed me to develop my educational tool and to gather important participant feedback on ways to improve it. I was able to use these suggestions to make the necessary additions and improvements so that it is now a more streamlined example of a technology-assisted pedagogy. Since these pilot studies included participants from outside the athletic therapy profession, the main purpose of my doctoral research is to explore the impact of using this technology- assisted pedagogical tool in an athletic therapy specific context. In preliminary interviews with athletic therapy educators, I was able to elicit responses about important components of case scenarios, how technologies have the potential to enhance these case studies, and what effective technology integration means to them. These responses were analyzed to make further modifications/improvements to the educational tool.

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Our Pedagogical Model

Instructor Led Analysis – First Case Study step-wise approach, Addressed in Lecture demonstration of techniques Student/Instructor Interaction – Socratic Questioning, Instructional Scaffolding

2 Practice Case Studies Peer Assisted Learning; Working with a Partner Critical Reflection

Independent Case Study

This educational tool follows the sequential analysis of completing an orthopedic assessment as commonly used by certified athletic therapists throughout Canada. The various components of an orthopedic assessment include: history taking, observations, rule outs, range of motion testing, strength testing, special structure testing, and palpations. Refer to the next page of this Instructor's Guide for a concept map that outlines the relationship of these different components.

Information gathered from these assessment components allows the therapist to make educated decisions about potential indices of suspicion and the required next steps. The purpose of this educational tool is to provide the student with realistic simulation of actual injury and to have them analyze important assessment information to come up with indices of suspicion (what is damaged and how severe?). 292

Case-Based Learning as a Pedagogy

• What is the main purpose of using Case-Based Learning? o Case-based learning is a particular method of teaching (or pedagogical strategy) that places the student into an active problem, centred on finding possible solutions to a real-life situation or hypothetical simulation (Berry, Miller, & Berry, 2011). o It allows a student to participate in a situated learning environment that emphasizes the need to find associations between content, context, understanding and meaning while also constructing various types of knowledge. When designing scenarios, educators should reflect on the important considerations towards making the context realistic. This will ensure an authentic learning environment for the student. o There are a number of different ways to integrate CBL into a course, ranging from it being the leading pedagogy to a specific assignment to achieve a singular objective. The most important thing for an educator is to identify the learning outcomes for a course, and then determine the specific content, teaching strategies, assignments, etc. that will be used to evaluate those outcomes.

• Why is there a need for Case-Based Learning in AT Education? o The pedagogical strategy of CBL is regularly used in medical professions, such as AT, because it provides a safe, dynamic, and simulated learning environment for students to acquire, analyze, learn, and judge the appropriate clinical decision- making skills to properly handle an injury situation (Thistlethwaite et al., 2012). If used properly, students can reflect upon their experiences with these case scenarios to identify any necessary areas of improvement, before they are faced with actual real-life situations. o Additionally, during clinical and field placements, students do not get to experience every possible injury/condition to every single joint. Therefore, CBL scenarios can be used to help simulate situations that are new to the student. If performed in a realistic context, the skills/knowledge learned may be transferred to other settings as well.

• Why would Case-Based Learning be an effective strategy for AT educators? o There is a very limited amount of research that has explored the use of CBL in an AT specific context. The research that has been done is more theoretical by nature. For example, an article by Speicher et al. (2012) theorized that CBL activities could be used to improve AT students’ clinical reasoning skills, student motivation, and critical thinking abilities. These assumptions were based on the findings of CBL use in other health professions. o In medical education (and through anecdotal evidence in the AT profession), many students consider CBL to be a more stimulating, 293

interactive, and motivating pedagogical strategy when compared to traditional didactic lectures (a passive mode of learning). It has also been suggested that CBL is a more effective way to bridge the gap between theory and practice in clinical courses. o A study that explored the use of CBL in Swedish Nursing students showed that this pedagogical strategy helped to develop a deeper understanding of the course material (self-perceived and in feedback from the instructors) because of the opportunity for collaborative discussion with other students. The students also suggested that CBL helped to improve their critical thinking abilities by integrating course theory with practical skills and forcing them to apply it to real- life situations (Hofsten, Gustafsson, & Haggstrom, 2010). o CBL also gives students the opportunity to integrate content theory with real world examples. A qualitative study that explored the use of CBL with Paramedic students suggested that the ability to associate a particular clinical situation with ‘real’ stories would make it more likely that they will remember the pertinent points when faced with a similar situation out in the job (Williams, 2006). o Even though CBL has been shown to be an effective pedagogical strategy in other health professions, it is still important to see if similar views are shared by AT students and educators.

• What is the difference between Case-Based Learning and Problem-Based Learning? o These two terms are often used interchangeably throughout the educational literature. However, from my experiences, oftentimes these terms are used in the wrong context (something called a PBL assignment is actually a CBL and vice versa). o Problem-Based Learning (PBL) is both a teaching method and a specific approach to curriculum design. True PBL consists of carefully planned problems that challenge students to use varying problem solving techniques, collaborative skills, disciplinary knowledge, and self-directed learning strategies to find the answers. Instructors act as facilitators but there is much less structure to the problem itself (and less structured facilitation). Students are provided with the freedom to figure out how to get to possible solutions. Several health professional programs have actually moved to PBL curricular models, including the medical education and physiotherapy programs at McMaster University. o Case-Based Learning uses a guided inquiry method and provides much more structure throughout a problem than PBL. In CBL, when learners are asked to explore tangents, the instructors (or facilitators) use a set of guiding questions to bring them back to the main learning objectives. Conversely, PBL is more of an open inquiry approach where instructors 294

play a minimal role in guiding the discussion/learning process.

Examples of Case-Based Learning for AT Education • Text Based Scenarios – these are commonly seen at the end of chapter reviews in text books. Some books do a good job of asking further stimulating questions but most follow the passive learning model of surface learning.

• Multimedia Case Scenarios – various technologies can be used to create a more realistic context for a particular injury scenario. Videos, images, and sounds can simulate a more authentic learning environment when compared to text-based scenarios. This is the rationale behind the multimedia approach used in the Multimedia CBL Sports Injury Assessment Educational Tool.

• Case Scenario Seminar Discussions (small group of larger group) – in these seminars, it is important to ensure that there are no obvious correct or incorrect answers to the questions. During these sessions, the instructor plays a facilitator role by stimulating group discussion and problem-solving through asking open questions such as “How can we solve this problem?” “What would you do here?” The main aim of using a seminar format is to allow for the sharing of knowledge, consideration of different situations (while critiquing each way), and identifying possible ways of dealing with a situation.

• Mid/High Fidelity Simulation Scenarios – many AT educators use these simulation manikins for case studies. But it is important for the educator to know why it is being used…why use a high fidelity manikin instead of a standardized human patient? What is the desired outcome for the scenario? What types of questions should be asked along the way? These questions should be answered before deciding upon the mode for the scenario.

Key Points for using Case-Based Learning effectively

• The case must be authentic – some studies even promote getting the students to develop case studies themselves so that they are based on their personal interest. Other suggest to have professionals or other educators create scenarios.

• The case should include practical skills – educators want their students to know what to do and when to do it, but in practical professions like AT the students also have to demonstrate the abilities to use these practical skills. Therefore an effective case study will allow for the practice of these practical

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skills.

• Questions should deepen the learning process – avoid asking questions that only result in surface learning. Careful consideration should be taken into designing questions that stimulate critical thought and deeper learning.

• The cases should involve information gathering and analysis – all the information should not be initially given to the student. They should have the opportunity to decide how to gather information and how to analyze it once they have it.

• Accrording to Heereid (2007), there are several basic rules for effective CBL use: o The case needs to tell a story (through text, video, pictures, a combination…) o It must focus on an interest-arousing issue (it should be interesting for the student) o It must be relevant to the reader (the student has to be able to form a connection with the scenario) o These activities must have pedagogic utility (it has to be used with a purpose…it should match the course outcomes, as identified by the instructor) o It should be conflict provoking (there should be no obvious correct/incorrect answers…the case should cause cognitive dissonance (mental discomfort) in the student) o The case should be decision forcing (the student should have to make some form of ultimate decision…critical analysis) o It should have generality (the ability for learning/knowledge/skills to be transferred to other situations)

Suggested References for Case-Based Learning

Berry, D. C., Miller, M. G., & Berry, L. M. (2011). Athletic & Orthopedic injury assessment: A case study approach. Scottsdale, AZ: Holcomb Hathaway.

Herreid, C. F. (2007). Start with a story: The case study method of teaching college science. NSTA Press.

Hofsten, A., Gustafsson, C., & Haggstrom, E. (2010). Case seminars open doors to deeper understanding – Nursing students’ experiences of learning. Nurse Education Today, 30, 533-538.

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Speicher, T. E., Bell, A., Kehrhahn, M., & Casa, D. J. (2012). Case-based analogical reasoning: A pedagogical tool for promotion of clinical reasoning. Athletic Training Education Journal, 7(3), 129-136.

Thistlethwaite, J. E., Davies, D., Ekeocha, S., Kidd, J. M., MacDougall, C., Matthews, P., . . .Clay, D. (2012). The effectiveness of case-based learning in health professional education. A BEME systematic review: BEME Guide No. 23. Medical Teacher, 34, e421-e444.

Williams, B. (2006). Qualitative analysis of undergraduate paramedic students’ perceptions of using case-based learning in an online learning environment. Journal of Emergency Primary Health Care, 4(3), 1-9.

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Other Pedagogies

Included in the

Multimedia Case-Based Learning Sports Injury Assessment Tool

After interviewing a large sample of athletic therapy educators in Canada, it quickly became apparent that there are a lot of educators out there that are interested in learning more about the methods of teaching and learning (also known as pedagogy). Few educators have actually studied pedagogy and/or medical education and the vast majority of participants expressed interest in further developing their knowledge/skills in these areas.

This pursuit of pedagogical knowledge is seen in other health professions as well. Health professional educators are often health professionals first (with high levels of content knowledge in their respective discipline) and educators second (with varying levels of pedagogical knowledge). According to Dent & Harden (2009), “new horizons in medical education continue to unfold as progress continues to be made to make teaching and learning in the healthcare professions relevant to the current requirements of students, educators, and society.” Therefore it is imperative that health professional educators familiarize themselves with effective contemporary pedagogical practices.

However it is important to note that when talking about effective pedagogy, there is no panacea…no magic answer to what makes an effective teacher. However a good teacher should be seen as one who makes good use of a range of pedagogical methods, applying each method for the use to which it is most appropriate.

The purpose of the Multimedia Case Based Learning Sports Injury Assessment Educational Tool is to bridge the gap between theoretical knowledge in medical education and the practical delivery of effective pedagogy in athletic therapy. It takes a hybrid approach by incorporating elements of several different effective pedagogies. While situated in the larger pedagogy known as Case-Based Learning, the tool also contains pedagogical strategies such as: the Socratic method of teaching, instructional scaffolding, peer-assisted learning, and critical reflection.

This section describes each of these pedagogical strategies in more detail, while providing a rationale for their use in athletic therapy education. As previously described, an educator can use these strategies by themselves (if they are deemed to be appropriate) or in a hybrid-like model as used in this educational tool.

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The Socratic Method of Teaching

“I cannot teach anybody anything; I can only make them think” Socrates

• What is the main purpose of using Socratic Teaching Methods? o The main purpose of this method of teaching is to stimulate student critical thinking and to expose faulty reasoning/errors through a series of questions and responses. It is used instead of just simply answering a student’s question for them. o https://www.youtube.com/watch?v=Rx-wvNol03M

• Why is there a need for Socratic Teaching Methods in AT Education? o Many educators try to encourage students to learn a body of knowledge by stating that knowledge in a sequence of lectures and then asking students to internalize that knowledge outside of class and on their own time. This is a passive type of learning. However, not all students possess the necessary thinking skills to analyze and synthesize this information without practice. o Currently, the Socratic method is not clearly defined as a tool for clinical teaching. Many health professionals (including AT educators) claim to use Socratic methods in their teaching but there are many different variations of this technique; ranging from “guess what I am thinking” to the masterful use of questions that leads the student to cognitive enlightenments. o Regardless, it is important to ask questions with a purpose…questions are only as good as the thought put into them and these should go beyond knowledge level recall (attempt to stimulate a higher-level of thinking or critical thinking). For example, asking a student to evaluate when proprioception exercises should be included in a rehab program is more challenging than asking them to just define the term proprioception.

• Why would Socratic Teaching be an effective strategy for AT educators? o The main benefits of this teaching strategy are: 1) it challenges the student’s preconceived notions of assessment/rehab by asking questions in a logical and stepwise fashion to hone critical thinking skills in the context of the patient; 2) it can be used to diagnose the student’s level of understanding to assess his/her learning needs through questioning; and 3) it can engage learners by focusing on self- directed learning or teaching key clinical pearls. o This is an important teaching strategy to use in health professional 299

education because it forces students to not focus on rote memorization and to avoid becoming rigid with their level of thinking. Because of the constant changes and development of innovative products in the AT field, therapists need to become lifelong skeptics and be able to analyze these new developments.This type of teaching can also help students to develop critical thinking skills so that they can make interpretations of a patient’s history or examination findings. o Socratic teaching is also useful because makes educators familiar with the crucial thought processes that are used by students, by showing what the student knows, and most importantly, what the student does not know. Using effective questioning can identify a student’s level of understanding and gaps in their knowledge. Once gaps in knowledge have been identified, the teacher and student can then engage in a discussion of key clinical points and teaching pearls.

Examples of Good Socratic Questions for AT Education • In the Multimedia CBL Sports Injury Assessment educational tool, the brainstorming questions (included in various sections) were developed using Socratic questioning principles. • The teacher should use words or phrases such as: ‘explain’; ‘compare’; ‘why’; ‘which is a solution to the problem’; ‘what is the best and why’; or ‘do you agree or disagree with this statement’. • Examples of Questions: what was the expected outcome of the special tests performed? Can you explain your reasoning for the special tests which were performed (why were these chosen)? Explain the hierarchy of special tests that were used for this particular problem? Explain the reliability and validity of the special tests performed.

Key Points for using the Socratic Method of Teaching effectively

• Ask questions with a purpose (avoid using ambiguous questions) • Questions should look to build upon and expand on the preexisting knowledge of students • Do not focus on the student’s ability to answer the questions…focus on what they are saying. This will decrease the likelihood of developing fear, humiliation, or other psychological disturbances in the student. • This type of teaching is grounded in psychologist Lev Vygotsky’s Zone of Proximal Development. This concept proposes that there is a distance between what a student can achieve all alone and what the same student can achieve with help from more capable others. Socratic teaching is one technique that can help develop higher-level cognitive skills.

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Vygotsky’s Zone of Proximal Development (Adapted from Vygotsky, 1978) https://www.youtube.com/watch?v=Du6vqSOj7U U

Discussion Starter Example Application for AT Education Ask about a known case What was the role of the team Identifies the role of the team physician in the recent spine physician relative to the AT boarding incident at the game staff on Saturday? Ask for specific factors Why did the team physician Explains specific roles of the stand back and allow the AT’s health care team. Clarification to command the situation? that the physician needed to be available to treat rather than lift during this situation Ask for immediate factors Why did the team physician Identifies the relationships and allow the AT staff to perform trust of the health care team. such critical duties Validation of the education of the AT Ask for prior factors Why are ATs in command in Identifies the training required the field evaluation settings? to be an AT. Emphasizes the need to have a standard operating procedures established with the physician.

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Ask for insufficient factors Do all team physicians allow Strengthens the understanding ATs to command care of the between various venues. athlete in these situations Fortifies the need for strong working relationships with the team physician. Identifies various subspecialties of physicians. Ask for counterexamples Do you think that the team Establishes an understanding physicians at all of individual settings and colleges/universities allow relationships. ATs to command the situation? Ask for counterexamples if an If the counterexample was that Establishes a cause and effect unnecessary factor is the team physician did not like relationship. Forces students identified the AT than the to address issues that may not counterexample could be: be rooted in practice or theory. How does the personal relationship affect the care that is provided to the athlete in this setting? Ask for extreme value factors Does the trust/relationship Connects personal and established by the AT and professional values. Facilitates team physician have anything consideration of alternative to do with the way the AT discussion points that may be performed on the certification of more relevance exam? Ask for comparison of two Did the team physician in the Connects behaviours and cases video clip (show video from allows students to contemplate NFL spinal situation) act confounding factors that may similarly to the team physician account for behavioural at the game here at XYZ patterns. university? Ask for a predication for an What if the team physician Facilitates consideration of unknown case had forced his way into roles and responsibilities. controlling the command Engages thoughtful prediction position of the spine boarding of the ‘what-ifs’ to process the incident and the athlete ceased most appropriate breathing? alternatives/solutions. Socratic Method of Teaching in AT Education (modified from Schlabach & Peer, 2008)

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Suggested References about Socratic Method of Teaching

Mehul, S. (2008). The Socratic teaching method: A therapeutic approach to learning. Teaching Philosophy, 31(3), 267-275.

Oh, R. C. (2005). The Socratic method in medicine: The labor of delivering medical truths. Family Medicine, 37(8), 537-539.

Schlabach, G. A., & Peer, K. S. (2008). Professional ethics in athletic training. Mosby.

Walker, S. E. (2003). Active learning strategies to promote critical thinking. Journal of Athletic Training, 38(3), 263-267.

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Instructional Scaffolding

• What is the main purpose of using Instructional Scaffolding? o Instructional Scaffolding is a learning process that is designed to promote a deeper level of learning and understanding in students. More specifically, scaffolding is the support given by the instructor (and/or other peers) during the learning process which is tailored to the individual needs of the student with full intention of helping the student achieve his/her learning goals. Possible supports used for Instructional Scaffolding include: multimedia technologies, educational resources, concept maps, flow charts, instructional templates, written guides, guidance on the development of cognitive and social skills. o These supports are gradually removed as students develop autonomous learning strategies, thereby promoting their own cognitive, affective, and psychomotor learning skills/knowledge.

• What is required for effective Instructional Scaffolding? o To use scaffolding effectively, an educator needs to address the following areas: ▪ The selection of the learning task – the task should be engaging, interesting, and ensure that the student uses the developing skills that need to be mastered (meets the curriculum goals/learning objectives). ▪ The anticipation of errors – the educator needs to anticipate errors that the students are likely to commit while learning the task. This anticipation enables the educator to guide students away from these ineffective directions. ▪ The consideration of emotive and affective factors – this strategy is not limited to use with cognitive skills but can also relate to emotive and affective factors. ▪ The application of scaffolds during the learning task – scaffolds can range from simple skill acquisition guides to dynamic/generative tasks.

• What are some different types of Scaffolding? o Soft (Contingent) Scaffolding – this strategy is effective in smaller class sizes (like the size of most AT classes). An example of a soft scaffolding strategy would be a teacher who moves around the classroom and has individual conversations with each student. This teacher may question the students approach to answering a particular problem and then provide constructive feedback, or use other 304

techniques (e.g., Socratic teaching) to help promote student learning.

o Hard Scaffolding - An example of a hard scaffolding strategy is when a teacher uses a more structured approach to giving hints and/or cues to help students reach a higher-level of thinking. This technique often uses detailed supports and is thought to be effective when students are working on more difficult problems.

o Reciprocal Scaffolding – this strategy uses specific peer activities that help to improve higher-level thinking. This method involves in-class activities within a peer-group, where two or more students are working together collaboratively and sharing each other’s experiences and knowledge. These students will learn from one another and be able to reflect critically on the knowledge exchange, especially if the students share different perspectives. This approach can be particularly useful in AT education.

o Technical Scaffolding - in this innovative approach, technology (e.g., educational software) replaces teachers and peer groups to help guide students through the learning process.

• Why is there a need for Instructional Scaffolding in AT Education? o In this teaching strategy, the instructor becomes a mentor/facilitator instead of the traditional dominant content expert. This change in the role of the educator encourages students to take ownership of their learning and to take on a more active role. o This type of teaching strategy creates a supportive learning environment by allowing students to ask questions, provide feedback, and support their peers while learning new material. o There is research-based evidence that suggests that all case-based learning or problem-based learning activities (which are commonly used by AT educators) should involve careful scaffolding planning and preparation (Lajoie, 2005; Mensch & Ennis, 2001; Weidner & August, 1997).

• Why would Instructional Scaffolding be an effective strategy for AT educators? O This is a teaching technique that many AT educators already use as a part of their teaching (probably without realizing it). Most educators will demonstrate something first (e.g., a Lachman special test) and then have their students practice it. By using specific instructional scaffolding strategies, it takes this process and adds in more detailed learning strategies to help promote a higher level of student thinking.

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Examples of Instructional Scaffolding for AT Education

o In the Multimedia CBL Sports Injury Assessment educational tool there are a few different supports/resources that can be used during the scaffolding process: the initial concept map that outlines the various components of an orthopedic assessment; the pedagogy that accompanies the educational tool (follows the steps as discussed above). o First the instructor demonstrates how to perform the new/difficult task (e.g., how to do an orthopedic assessment of the ankle). Second, the instructor and students work together to perform the task (e.g., as a group, the instructor and students can go through an assessment of the knee). Thirdly, students will work with a partner or small group on their own assessment. Finally, the individual completes an independent practice stage where they are responsible to demonstrate their task mastery (e.g., an assignment where the students have to complete an orthopedic assessment – written or practical).

Key Points for using Instructional Scaffolding effectively

o Select suitable tasks that match curriculum goals, learning objectives, student needs, etc. o Consider students’ backgrounds and prior knowledge to assess their progress. Material that is too easily will reduce their motivation. o Use a variety of supports as students’ progress through the task (e.g., flow charts, diagrams, concept maps, etc.) o Monitor student performance through feedback o Help students become less dependent on instructional supports and encourage them to practice the task in different contexts (knowledge transfer). o This teaching strategy is also grounded in Lev Vygotsky’s theory of the Zone of Proximal Development.

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Suggested References about Instructional Scaffolding

Holton, D., & Clark, D. (2006). Scaffolding and metacognition. International Journal of Mathematical Education in Science and Technology, 37, 127-143.

Lajoie, S. (2005). Extending the scaffolding metaphor. Instructional Science, 33, 541- 557.

Mensch, J. M., & Ennis, C. D. (2001). Students’ educational experiences in CAAHEP-accredited athletic training programs. Journal of Athletic Training, 36, 45.

Simons, K. D., & Klein, J. D. (2007). The impact of scaffolding and student achievement levels in problem-based learning environment. Instructional Science, 35, 41-72.

Weidner, T. G., & August, J. A. (1997). The athletic therapist as clinical instructor. Athletic Therapist Today, 2, 49-51.

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Peer-Assisted Learning

• What is the main purpose of using Peer-Assisted Learning? o Many educators in professional programs use peer activities or interactions as a part of their courses. These interactions are called by many different names. Peer- Assisted Learning (PAL) is a specific type of peer interaction that provides the opportunities for students’ to teach one another. The idea is that the student who does the teaching, gains a deeper understanding regarding the subject matter being taught. This coincides with the common assumption that “you do not know something unless you can explain it to someone else.” o PAL is different from peer mentoring which is another peer interaction strategy commonly seen in Athletic Therapy accredited programs. Peer mentoring often involves an emotional support role (directly or indirectly) whereas PAL focuses on establishing teaching roles.

• Why is there a need for Peer-Assisted Learning in AT Education? o Certified Athletic Therapists have to possess the necessary abilities to explain and educate the patients’ that they work with. To have a successful rehab, the patient needs to understand exactly what is going on and what is being done (along with what they can and cannot do). Therefore successful therapists are required to have excellent communication skills. o PAL is a pedagogical strategy that is used widely throughout professional programs including education, dentistry, nursing, occupational therapy, and physical therapy (Henning et al., 2006). It is unknown if AT programs in Canada actually use PAL. The effects of this strategy have not been investigated in an AT population.

• Why would Peer-Assisted Learning be an effective strategy for AT educators? o Research shows that PAL helps to: improve communication skills, increase self- confidence, promote critical thinking skills, improved organizational skills, enhanced learning of course material, and decreased anxiety/stress (it is often viewed as being less stressful to work with a peer rather than course instructor) (Buckley & Zamora, 2007; Heckmann et al., 2008; Kurtz, Constance, & Alverson, 2010; Weyrich et al., 2009). o This is a teaching technique that many AT educators already use (somewhat) in their classrooms. AT educators often get students to work in small groups (usually in partners) to practice different assessment and rehab techniques with one another. The main difference for PAL as

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a teaching strategy is to structure those peer interactions as teaching opportunities. For example, the students could take turns teaching one another on the specific special test. This will allow students to share their previous experiences and current knowledge with each other.

Examples of Peer-Assisted Learning in AT Education

• Clinical/Field Skill Practice – students often practice clinical and field skills with other AT students, both in and out of the classroom. As a PAL strategy, instructors could provide students with a set of debriefing questions so that they can learn from one another by sharing their current level of knowledge and previous experiences. Throughout the Multimedia CBL Sports Injury Assessment Educational Tool there are a series of Peer Activities in each section to encourage these peer interactions.

• Field/Clinical Mentors – beginner students can be “matched up” with senior level students to shadow them in field and clinical placements. This will allow the beginner to become more comfortable and acclimatized with the various settings. Additionally they will be able to interact with the senior level student and learn from them.

• Study Groups – these are commonly used in AT education but are usually informal. Group studying allows students to interact and learn from one another. This type of PAL is especially important in AT education because students often have differing field and clinical experiences. One student may have dealt with ten ankle injuries in the sport of basketball, while another only saw shoulder injuries in volleyball as a part of their placement. These informal study groups give students the opportunities to share these experiences.

Key Points for using Peer-Assisted Learning effectively

• Does PAL align with your intended learning outcomes – if it does not help you achieve what you are trying to achieve, then there is no point in using it.

• Will PAL be enjoyed by the students – as an educator, it is important to know your students. You get a sense of the types of strategies/activities that will work with a particular group. Negative experiences with PAL can actually have negative consequences such as decreased confidence, motivation, and reflection. 309

• Matching Students – it is important to organize your target groups into “peer learners” and “peer educators”…who is to teach what, to whom, and for what purpose.

• Important Logistical Information – timing (when should it take place?), length of sessions, frequency of sessions, location, equipment, cost, and training.

Suggested References about Peer-Assisted Learning

Buckley, S., & Zamora, J. (2007). Effects of participation in a cross year peer tutoring programme in clinical examination skills on volunteer tutors’ skills and attitudes towards teachers and teaching. BMC Medical Education, 7(20), 20-29.

Heckmann, J., Dutsch, M., Rauch, C., Lang, C., Weih, M., & Schwab, S. (2008). Effects of peer-assisted training during the neurology clerkship: A randomized controlled study. European Journal of Neurology, 15, 1365- 1370.

Henning, J., & Marty, M. (2008). A practical guide to implementing peer assessment in athletic training education. Athletic Therapy Today, 13, 29- 32.

Kurtz, C., Constance, S., & Alverson, E. (2010). The master student presenter: Peer teaching in the simulation laboratory. Nursing Education Perspectives, 31(1), 38-40.

Weyrich, P., Schrauth, M., & Nikendei, C. (2008). Peer-assisted learning: A planning and implementation framework. Guide supplement 30.4- Practical Application. Medical Teacher, 30, 444-445.

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Critical Reflection

“We do not learn directly from the experience itself. We learn by deliberately reflecting upon that experience” John Dewey

• What is critical reflection? o Critical reflection can be defined as a process regarding thinking about, and exploring, an issue of concern which is triggered by an experience (Walker, 2006). It allows a student to take ownership of their own learning by taking on an active approach to learning.

https://www.youtube.com/watch?v=XIsznZR4hzY

o Schon’s 1983 book, The Reflective Practitioner, challenged practitioners to reconsider the role of reflection in developing professional excellence. He coined the terms knowing-in-action, reflection-in-action, and reflection-on-action to describe the important components of the reflective process. ▪ Knowing-in-action refers to the “know how” a practitioner demonstrates while performing a particular action. These practitioners show competency by displaying the appropriate actions. An example in the AT profession would be the knowledge/competencies required to perform an ankle orthopedic assessment. The concept of “knowing-in-action” benefits a student, except when a familiar procedure yields unexpected results. For example, a student who has completed several successful ankle assessments in the past completes a new ankle assessment and finds inconclusive results. When faced with this situation, a student can become frustrated. Therefore a useful reflective strategy for them would be to use reflect-on- action. ▪ Reflecting-on-action refers to reflecting on an experience after it has already happened. It encourages practitioners to analyze the situation, explore the reasons around their actions, and the consequences of these actions. Unfortunately, more times than not, no time/activities are scheduled for students to engage in this type of reflection. Additionally when it is used, students are often left to reflect by themselves, without being taught different strategies or provided with guiding questions.

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▪ Reflecting-in-action refers to reflecting on the experience while actually doing it. This type of reflection is often used by expert practitioners and is sometimes referred to as “thinking on your feet” or “felt-knowing”. When faced with a professional issue, expert practitioners connect with their feelings, emotions, and prior experiences to attend to the situation directly. Unfortunately, many students do not possess the abilities to use this type of reflection effectively so they need to be exposed to pedagogies and activities in their education to stimulate this type of reflection.

• What is the main purpose of using critical reflection in AT education? o Critical thinking has long been considered as an important skill to foster in higher education programs, and can be traced back as far as Socrates in 399 BC (Daly, 1998). The idea of questioning known truths is the foundation of the contemporary construction and utilization of critical thinking. o Critical thinking skills are necessary for competent athletic therapists because of the many changes/advancements in assessment, rehabilitation, education, technology, and health care reform. Effective AT’s require the abilities to analyze, critique and problem solve when challenged with these changes/advancements. o The purpose of using critically reflective activities in AT education is to help produce health professionals that are capable of: 1) thinking critically; 2) sequentially analyzing and solving dynamic problems; and 3) taking in the information at hand and making critical decisions (Heinrichs, 2002). Educators hope that their students are able to reflect on their own knowledge (deeper learning…thinking critically) without focusing on passive rote memorization (surface learning…a lack of understanding).

• Why is there a need for critical reflection in AT education? o Upon graduating from an accredited institution, certification candidates are expected to have high levels of critical thinking and the required skills and abilities to transition into becoming competent health professionals. According to Leaver-Dunn et al. (2002), the ability to critically reflect distinguishes expert practitioners from their peers. In many AT education programs, the disposition of students to think critically exists, but is weak (Walker, 2003). More structured reflective activities could potentially benefit AT students, and help them transition into becoming expert practitioners. o Within each CATA accredited institution, AT students experience the assessment and management of many different injuries both in and out of

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the classroom environment. To allow for deeper learning to occur, and to truly learn from these experiences, students must practice, enhance, and habitually use their reflection skills. • Critical thinking/reflective activities have long been incorporated into the educational standards and outcomes of other health professional education programs including: medical education, nursing, dentistry, and physical therapy. This topic has also been extensively studied in these fields and shown to be effective. Therefore similar research should be completed in the athletic therapy profession.

• Why would critical reflection be an effective strategy for AT educators? o Imagine an AT who does not consider all of the possible injury options when performing an assessment, or an AT who is unable to react calmly during an emergency situation because they never practice an emergency action plan, or mentally prepared for it. Oftentimes educators expect their students to be able to problem-solve in these situations and to just think back about what they would do differently if faced with a similar situation in the future. However, many students do not have the required knowledge, experience, or abilities to use reflection to actually improve decision-making ability. As they move through their AT education program, students should be able to practice and enhance their reflection skills along the way. o Active-learning strategies can be used to promote critical thinking and critical reflection to extend learning beyond the classroom. If students are taught (and able to practice) how to truly be critically reflective, then they can gain the ability to use information from previous experiences, as well as insights gained from the reflective process, to improve their problem-solving and decision-making abilities.

Examples of Critical Reflective activities in AT education

• Journal Writing – this assignment helps create a dialogue between the instructor and student and provides guided opportunities for students to reflect upon their own perceptions and/or understandings of their experiences. When using these assignments, educators should push the students to reflect more deeply. Ask questions such as: “why a particular decision was made?” “why did they use a particular special test?” “what would he/she do differently the next time?”. It is important for an instructor to set expectations for this assignment (e.g., increasing confidence, critical thinking, reflection) and potentially provide a list of sample questions for the student to use as a template. Remember not all students know how to reflect effectively (they are

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not experts).

• Blog Postings - an innovative activity is to have the students write journal entries as blog posts. These postings should be treated in the same manner as described above, to ensure a deeper level of reflection. There are definitely pros and cons to using this type of technology. Students may learn from reading each other’s posts and by having the opportunity to comment on each other’s postings, but they may be selective in what they share since it is not anonymous or private. There are entries/topics that a student may share with an instructor in private journals that they do not feel comfortable in sharing with classmates (or over the internet).

• Case Scenario Assignments (completed individually and in small groups) – critically reflective questions can be added to the end of case scenario assignments (or in-class activities) to help stimulate deeper learning. Students should be asked specific questions related to “reflection-on-action”, so that they can explore the reasoning behind their decisions/actions, and the consequences of these decisions. This activity has been added to the Multimedia CBL Sports Injury Assessment Educational Tool.

• Debriefing Sessions – all accredited institutions use some form of case scenario as a part of their educational programs. Students are often brought through simulated injury scenarios to mimic situations found in the clinic or on-field. After these sessions, students can be brought through structured (or semi- structured) debriefing sessions to reflect on their experiences, decisions, and actions. Similar questions should be asked (as presented above) to have students think about the reasoning behind their decisions/actions.

Key points for using Critical Reflection effectively

• There are a number of different models of reflective practice that are applicable to AT education. The ones that are most commonly seen in the medical education literature are: o Kolb’s Reflective Model of Experiential Learning – students face a concrete experience, they observe and reflect, they format abstract concepts and generalizations, they test implications of these concepts in new situations, repeat the cycle. o Gibb’s Structured Debriefing – students face an initial experience, they describe it, they describe their feelings, evaluate what was good/bad about the experience, analyze the situation, draw general conclusions,

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draw specific conclusions, and finally develop personal action plans. o John’s Mode of Reflection for Nurse Practitioners – reflection occurs through “looking in” on individual thoughts and emotions and “looking out” at the situation that was just experienced.

• Important Logistical Information – What is the expected format of the reflections? When will the reflections be due? How will students be graded? How will students be given feedback? What will the students be asked to write about? Will there be guiding questions provided? If so, what are they?

• Remember that Critical Reflection is NOT: o a didactic retelling of the events that happened. This is a very common strategy for students to use. If this is the case, then more guiding questions need to be incorporated to stimulate deeper reflection. o only an emotional outlet o a black & white activity that brings about closure to the topic…this should be an ongoing learning process.

• Critical Reflection SHOULD BE: o Challenging – these activities should avoid simple conclusions, and instead raise deeper, more stimulating, questions o Contextualized – to be beneficial, the purpose needs to be stated and situation in the context of learning. The educator needs to identify the purpose of reflection. o Promoting Active-Learning – if used effectively, these activities can identify educational needs, personal/professional strength and weakness, and areas for improvement. o Self-Motivating – if used effectively, an individual can gain a better understanding of their own beliefs, attitudes, and values.

Suggested References about Critical Reflection

Daly, W. M. (1998). Critical thinking as an outcome of nursing education: What is it? Why is it important to nursing practice? Journal of Advanced Nursing, 28(2), 323-331.

Gibbs, G. (1988). Learning by doing: A guide to teaching and learning methods. London, UK: Further Education Unit.

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Heinrichs, K. I. (2002). Problem-based learning in entry-level athletic training professional- education programs: A model for developing critical-thinking and decision-making skills. Journal of Athletic Training, 37, 189-198.

Hughes, W., & Lavery, J. (2004). Critical thinking: An introduction to the basic skills. Peterborough, ON: Broadview.

Johns, C., & Burnie, S. (2013). Becoming a reflective practitioner. 4th ed. Chichester, UK: Wiley-Blackwell.

Leaver-Dunn, D., Harrelson, G. L., Martin, M., & Wyatt, T. (2002). Critical thinking predisposition among undergraduate athletic training students. Journal of Athletic Training, 37(4 suppl), S147-S151.

Schon, D. A. (1983). The reflective practitioner: How professionals think in action. New York, NY: Basic Books.

Walker, S. E. (2003). Active learning strategies to promote critical thinking. Journal of Athletic Training, 38(3), 263-267.

Walker, S. E. (2006). Journal writing as a teaching technique to promote reflection. Journal of Athletic Training, 41(2), 216-221.

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Learning Outcomes for the Multimedia CBL Sports Injury Assessment Educational Tool: A Foundation for Molding Competent and Reflective Professionals

Communication Skills

Outcomes

• Utilizing and incorporating technology into discipline specific work. • Communicating effectively (verbally, nonverbally and in the written form) utilizing appropriate technology. • Interacting effectively and collaboratively with peers through semi-structured activities. • Engaging in reflective thinking/writing for the purpose of self-assessment.

Professional Competence/Application of Performance

Outcomes

• Demonstrating cognitive competence in core athletic therapy content areas as defined by the CATA, including the areas of: o Assessment of Athletic Injuries (shoulder, elbow, knee, and ankle) o Human Anatomy (musculoskeletal) o Biomechanics o Sport Psychology o Therapeutic Modalities (cryotherapy, ultrasound, interferential current, neuromuscular stimulation, transcutaneous electrical nerve stimulation) o Therapeutic Exercise o Progression of Rehabilitation Principles

• Demonstrating psychomotor competence in core athletic therapy content areas as defined by the CATA, including: o Construction and phrasing of questions appropriate to obtaining a medical history of an injured athlete. o Identification of observable clinical signs typically associated with common athletic injuries including structural deformities, edema, discoloration, etc. o Administration of active, passive, and resisted range of motion tests for the shoulder, elbow, knee, and ankle. o Describing commonly used special tests anatomically and

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biomechanically (test that are used for the evaluation of athletic injuries for the shoulder, elbow, knee, and ankle) o Administration of commonly used “special tests” for the evaluation of athletic injuries for the shoulder, elbow, knee, and ankle. o Location and palpation of key anatomical structures involved in injury pathology.

Professional Decision Making/Critical Thinking

Outcomes

• Identifying potential indices of suspicion after watching mechanism of injury videos. • Interpreting commonly used special tests for the evaluation of athletic injuries for the shoulder, elbow, knee, and ankle. Understanding • Interpreting assessment findings to make indices of suspicion (including anatomical and biomechanical rationalization). • Determining appropriate treatment of injured athletes based on subjective and objective findings from the assessment.

Ethical Decision Making

Outcomes

• Adhering to the Canadian Athletic Therapists Association (CATA) Code of Ethics. • Identifying potential ethical issues in case scenarios.

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