On the posttest assessment, in the classroom (ITC) educators showed significantly greater gains in TBI knowledge (P < .0001, d = 1.36 [large effect]), TBI knowledge application (P = .0261, d = 0.46 [medium effect]), and general self-efficacy (P = .0106, d = 0.39 [small to medium effect]) than the LEARNet controls (see Table 4). The ITC educators showed greater trend-level applied self-efficacy posttest scores (P = .0152, d = 0.26 [small effect]) than the LEARNet controls. Over the follow-up period, the condition × time interaction was significant but negative for TBI knowledge (P = .0224, d = −0.54 [medium effect]), indicating that after a significant increase at posttest, the ITC educators showed significantly greater decreases relative to the LEARNet controls after the 2-month follow-up period. We estimated the model-implied least squares means at 2-month follow-up to evaluate whether the significant gains at posttest for ITC educators maintained through the end of the study period. Differences in least squares means showed that ITC educators, relative to LEARNet controls, maintained significant gains in TBI knowledge (P = .001, d = 0.82 [large effect]) and general self-efficacy (P = .018, d = 0.38 [small to medium effect]) but not in TBI knowledge application (P = .921, d = .02 [small effect]). The higher trend-level applied self-efficacy scores favoring ITC at posttest were significantly greater than the scores of the LEARNet controls at follow-up (P = .006, d = 0.66 [medium effect]). The general self-efficacy growth model was rerun excluding the 1 outlier, and the results were similar to the original analysis.
We detected no group differences at posttest or follow-up for the number of strategies identified from video-based knowledge application item 1 (see Table 5). However, at posttest, the ITC educators identified 46% more strategies than the LEARNet control educators for video-based knowledge application item 2, a significant difference (odds ratio = 1.46, 95% confidence interval = 1.01-2.10, P = .042). The gains at posttest for ITC educators for the second video item were not maintained after the 2-month follow-up period (odds ratio = 1.19, 95% confidence interval = 0.79-1.82, P = .407).
These findings are especially promising because the sample consisted entirely of general education classroom teachers. Most students with TBI are primarily served in general education settings, where teachers rarely have knowledge or expertise in brain injury.23 , 41 , 42 Indeed, the average TBI knowledge score across all teachers in our sample was approximately 66%. This inadequate level of TBI knowledge among general educators likely contributes to weak service delivery and support for students with TBI. In fact, teachers' limited knowledge is associated with a lack of self-confidence in knowing how to effectively teach a student with a severe TBI.41 Knowledge gaps that affect service delivery and supports for students with TBI are critical for the field to address. Recent research evidence demonstrates how important it is for educators to adequately understand students with TBI.43 Traumatic brain injury–specific training could leave individual teachers better prepared to monitor students' postinjury problems and better equipped with strategies to deal with learning and behavioral challenges as they arise. Well-trained teachers would also be able to better understand parents' perspectives and communicate knowledgably about how best to address students' challenges.
The finding that knowledge application scores decreased over time was disappointing but not surprising. To increase maintenance, the program might benefit from online booster sessions. It might also be supplemented by hands-on, real-world experiences with students who have sustained TBIs. If a teacher has limited opportunity to apply new ideas from professional development to classroom instruction, improved student learning cannot be expected.44 Thus, the In the Classroom training could provide the foundation for more comprehensive professional development in TBI that is reinforced by practice and feedback in classroom settings.
Although recommendations for educational management of TBI in school settings consistently include training for educators,28 , 29 no intervention studies to date have examined how best to provide such training. In this study, we have taken an initial step to answer that question. The findings show that online training is effective in improving knowledge and self-efficacy and that those gains maintain over time. The next step in this line of research is to conduct additional studies looking at the real-world applications of this training. For example, what happens when this course is integrated within a broader professional development program in a school district? Do educators access the training on their own time, and if so, does the training result in gains in knowledge, knowledge application, and self-efficacy? How might this type of training be combined with evidence-based consultation and support to create a more robust model?45 And, most important, what are the effects of the training on outcomes among students with TBI?
Although our results are promising, this study has several limitations. Its scope was limited to examining the effects of In the Classroom on educator knowledge and self-efficacy in implementing effective instructional and behavior management practices with students with TBI. Although changes in knowledge and self-efficacy have been theoretically linked to behavior change in the health behavior literature,31 , 32 the potential correlation of these measures with educator behavioral change is unclear. There are additional flaws with the measures utilized; the test-retest reliability for both the knowledge and knowledge application measures was low (0.64 and 0.57, respectively), and clinical meaningful change is unknown for these measures.
Unfortunately, our assessment protocol precluded a more in-depth examination of the range of variables that might affect TBI management practices in schools. For example, we did not include an assessment of how educators actually used the learned skills in their classrooms with students with TBI. A large body of research has shown that trainings such as In the Classroom, without hands-on practice and feedback in the instructional context, are unlikely to transfer to classroom practice.45 We have demonstrated that educators can effectively learn new strategies and apply that knowledge to text and video-based scenarios. However, additional practice and feedback/coaching will be required to ensure that those gains transfer to the classroom.
The sample was also a limitation of this study. Because most students with TBI are served in general education classrooms,42 we chose to evaluate the training with only classroom teachers and did not include special education teachers or other educators (eg, school psychologists, speech/language pathologists). Thus, we were unable to compare the differences in gains between groups of educators. We also acknowledge a significant lack of ethnic diversity in the study population. Differences in study outcomes by minority status are important, but because our sample included primarily white women, we lack the statistical power to adequately address differential effects as a function of minority and gender status. This limits the generalizability of the findings. Third, there is a small chance that during the 2-month follow-up period, participants may have sought out training in TBI (perhaps via online sources or independent study), thus compromising the follow-up data. Finally, because the follow-up assessment occurred at 2 months, we have no information about the long-term maintenance of the gains educators demonstrated in TBI knowledge and self-efficacy. Future evaluation efforts could include a longer follow-up assessment.
Interactive online instruction is an effective vehicle for delivering educator training and is increasingly being used for professional development.46–48 The US Department of Education's 2009 meta-analysis of online learning reviewed more than 1000 empirical studies and found that, on average, students using online learning environments outperformed their counterparts who received face-to-face instruction.38 Studies examining the efficacy of Web-based training found increases in knowledge, skills, and participant satisfaction and engagement.49 , 50
The current climate of school reform emphasizes, and often requires, professional development51 but that creates financial and time burdens for already strained educational systems.52 Therefore, schools need affordable tools that promote educator knowledge and practices, build educator capacity, and respect educator time constraints. Online professional development is efficient and can overcome the barriers of time, cost, scheduling, and travel.50 , 53
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